Before he was named Trump’s health secretary, Price took a congressional trip to Australia and pressed officials to extend protections for drug companies in an international trade agreement.
This article first appeared May 31, 2017 on ProPublica.
In the spring before the 2016 presidential election, the Obama administration’s 12-nation trade agreement known as the Trans-Pacific Partnership, or TPP, was still alive. Negotiators worked on details as Congress considered whether to ratify the pact.
The Australian government was getting in the way of one change demanded by U.S. pharmaceutical companies. Makers of cutting-edge biological drugs wanted to have data from their clinical trials protected from competitors for 12 years, as they are under U.S. law — not the roughly five years permitted under the TPP. Australian officials insisted that an extension would deprive consumers of cheaper alternatives for too long.
On April 5, 2016, a bipartisan group of U.S. lawmakers arrived in Canberra, Australia’s capital, for meetings with government officials on a broad range of subjects. Among those on the routine congressional trip was Rep. Tom Price, a Georgia Republican who would go on to become President Trump’s secretary of health and human services. Three weeks before the trip, Price had purchased up to $90,000 worth of pharmaceutical stocks — trades that would come under scrutiny after his nomination to Trump’s cabinet.
In Canberra, Price and another Republican, Rep. John Kline of Minnesota, pressured senior Australian trade officials to modify their position on the 12-year extension, according to a congressional aide who was on the trip. The Australians explained that they had no intention of changing their laws or rules in ways that could increase drug prices. Price and Kline continued pushing, according to the aide, asking for a side letter or other written guidance that the period would be extended in Australia even if it weren’t spelled out in the TPP itself.
Price’s lobbying abroad, which has not previously been reported, is another example of how his work in Congress could have benefitted his investment portfolio. He traded hundreds of thousands of dollars’ worth of shares in health-related companies while taking action on legislation and regulations affecting the industry. ProPublica previously reported that Price’s stock trades are said to be under investigation by federal prosecutors.
Price, who did not respond to an interview request for this story, has said he did nothing wrong, that his broker generally chose stocks without his knowledge and that all of his trades were publicly disclosed.
Price’s financial disclosures submitted to the House Office of the Clerk show that on March 17, 2016, he purchased shares worth between $1,000 and $15,000 each in Eli Lilly, Amgen, Bristol-Meyers Squibb, McKesson, Pfizer and Biogen. All six companies had an interest in biological drugs, which are grown from live cells and are known for short as biologics. Eli Lilly, for example, is behind Portrazza, the first biologic approved to treat a common type of lung cancer. Amgen makes a top-seller for rheumatoid arthritis and psoriasis. Biogen developed a biologic for people suffering multiple sclerosis relapses.
Kline, who has since retired from Congress, said he could not recall if he or anyone else raised the biologics issue. His financial disclosures do not show direct holdings in pharmaceutical companies.
Australia has played another role in Price’s financial activities. In 2015 the congressman bought about $10,000 worth of shares in Innate Immunotherapeutics, a small biologics firm with an office in Sydney. After the congressional trip, which also made a stop in Sydney, Price purchased a larger stake in the company, about $84,000 worth, in two private placements, the first of which was announced in June. Price was invited to purchase the shares at a discounted rate.
It’s not known if Price had any contact with the firm while in Sydney. Price didn’t respond to questions about when and where he discussed the discounted offering with company officials. The company’s officials also did not respond.
Traveling congressional delegations typically meet with a variety of local officials, and at the time of the visit to Australia it wasn’t unusual for Republican lawmakers to side with the pharmaceutical industry on the trade deal’s protections for biologics. Price’s advocacy stands out because he pushed the cause directly with foreign officials, while at the same time owning stakes in companies that could have benefited.
An itinerary for the trip reviewed by ProPublica mentions TPP in relation to one of the meetings, but does not list the biologics provision. A former Australian trade official, who asked not to be named and attended one of the meetings, confirmed that the 12-year lockup was addressed, but said he could not recall which Congress members were pushing it.
Others on the trip, organized by the House’s Education and the Workforce Committee, were Robert Scott, D-Va., Ruben Hinojosa, D-Texas, Erik Paulsen, R-Minn. and Dan Benishek, R-Mich. Those members who responded to requests for comment said they could not recall whether the provision was discussed.
The data collected during clinical trials of drugs can save competitors time in developing the cheaper alternatives to biologics known as biosimilars. Keeping the data proprietary longer extends the original drugmaker’s monopoly. While some big brand-name pharmaceutical companies also make biosimilars, they and their trade association — the Pharmaceutical Research and Manufacturers of America — advocated strongly for longer exclusivity.
In the end, the debate over the provision became moot. Trump scrapped the TPP days after taking office. Price divested his drug stocks upon taking the cabinet post. His investment in Innate Immunotherapeutics yielded a profit of at least $150,000.
Special correspondent Anne Davies in Sydney contributed to this story.
Do you have access to information about Tom Price that should be public? Email robert.faturechi@propublica.org or send him encrypted messages on Signal at 213-271-7217. Here’s how to send tips and documents to ProPublica securely.
Amid public concern over spiking drug prices, a powerful middleman is suing a tiny drugmaker over unpaid rebates and fees. The maker calls the suit baseless; analysts say the suit offers a window into an opaque world.
by Charles Ornstein, ProPublica, and Katie Thomas, this article is a collaboration between ProPublica and The New York Times, May 31, 2017
A company that manages prescription drug plans for tens of millions of Americans has sued a tiny drug maker that makes an emergency treatment for heroin and painkiller overdoses, increasing the tension between the companies that make drugs and those that decide whether they should be covered.
Express Scripts, the nation’s largest pharmacy benefits manager, is suing Kaléo, the manufacturer of Evzio, the injectable overdose treatment whose price quintupled last year, drawing widespread outrage and inquiries from members of Congress. Express Scripts claims it is owed more than $14.5 million in fees and rebates related to Evzio, and it has dropped the drug from its preferred list.
In recent months, anger over rising drug costs set off a civil war within the pharmaceutical industry, pitting drug makers against other players in the health care system, including the little-known pharmacy benefit managers who negotiate with drug makers on behalf of insurers, large employers and government health programs. Drug makers and some members of Congress have accused Express Scripts and other benefit managers of operating in the shadows, pocketing an undisclosed share of the payments they exact from drug makers even as consumers are asked to pay inflated prices for the medicines they need.
The lawsuit was heavily redacted because Express Scripts said it contained “sensitive business information,” but nevertheless it provides some tantalizing details about the company’s dealings. Consultants and brokers — who advise employers on their prescription drug plans — said it showed that Express Scripts is collecting fees that keep rising as drug prices go up.
For example, according to the lawsuit, which was filed in federal court in St. Louis, Express Scripts charged Kaléo “administrative fees” that climbed sharply at the same time that Evzio was rising in price. In January 2016, when Evzio carried a list price of $937.50 for two injectors, Express Scripts billed Kaléo monthly administrative fees of about $25,000 for its commercial clients. But three months later, Evzio’s price had climbed to $4,687.50, and these fees totaled nearly $130,000. That’s on top of charges that included “formulary rebates,” or drug discounts, and “price protection rebates,” which are triggered when a drug jumps in price. Those price-protection rebates totaled $14 million — most of the money that Express Scripts is trying to recoup.
Benefit managers like Express Scripts typically pass the rebates they collect from manufacturers along to their clients — insurers and large employers — after taking a portion of the rebates for themselves. But critics, like Linda Cahn, the chief executive of Pharmacy Benefit Consultants in Morristown, New Jersey, say that the benefit managers are not transparent about what share of fees they keep, and what share they pass along to clients.
Administrative fees are particularly murky, she and others said. Some of the fees are passed to clients, but benefit managers also collect other fees that are not returned to clients.
“The lawsuit reveals that Express Scripts is collecting immense sums of money. No one knows what they’re passing through and what they’re retaining,” said Cahn, who flagged the lawsuit in a note to clients Monday. “Every client and the federal government and taxpayers should insist that they do.”
But Brian Henry, a spokesman for Express Scripts, disagreed with her assessment and described Kaléo as a “deadbeat dad.” “They owe rebates and administrative fees that we share with our clients and we are working to get that money back,” he said in a statement.
Henry also said, “The vast majority of the administrative fees are passed back to our clients.” In cases in which they are not, he said, it is with the consent of the client. While Henry initially said that all administrative fees are passed along to Medicare plans, he later said he misspoke and that he should have said the “vast majority” of such fees were passed along to Medicare plans.
Spencer Williamson, the chief executive of Kaléo, said in a statement that the lawsuit was “baseless” and that the company was committed to providing affordable access to its drug “without burdensome paperwork or high out-of-pocket costs.”
The lawsuit is the latest piece of bad news for Kaléo, a private Virginia company with just two products on the market. When Evzio arrived on the market in 2014, it was sold as an easy-to-use device, similar to an EpiPen, that could be stowed in a pocket or medicine cabinet and quickly used by friends or relatives to reverse the effects of a drug overdose.
But while the device was initially hailed by addiction experts who said it would make it easier to stop fatal overdoses, the company came under heavy criticism in 2016, when it quintupled the price of Evzio. The price increase — which came in the midst of a national opioid abuse epidemic — prompted letters from members of Congress, demanding to know what had prompted the change.
Kaléo has said it sharply raised the price of Evzio to cover the cost of a new patient-assistance program that lowers the out-of-pocket costs for people who cannot afford the product. Kaléo covers all of the out-of-pocket costs for patients with private insurance, and offers Evzio free of charge to uninsured people who make less than $100,000 a year.
But critics have said that such patient-assistance programs serve to drive up the cost of drugs to the health care system because while they ease the burden on patients, they leave insurers with the bulk of the bill, especially when a less expensive alternative is available. Other forms of naloxone, the active ingredient in Evzio, are available at a much lower price.
This is not the first time Express Scripts has sued a drug maker with expensive products. In 2015, Express Scripts filed suit against Horizon Pharma, also over unpaid fees. Horizon agreed to pay Express Scripts $65 million in September 2016 to settle the case. After initially dropping coverage of Horizon’s drugs, Express Scripts added them back to its preferred drug list.
Express Scripts is also being sued. Last year, the insurance giant Anthem sued Express Scripts in federal court in New York for $15 billion and claimed the company had been overcharging it for drugs. Express Scripts, which denied the claims, said recently that it would most likely lose Anthem, its largest customer, beginning in 2020, leading to speculation about how the company will replace the business it is losing.
During a 15-month period between April 1981 and June 1982, the eight-bed pediatric ICU at Bexar County Hospital experienced 42 deaths—an extraordinarily high number. One licensed vocational nurse, had cared for 20 of them.
This article first appeared May 25, 2017 on ProPublica.
By Peter Elkind
Update, May 25, 2017: Immediately after indicting Genene Jones today for murder, the grand jury set a bond of $1 million. It is a sufficiently large amount that it likely guarantees Jones will remain in prison until the case comes to trial, even if that is not until after her scheduled release date of March 1, 2018.
SAN ANTONIO — Three decades ago, a young nurse named Genene Jones made international headlines as the suspected serial killer of more than a dozen infants in the pediatric intensive care unit at San Antonio’s charity hospital.
The story brought to life every parent’s worst nightmare: losing a child at the hands of a caregiver who took some sort of perverse thrill from the baby’s final moments.
Jones was ultimately convicted of a single charge of murder at a clinic in Kerrville, a nearby town. None of the parents who lost their children in San Antonio under suspicious circumstances had the solace of hearing a jury foreman intone “Guilty of murder in the first degree” in a trial involving their loved one. But they took comfort in knowing that Jones was serving a 99-year sentence and would remain behind bars for the rest of her life.
No more. A few years ago, it became clear that the state of Texas would be forced to release Jones in March 2018 because of an effort to reduce prison overcrowding that gave convicts outsized credit for good behavior. Hoping to keep Jones locked up, prosecutors launched a secret investigation to see if they could bring a new murder charge in one of the coldest cases imaginable.
On Thursday, that effort took a big step forward: A San Antonio grand jury indicted Jones, now 66, for murdering 11-month-old Joshua Sawyer on Dec. 12, 1981. Her alleged weapon: a massive overdose of the sedative drug Dilantin.
“It’s the right thing to do,” District Attorney Nicolas “Nico” LaHood told me. “This woman is evil. Her behavior shocks the conscience of anyone with a moral compass. Genene Jones is in a class by herself. This is doing what’s right. But it’s a 30-year-old case. It’s not going to be easy.”
Getting to this point wasn’t easy either: It involved a grizzled criminal investigator who wouldn’t give up; a young prosecutor who was shocked to hear about Jones for the first time; and a mom who clung to her dead child’s medical chart for three decades.
The prosecution is certain to face an array of legal challenges. In an interview before Thursday’s grand jury action, San Antonio attorney John Convery, president of the Texas Criminal Defense Lawyers Association, says the very idea of bringing a new murder charge in the decades-old case raises fundamental legal and fairness questions. (He spoke about the matter without knowing the DA planned to seek such an indictment.) “I’m not being critical of victims,” Convery says. “I’m completely understanding of their incredible loss. But that isn’t justice; it’s revenge.” Any such move, he says, would be “bringing a murder case to solve a parole problem.”
While the legal prospects for the case are uncertain, it’s clear that the prosecution will rekindle painful memories for the families who have spent decades mourning their lost children. “I’m scared,’’ said one sobbing mother as she prepared Thursday to deliver her testimony before the San Antonio grand jury.
Jones has always insisted she was innocent of any crimes. She never testified at the trial that ended with the 99-year prison term or during a second case, for injury to a child, that produced a 60-year sentence to be served concurrently. A prison spokesman says she has instructed officials to decline requests for interviews.
Early in my journalism career, I wrote extensively about Jones, first in a lengthy 1983 Texas Monthly article, then in my 1989 true crime book, titled “The Death Shift.” Decades later, after prosecutors told me of their plan to try Jones again for murder, they agreed to speak with me for a story about how and why they were bringing their new case. There was just one condition: I would keep the news secret until the grand jury handed down its murder indictment.
This is that story. It is based on detailed interviews with the DA, two deputies responsible for today’s indictment, two mothers invited to testify before the grand jury and my own decades-old files on the troubling case of Genene Jones and the Texas baby deaths.
During a 15-month period between April 1981 and June 1982, the eight-bed pediatric ICU at Bexar County Hospital experienced a strange epidemic: 42 children — an extraordinarily high number — died there. Even more peculiar: 34 of the patients died during the 3-11 p.m. shift, and Jones, a licensed vocational nurse, had cared for 20 of them.
Several nurses had complained directly to supervisors about this disturbing pattern, later documented by a Centers for Disease Control investigation. But the supervisors had dismissed the notion that Jones — who spoke passionately about her patients — could be deliberately harming children. Certain something was terribly wrong, members of the medical staff began calling Jones’ hours on duty “the Death Shift.”
Jones, then 31, was a deeply divisive figure in the ICU, overbearing and foul-mouthed yet exceedingly confident of her medical knowledge and nursing skills. She seemed to thrive on the excitement of being in the middle of a “code” — a life-threatening medical emergency. But was she drawn to crises or causing them? The CDC study would later conclude that during a shift Jones worked in this period, a child was 25.5 times as likely to suffer a medical emergency — and 10.7 times as likely to die. Kids who were recovering on other shifts took a sudden turn for the worse under Jones, in a pattern repeated on multiple days; there were dozens of unexpected crises. When a patient didn’t make it, Jones broke down, sobbing as she picked up the baby’s body and rocked it.
Joshua Sawyer arrived at the pediatric ICU on Dec. 8, 1981 — at the height of the ICU’s mysterious “epidemic.” Eleven months old, he was suffering from severe smoke inhalation after being rescued from an explosion and fire at his family’s small rental home. Like many of the ICU’s patients, the little boy had been transferred to the county hospital because his family lacked insurance. Recalls Connie Weeks, Joshua’s mother, who was then 20, “We were very, very poor.” Weeks describes her son as “pretty laid-back … just a happy-go-lucky kid.”
Joshua came to the ICU in a coma and covered with soot; he’d already experienced seizures and one arrest. Doctors ordered sedative drugs — Dilantin and phenobarbital — to prevent more seizures. Though Joshua’s condition was critical, a scan of his skull revealed brain activity, an encouraging sign. “Given the patient’s age and early signs of brain’s general recovery,” a pediatric neurologist noted in his records, “prognosis for further neurologic recovery, though guarded, probably warrants aggressive treatment.”
By Joshua’s fourth day in the ICU, his seizures had stopped, and he was breathing without a respirator. His mom let a friend talk her into taking a break — for a shower, a change of clothes and a movie at the nearby Galaxy Theater. “I knew he was doing better,” says Weeks.
An usher came into the darkened movie theater to summon her back to the ICU.
Jones had taken over Joshua’s care at 3 p.m. that day. At 7 p.m. his heart began beating too rapidly, a condition known as tachycardia. Doctors pulled him out of that emergency. Another ICU nurse, Pat Alberti, later recounted hearing Jones tell Connie and her husband afterward that their son would have permanent brain damage if he survived. Their baby would have to be institutionalized, Jones declared. He would be better off dead. (Weeks says she doesn’t have any recollection of Jones.)
The next day — again under Jones’ care — Joshua Sawyer died at 9:22 p.m. The baby’s downward spiral had surprised his doctors. Joshua had suffered two arrests during the 3-11 p.m. shift. His heart had begun contracting erratically at 7:55 p.m.; electrical shock and drugs had brought it back to a normal rhythm by 8:20 p.m. Thirty minutes later, his blood pressure started to drop, and then his heart failed a final time.
During the brief period between the two arrests, doctors had sent a blood sample down to the lab to check the level of Dilantin in his body; Joshua’s last scheduled dose of the drug had been 11 hours earlier. The test result was not completed before the baby’s demise, and in the chaotic aftermath — coming too late to make a difference, with parents to inform and paperwork to finish — the lab study was ignored. But it told a troubling story.
Joshua’s sample had gone to the hospital’s third-floor pathology lab, where a technician took the test tube of blood and fed it into a large, complex machine called an Automated Chemical Analyzer. The normal range for Dilantin was between 10 and 20. But the number that registered was more than double that — 55.5, bumping the equipment’s upper limit the way boiling water would overheat a body thermometer. To get a precise reading, the technician carefully diluted the sample’s concentration by half, recalibrated for the dilution and ran it through again. This time, the Automated Chemical Analyzer showed 59.6 — a toxic level of Dilantin, more than enough to throw a baby’s heart into cardiac arrest. The technician entered the result into the hospital’s computer, which printed it out for Joshua’s bulky medical chart, where the evidence would go unnoticed for more than a year.
In the weeks after Joshua’s death, officials at the county hospital and its affiliated University of Texas medical school had begun taking suspicions of “purposeful nursing misadventure” (as the pediatrics department chairman put it) seriously. They convened high-level meetings, prepared internal memos, conferred with their outside lawyer and brought in an expert review committee to quietly investigate. They’d explicitly identified Jones as the central problem.
But in the midst of an image makeover for the old charity hospital — it was being renamed Medical Center Hospital — they were unwilling to alert the authorities, fearing bad publicity and lawsuits. So instead of simply firing Jones outright, they replaced all seven LVNs in the ICU in March 1982, under the cover of upgrading the unit to an all-RN staff. While they privately celebrated Jones’ departure, hospital officials presented her with a warm letter of recommendation, calling her “loyal, dependable, and trustworthy” and “an asset to the Bexar County Hospital District.” The letter added: “This move in no way reflects on her performance in the unit.”
With Jones finally gone, the pattern of unexpected emergencies and deaths in the San Antonio hospital immediately stopped. But it wasn’t the end of the problem.
Five months later, Jones began work in Kerrville, a small town 60 miles to the northwest, at the new pediatric clinic of Dr. Kathleen Holland. Holland had trained at the Bexar County hospital but was dismissive of the rumblings about Jones — and reassured by her letter of recommendation.
Over a period of 31 days starting in late August, six different children arriving at Holland’s clinic with routine problems suddenly stopped breathing and were rushed to Sid Peterson Hospital in Kerrville. One of them — a blue-eyed 15-month-old girl named Chelsea Ann McClellan — died on Sept. 17. Chelsea had gone into respiratory arrest after Jones gave her what were supposed to be routine baby shots. Tests later confirmed she’d been injected with succinylcholine, a powerful muscle relaxant.
This bizarre outbreak prompted local doctors to confront Holland and report their suspicions to the Texas Rangers, triggering parallel criminal investigations in Kerrville and San Antonio. Sam Millsap, the newly elected Bexar County DA, soon leaked the story to a local TV reporter, leading to a front-page headline in The New York Times: TEXAS INQUIRY ON 47 BABY DEATHS.
Under public suspicion, Jones remained defiant. “I’m sick and tired of being crucified alive and having people think I’m a baby killer,” she told me in May 1983, three weeks before her indictment. “I haven’t killed a damn soul.” In February 1984, after being tried and convicted for Chelsea McClellan’s murder, Jones received a 99-year sentence.
Months later, Millsap won the only case brought against Jones in San Antonio, for injury to a child, a one-month-old baby named Rolando Santos. Santos had nearly died after receiving repeated overdoses of the blood-thinner heparin under Jones’ care — even when he wasn’t supposed to be getting any heparin. A doctor had halted his final massive bleeding episode with an emergency injection of protamine sulfate, a drug that reverses the effects of heparin. Jones was sentenced to 60 years, to run concurrently with her murder sentence.
As the end of the 20-month probe neared, Millsap’s criminal investigators, led by a relentless Army vet named Art Brogley, pushed hard for more indictments. They’d recommended charging seven top hospital and medical school administrators for failing to stop Jones — if they’d alerted criminal authorities promptly, the investigators noted, Jones never would have harmed so many children. Instead, the San Antonio officials had volunteered nothing — even after learning about the nurse’s rampage in Kerrville — following instructions to maintain a “judicious silence.” (Medical school and hospital officials later acknowledged they were fearful of civil lawsuits and reluctant to call authorities without proof of wrongdoing.)
Brogley had also pressed for murder indictments against Jones, whose San Antonio victims, mostly Hispanic, were poor and powerless. If it had been the mayor’s kids, he angrily told his bosses, they’d pursue it to the bitter end.
Among the potential murder cases the investigators scrutinized, Brogley viewed the death of Joshua Sawyer as his best prospect. He prepared a separate 23-page report on the case, backed by 46 exhibits and 30 witness statements. The toxicologist for the Bexar County medical examiner’s office told him Joshua’s death resulted from a massive Dilantin overdose.
But this particular crime scene presented major obstacles to a murder conviction. No one had actually seen Jones give Joshua the drug. Many people were in and out of his room. And as Dr. Arthur McFee, a surgeon who chaired the ICU’s oversight committee, reasoned, explaining the hospital’s dismissiveness about possible criminal acts: “If they’re sick enough to be in the pediatric ICU, they’re fucking sick enough to die.”
After securing the resignations of key medical administrators, Millsap was ready to call it quits. “There will be no additional indictments of Genene Jones,” he announced in October 1984. “No useful purpose will be served. I think she will spend the rest of her life in jail.”
It was nearly three decades later that relatives of Genene Jones’ victims began to realize she might someday walk free. Under a 1977 Texas law that was changed in 1996 (but not applied retroactively), Jones has received credit for about two days of “good time” for every day she’s been behind bars. That set her mandatory parole date at March 1, 2018, after imprisonment in Gatesville, Texas, for 34 years and eight months.
(During my most recent contact with Jones — a 1987 prison interview for my book — she appeared less angry, citing newfound religious beliefs, but was no less adamant about her innocence. She doesn’t appear to have granted a media interview since.)
In 2013, family members formed a Facebook support group called “Victims of Genene Anne Jones,” and began pressing the Bexar County DA’s office to bring a new murder charge against her. (There is no statute of limitations on murder.) Andy Kahan, the crime-victims advocate for the city of Houston, coordinated an informal media campaign. A grown-up Rolando Santos made a TV appearance to oppose Jones’ release, displaying a needle scar from the ICU bleeding episodes that had nearly claimed his life back in 1982.
The group’s most passionate advocate was Chelsea McClellan’s mom. A secretary at the time of her daughter’s death, Petti McClellan had become a nurse two years later. She spoke of her fear that Jones would get out and kill again. “This is my mission now,” she said in 2013. “Losing a child does not consume you; it drives you.”
Winning a new murder conviction was a formidable challenge. The evidence in the hospital deaths, involving seriously ill children, had always been circumstantial; with the passage of time, witnesses had died, memories had faded and records had disappeared. The county hospital even had a new name: It was now called University Hospital.
After four-term DA Susan Reed invited tips from the public, generating hundreds of calls, the Jones case became the personal project of investigator Larry DeHaven, a dogged former San Antonio cop. “I’ve been wanting to get her for a long time,” says DeHaven, now 70 and a year from retirement. “To me, I don’t really believe in coincidences. For her to be in one spot, and all those babies die, and when she leaves, the deaths drastically reduce? That’s too much. You’ve got one common denominator, and that’s Genene Jones.”
DeHaven retrieved files from the widow of Art Brogley, who had died in 2012 but stashed materials from his 1980s investigation — including a seven-foot color-coded chart of suspected victims — in his garage. He perused what could be found in storage. But most of the medical records from the 1980s were missing — from the DA’s files and the county hospital. A difficult prosecution now looked hopeless.
After LaHood, a former criminal defense attorney, ousted Reed in November 2014, DeHaven was assigned to a new court, overseen by an aggressive assistant DA named Jason Goss. Over lunch in the summer of 2015, DeHaven bent his ear about the Jones case.
Goss, now 36, had never even heard of Genene Jones; he was six months old when Joshua Sawyer died. But the story DeHaven told — and the prospect of Jones’ release — shocked him. In December 2016, Goss decided to take on the mission of trying to keep her from getting out, and won LaHood’s blessing. But he had to do all the work after hours; Goss was the lead prosecutor in a busy criminal court. (His most recent trial pits a gunman named “Fat Boy” against a wheelchair-bound man under investigation for ordering torture and capital murder.)
An earnest native of Bryan, Texas, Goss dips snuff and wears Caiman boots. After having 20 boxes of Jones files — and Brogley’s giant chart — moved into an unmarked windowless office, Goss began spending his evenings at work, poring through decades-old records and searching for a winnable case. “I did Genene at night,” he says. DeHaven was no longer operating solo.
A breakthrough came from Connie Weeks, now 56 and employed at a bank, who revealed that she’d saved her son’s three-inch-thick medical record for 30 years. “It’s all I had left of Joshua,” she says. “Everything else was destroyed in the fire.” The Sawyer case moved to the top of the list. Goss and DeHaven began tracking down witnesses, including the lab technician who ran the test revealing the baby’s massive Dilantin overdose; he’s now a suburban San Antonio dentist.
In late April, Goss took his case for bringing a new murder charge to LaHood, making his argument with a two-hour PowerPoint presentation. LaHood signed off, and says he hopes to seek more murder indictments against Jones in future months. “I don’t want her stepping out onto free soil,” says the DA. “My goal is not to leave one baby behind. In a perfect world, we believe she’d be held accountable for every baby we believe she stole from their families.”
Today’s action is proof that prosecutors can quickly win a grand jury indictment in even the most complex matter. Goss says he presented all his evidence in a single day, starting with the PowerPoint presentation that persuaded his boss. He brought in just a handful of witnesses, including Connie Weeks, Joshua Sawyer’s mother, and Petti McClellan, who watched Jones inject Chelsea with a muscle-paralyzing drug.
Goss says he expects the Sawyer case will take up to two years to get to trial, but expects today’s indictment to produce a bond high enough to keep Jones behind bars until then.
Winning a conviction in a case judged too tough to bring back in 1984 won’t be easy. But Goss believes he’ll benefit from changes in the Texas rules of evidence, providing freer rein to introduce related acts — including previous offenses — to prove the identity, motive, methods and intent of the perpetrator. “It’s not necessarily that we need a needle in her hand. It’s that we can show this is how she is, how she does her crimes, this is her M.O.”
“It’s difficult,” says Goss. “The documents are old. There’s no smoking gun. There’s no confession. If it’s not a Hail Mary, it’s fourth and 15, so you’ve got to really draw up the right play. If you do it right, this case will be won. We feel like we can go all the way. Everybody wanted to make this baby killer accountable.”
Jones’ defense will surely dispute that notion. Convery, the president of the Texas Criminal Defense Lawyers Association, says he believes prosecuting a 35-year-old murder would violate Jones’ rights to due process and a speedy trial; availability of witnesses and chain-of-custody issues involving documents may pose “serious evidentiary problems.” (A defense lawyer could raise this issue about Joshua Sawyer’s medical records.) Any such prosecution would be “an extraordinary event,” Convery noted. “To think you can just dust the case off and throw it up there is wishful thinking. Cases don’t get better over time; they get worse.”
But prosecutors and parents fear Jones’ release would pose a threat to a new generation of children. “I feel like she’s been waiting 30 years to get that Code-Blue feeling again,” says Goss. “I don’t think it’s ever gone away. That’s dangerous. The only control we have is to do this.”
For her part, Connie Weeks says she is “scared and nervous,” as prosecutors finally seek to convict Jones of killing her son. But she has no doubt about her goal: “I want her to stay in prison. I want her to die in there.”
The death of a neonatal nurse in the hospital where she worked illustrates a profound disparity: The healthcare system focuses on babies but often ignores their mothers.
This article by Nina Martin, ProPublica, and Renee Montagne, NPR, originally appeared on ProPublica on May 12, 2017.
As a neonatal intensive care nurse, Lauren Bloomstein had been taking care of other people’s babies for years. Finally, at 33, she was expecting one of her own. The prospect of becoming a mother made her giddy, her husband Larry recalled recently — “the happiest and most alive I’d ever seen her.” When Lauren was 13, her own mother had died of a massive heart attack. Lauren had lived with her older brother for a while, then with a neighbor in Hazlet, New Jersey, who was like a surrogate mom, but in important ways she’d grown up mostly alone. The chance to create her own family, to be the mother she didn’t have, touched a place deep inside her. “All she wanted to do was be loved,” said Frankie Hedges, who took Lauren in as a teenager and thought of her as her daughter. “I think everybody loved her, but nobody loved her the way she wanted to be loved.”
Other than some nausea in her first trimester, the pregnancy went smoothly. Lauren was “tired in the beginning, achy in the end,” said Jackie Ennis, her best friend since high school, who talked to her at least once a day. “She gained what she’s supposed to. She looked great, she felt good, she worked as much as she could” — at least three 12-hour shifts a week until late into her ninth month. Larry, a doctor, helped monitor her blood pressure at home, and all was normal.
On her days off she got organized, picking out strollers and car seats, stocking up on diapers and onesies. After one last pre-baby vacation to the Caribbean, she and Larry went hunting for their forever home, settling on a brick colonial with black shutters and a big yard in Moorestown, not far from his new job as an orthopedic trauma surgeon in Camden. Lauren wanted the baby’s gender to be a surprise, so when she set up the nursery she left the walls unpainted — she figured she’d have plenty of time to choose colors later. Despite all she knew about what could go wrong, she seemed untroubled by the normal expectant-mom anxieties. Her only real worry was going into labor prematurely. “You have to stay in there at least until 32 weeks,” she would tell her belly. “I see how the babies do before 32. Just don’t come out too soon.”
When she reached 39 weeks and six days — Friday, Sept. 30, 2011 — Larry and Lauren drove to Monmouth Medical Center in Long Branch, the hospital where the two of them had met in 2004 and where she’d spent virtually her entire career. If anyone would watch out for her and her baby, Lauren figured, it would be the doctors and nurses she worked with on a daily basis. She was especially fond of her obstetrician-gynecologist, who had trained as a resident at Monmouth at the same time as Larry. Lauren wasn’t having contractions, but she and the OB-GYN agreed to schedule an induction of labor — he was on call that weekend and would be sure to handle the delivery himself.
Inductions often go slowly, and Lauren’s labor stretched well into the next day. Ennis talked to her on the phone several times: “She said she was feeling okay, she was just really uncomfortable.” At one point, Lauren was overcome by a sudden, sharp pain in her back near her kidneys or liver, but the nurses bumped up her epidural and the stabbing stopped.
Inductions have been associated with higher cesarean-section rates, but Lauren progressed well enough to deliver vaginally. On Saturday, Oct. 1, at 6:49 p.m., 23 hours after she checked into the hospital, Hailey Anne Bloomstein was born, weighing 5 pounds, 12 ounces. Larry and Lauren’s family had been camped out in the waiting room; now they swarmed into the delivery area to ooh and aah, marveling at how Lauren seemed to glow.
Larry floated around on his own cloud of euphoria, phone camera in hand. In one 35-second video, Lauren holds their daughter on her chest, stroking her cheek with a practiced touch. Hailey is bundled in hospital-issued pastels and flannel, unusually alert for a newborn; she studies her mother’s face as if trying to make sense of a mystery that will never be solved. The delivery room staff bustles in the background in the low-key way of people who believe everything has gone exactly as it’s supposed to.
Then Lauren looks directly at the camera, her eyes brimming.
Twenty hours later, she was dead.
In the U.S., unlike some other developed countries, maternal deaths are treated as a private tragedy rather than as a public health catastrophe. A death in childbirth may be mourned on Facebook or memorialized on GoFundMe, but it is rarely reported in the news. Most obituaries, Lauren’s included, don’t mention how a mother died.
Lauren’s passing was more public than most, eliciting an outpouring of grief. Hundreds of people attended her wake and funeral — doctors and nurses from the hospital, friends from around the country, families Lauren had taken care of. Vaclavik was there, utterly devastated, Larry’s family said. The head of Monmouth’s OB-GYN department paid his respects and, according to Larry, promised in a private conversation at the wake to conduct a full investigation.
In the days after Lauren’s death, Larry couldn’t dwell on the implications of what had happened. He had to find a burial plot, choose a casket, write a eulogy. He was too shattered to return to the Mooresville house, so he took Hailey to his parents’ place, a one-bedroom apartment they were renting while they renovated their home, and slept with the baby in the living room for the first month.
After the funeral, he turned all his attention to his daughter. He knew nothing about newborns, always imagining Lauren would teach him — “What could be better than having your own NICU nurse to take care of your baby?” he had thought. He relied on his mother and sister and Lauren’s friends to guide him. He took time off from his job at Cooper, figuring three months would be enough. But as his return date approached, he knew he wasn’t ready. “I don’t think I can see a patient that’s on a ventilator right now,” he realized. “Or even just a hospital bed.” He didn’t want to leave Hailey. So he quit.
He sold the house, though he couldn’t bring himself to attend the closing — “I couldn’t stand handing those keys over to someone else.” He took Hailey a couple of times to stay with his sister and her family in Texas, where he didn’t have to answer the constant questions. But traveling with his baby daughter was painful in its own way. People didn’t know what to make of him. “It’s strange for people to see a father alone.” Wherever he went, he felt disconnected from almost everything around him. “You’re walking around this world and all these people are around you, and they’re going on with their lives and I just felt very, very isolated and very alone with that.”
Back in New Jersey, Larry found a job closer to his parents’ place, performed one operation and tried to quit. His new employers, though, persuaded him to stay. To avoid reliving the funeral, he returned to Texas for the first anniversary of Hailey’s birth and Lauren’s death in late September 2012. In one of his suitcases, he packed a giant cupcake mold Lauren had bought when they first married — she thought it would make a perfect first-birthday cake for the kids she yearned for. He baked the cake himself — chocolate, Lauren’s favorite, covered with sprinkles.
Other people in Lauren’s and Larry’s circle had been asking questions about her care since the night she died. “That was the first thing I literally said when I walked [into the hospital] — I said, ‘How did this happen?’” Jackie Ennis recalled. In the next week or two, she probed Larry again: “‘Did they do everything they could for her?’ He said, ‘No, there were warning signs for hours before.’” Ennis was too upset to dig any deeper.
As Larry’s numbness wore off, his orthopedist friends began pushing him as well. Larry was hesitant; despite the missteps he had witnessed, part of him wanted to believe that Lauren’s death had been unavoidable. “And my friends were like, ‘We can’t accept that. … With our technology, every single time a woman dies [in childbirth], it’s a medical error.’”
Lauren’s death, Larry finally admitted to himself, could not be dismissed as either inevitable or a fluke. He had seen how Lauren’s OB-GYN and nurses had failed to recognize a textbook case of one of the most common complications of pregnancy — not once, but repeatedly over two days. To Larry, the fact that someone with Lauren’s advantages could die so needlessly was symptomatic of a bigger problem. By some measures, New Jersey had one of the highest maternal mortality rates in the U.S. He wanted authorities to get to the root of it — to push the people and institutions that were at fault to change.
That’s the approach in the United Kingdom, where maternal deaths are regarded as systems failures. A national committee of experts scrutinizes every death of a woman from pregnancy or childbirth complications, collecting medical records and assessments from caregivers, conducting rigorous analyses of the data and publishing reports that help set policy for hospitals throughout the country. Coroners also sometimes hold public inquests, forcing hospitals and their staffs to answer for their mistakes. The U.K. process is largely responsible for the stunning reduction in preeclampsia deaths in Britain, the committee noted its 2016 report — “a clear success story” that it hoped to repeat “across other medical and mental health causes of maternal death.”
The U.S. has no comparable federal effort. Instead, maternal mortality reviews are left up to states. As of this spring, 26 states (and one city, Philadelphia) had a well-established process in place; another five states had committees that were less than a year old. In almost every case, resources are tight, the reviews take years and the findings get little attention. A bipartisan bill in Congress, the Preventing Maternal Deaths Act of 2017, would authorize funding for states to establish review panels or improve their processes.
New Jersey’s review team, the second-oldest in the U.S., includes OB-GYNs, nurses, mental health specialists, medical examiners, even a nutritionist. Using vital records and other reports, they identify every woman in New Jersey who died within a year of pregnancy or childbirth, from any cause, then review medical and other records to determine whether the death was “pregnancy-related” or not. Every few years, the committee publishes a report, focusing on things like the race and age of the mothers who died, the causes of death, and other demographic and health data. In the past, the findings have been used to promote policies to reduce postpartum depression.
But the New Jersey committee doesn’t interview the relatives of the deceased, nor does it assess whether a death was preventable. Moreover, like every other state that conducts such reviews, New Jersey “de-identifies” the records — strips them of any information that might point to an individual hospital or a particular woman. Otherwise, the medical community and lawmakers would refuse to go along. The goal is to “improve care for patients in general,” said Joseph Apuzzio, a professor of obstetrics and gynecology at Rutgers-New Jersey Medical School who heads the committee. This requires a process that is “nonjudgmental” and “not punitive,” he said. “That’s the best way to get a free discussion of all of the health care providers who are in the room.”
Yet the result of de-identification, as Larry soon realized, is that the review is of little use in assigning responsibility for individual deaths, or evaluating whether some hospitals, doctors or nurses are more prone to error than others. To Larry, this seemed like a critical oversight — or perhaps, willful denial. In a preventable death or other medical error, he said, sometimes the who and the where are as important as the why. “Unless someone points the finger specifically,” he said, “I think the actual cause [of the problem] is lost.”
Someone eventually steered Larry toward the New Jersey Department of Health’s licensing and inspection division, which oversees hospital and nursing home safety. He filed a complaint against Monmouth Medical Center in 2012.
The DOH examined Lauren’s records, interviewed her caregivers and scrutinized Monmouth’s policies and practices. In December 2012 it issued a report that backed up everything Larry had seen firsthand. “There is no record in the medical record that the Registered Nurse notified [the ob/gyn] of the elevated blood pressures of patient prior to delivery,” investigators found. And: “There is no evidence in the medical record of further evaluation and surveillance of patient from [the ob/gyn] prior to delivery.” And: “There was no evidence in the medical record that the elevated blood pressures were addressed by [the ob/gyn] until after the Code Stroke was called.”
The report faulted the hospital. “The facility is not in compliance” with New Jersey hospital licensing standards, it concluded. “The facility failed to ensure that recommended obstetrics guidelines are adhered to by staff.”
To address these criticisms, Monmouth Medical Center had implemented a plan of correction, also contained in the report. The plan called for a mandatory educational program for all labor and delivery nurses about preeclampsia and HELLP syndrome; staff training in Advance Life Support Obstetrics and Critical Care Obstetrics; and more training on the use of evidence-based methods to assess patients and improve communications between caregivers.
Some of the changes were strikingly basic: “Staff nurses were educated regarding the necessity of reviewing, when available, or obtaining the patients [sic] prenatal records. Education identified that they must make a comparison of the prenatal blood pressure against the initial admission blood pressure.” And: “Repeat vital signs will be obtained every 4 hours at a minimum.”
An important part of the plan of correction involved Vaclavik, though neither he nor the nurses were identified by name. The head of Monmouth’s OB-GYN department provided “professional remediation for the identified physician,” the Department of Health report said. In addition, there was “monitoring of 100% of records for physician of record per month x 3 months.” The monitoring focused on “compliance of timely physician intervention for elevated blood pressures/pain assessment and management.”
The department chairman, Robert Graebe, found Vaclavik’s charts to be 100 percent compliant, Vaclavik said in the deposition. Graebe was asked in a March 2017 deposition if Vaclavik was in good standing at the hospital at the time of Lauren’s treatment. “Was and is,” Graebe replied.
In a separate note, the Department of Health told Larry that it forwarded his complaint to the Board of Medical Examiners and the New Jersey Board of Nursing. Neither agency has taken disciplinary action, according to their websites.
Larry’s copy of the DOH report arrived in the mail. He was gratified by the findings but dismayed that they weren’t publicly posted. That meant hardly anyone would see them.
A few months after the DOH weighed in, he sued Monmouth, Vaclavik and five nurses in Monmouth County Superior Court in Freehold, New Jersey. For a medical malpractice lawsuit to go forward in New Jersey, an expert must certify that it has merit. Larry’s passed muster with an OB-GYN. But beyond the taking of depositions, there’s been little action in the case.
As the maternal death rate has mounted around the U.S., a small cadre of reformers has mobilized. Some of the earliest and most important work has come in California, where more babies are born than in any other state — 500,000 a year, one-eighth of the U.S. total.
Modeled on the U.K. process, the California Maternal Quality Care Collaborative is informed by the experiences of founder Elliott Main, a professor of obstetrics and gynecology at Stanford and the University of California-San Francisco, who for many years ran the OB-GYN department at a San Francisco hospital. “One of my saddest moments as an obstetrician was a woman with severe preeclampsia that we thought we had done everything correct, who still had a major stroke and we could not save her,” he said recently. That loss has weighed on him for 20 years. “When you’ve had a maternal death, you remember it for the rest of your life. All the details.”
Launched a decade ago, CMQCC aims to reduce not only mortality, but also life-threatening complications and racial disparities in obstetric care. It began by analyzing maternal deaths in the state over several years; in almost every case, it discovered, there was “at least some chance to alter the outcome.” The most preventable deaths were from hemorrhage (70 percent) and preeclampsia (60 percent).
Main and his colleagues then began creating a series of “toolkits” to help doctors and nurses improve their handling of emergencies. The first one, targeting obstetric bleeding, recommended things like “hemorrhage carts” for storing medications and supplies, crisis protocols for massive transfusions, and regular training and drills. Instead of the common practice of “eye-balling” blood loss, which often leads to underestimating the seriousness of a hemorrhage and delaying treatment, nurses learned to collect and weigh postpartum blood to get precise measurements. Hospitals that adopted the toolkit saw a 21 percent decrease in near deaths from maternal bleeding in the first year; hospitals that didn’t use the protocol had a 1.2 percent reduction. By 2013, according to Main, maternal deaths in California fell to around 7 per 100,000 births, similar to the numbers in Canada, France and the Netherlands — a dramatic counter to the trends in other parts of the U.S.
“Prevention isn’t a magic pill,” Main said. “It’s actually teamwork [and having] a structured, organized, standardized approach” to care.
CMQCC’s preeclampsia toolkit, launched in 2014, emphasized the kind of practices that might have saved Lauren Bloomstein: careful monitoring of blood pressure and early and aggressive treatment with magnesium sulfate and anti-hypertensive medications. Data on its effectiveness hasn’t been published.
The collaborative’s work has inspired ACOG and advocates in a few states to create their own initiatives. Much of the funding has come from a 10-year, $500 million maternal health initiative by Merck, the pharmaceutical giant. Originally intended to focus on less developed countries, Merck for Mothers decided it couldn’t ignore the growing problem in the U.S. The U.S. maternal mortality rate is “unacceptable,” said Executive Director Mary-Ann Etiebet. Making pregnancy and childbirth safer “will not only save women’s lives but will improve and strengthen our health systems … for all.”
But the really hard work is only beginning. According to the Institute of Medicine, it takes an average of 17 years for a new medical protocol to be widely adopted. Even in California, half of the 250 hospitals that deliver babies still aren’t using the toolkits, said Main, who largely blames inertia.
In New York state, some hospitals have questioned the need for what they call “cookbook medicine,” said Columbia’s Mary D’Alton. Her response: “Variability is the enemy of safety. Rather than have 10 different approaches to obstetric hemorrhage or treatment of hypertension, choose one or two and make it consistent. … When we do things in a standardized way, we have better outcomes.”
One big hurdle: training. Another: money. Smaller providers, in particular, may not see the point. “It’s very hard to get a hospital to provide resources to change something that they don’t see as a problem,” ACOG’s Barbara Levy said. “If they haven’t had a maternal death because they only deliver 500 babies a year, how many years is it going to be before they see a severe problem? It may be 10 years.”
In New Jersey, providers don’t need as much convincing, thanks to a recent project to reduce postpartum blood loss led by the Association of Women’s Health, Obstetric and Neonatal Nurses. A number of hospitals saw improvements; at one, the average length of a hemorrhage-related ICU stay plunged from 8 days to 1.5 days. But only 31 of the state’s 52 birthing hospitals participated in the effort, in part — perhaps — because nurses led it, said Robyn D’Oria, executive director of the Central Jersey Family Health Consortium and a member of the state’s maternal mortality committee. “I remember having a conversation with [someone from] a hospital that I would describe as progressive and she said to me, ‘I cannot get past some of the physicians not wanting to buy into this.’”
So New Jersey hospitals are about to try again, this time adopting mini-toolkits created by the ACOG-led Alliance for Innovation on Maternal Health for hemorrhage and preeclampsia. “We’re at the very beginning” of a rollout that is likely to take at least two years, D’Oria said. Among those helping to create momentum has been Ryan Hansen, the husband of the teacher who died at Monmouth Medical Center a few months before Lauren Bloomstein.
Still, as hospitals begin to revamp, mothers in the state continue to perish. One was Ashley Heaney Butler. A Rutgers University graduate, she lived in Bayville, where she decorated the walls of her house with anchors, reflecting her passion for the ocean. She worked for the state Division of Vocational Rehabilitation Services as a counselor, and served as president of the New Jersey Rehabilitation Association. Her husband Joseph was a firefighter. She gave birth at Monmouth last September to a healthy boy and died a couple of weeks later at the age of 31, never leaving the hospital. It turned out that she had developed an infection late in her pregnancy, possibly related to a prior gastric bypass surgery. She was under the care of several doctors, including Vaclavik.
The death of a new mother is not like any other sudden death. It blasts a hole in the universe. “When you take that one death and what that does, not only to the husband, but to the family and to the community, the impact that it has in the hospital, on the staff, on everybody that’s cared for her, on all the people who knew them, it has ripple effects for generations to come,” Robyn D’Oria said.
Jackie Ennis felt Lauren’s loss as an absence of phone calls. She and Lauren had been closer than many sisters, talking several times a day. Sometimes Lauren called just to say she was really tired and would talk later; she’d even called Ennis from Hawaii on her honeymoon. The night Lauren died, Ennis knew something was wrong because she hadn’t heard from her best friend. “It took me a really long time not to get the phone calls,” she said. “I still have trouble with that.”
During Lauren’s pregnancy, Frankie Hedges had thought of herself as Hailey’s other grandmother. She and Lauren had made a lot of plans. Lauren’s death meant the loss of their shared dreams for an entire extended family. “I just feel she didn’t get what she deserved,” Hedges said.
Vaclavik’s obstetric practice is “larger” than in 2011, and he continues to have admitting privileges at Monmouth and two other hospitals, he said in his deposition. “I will never forget” Lauren’s death, he said. “… I probably suffer some post-traumatic stress from this.”
Hailey is five years old, with Lauren’s brown hair and clear green eyes. She feels her mother’s presence everywhere, thanks to Larry and his new wife Carolyn, whom he married in 2014. They met when she was a surgical tech at one of the hospitals he worked at after Lauren died. Photos and drawings of Lauren occupy the mantle of their home in Holmdel, the bookcase in the dining room and the walls of the upstairs hallway. Larry and Carolyn and their other family members talk about Lauren freely, and even Larry’s younger daughter, 2-year-old Aria, calls her “Mommy Lauren.” On birthdays and holidays, Larry takes the girls to the cemetery. He designed the gravestone — his handprint and Lauren’s reaching away from each other, newborn Hailey’s linking them forever. Larry has done his best to keep Lauren’s extended family together — Ennis and Hedges and their families are included in every important celebration.
Larry still has the video of Lauren and Hailey on his phone. “By far the hardest thing for me to accept is [what happened] from Lauren’s perspective,” he said one recent evening, hitting the play button and seeing her alive once more. “I can’t, I literally can’t accept it. The amount of pain she must have experienced in that exact moment when she finally had this little girl. … I can accept the amount of pain I have been dealt,” he went on, watching Lauren stroke Hailey’s cheek. “But [her pain] is the one thing I just can’t accept. I can’t understand, I can’t fathom it.”
This story was originally published by ProPublica. It was co-published with NPR's Shots blog.
Doctors prescribed fewer brand-name drugs when teaching hospitals restricted access to pharmaceutical sales representatives, research shows.
When teaching hospitals put pharmaceutical sales representatives on a shorter leash, their doctors tended to order fewer promoted brand-name drugs and used more generic versions instead, astudy published today in the Journal of the American Medical Association shows.
The results were significant compared to doctors who did not work at hospitals that limited sales reps from freely walking their halls or providing meals or gifts, according to research by Ian Larkin, an assistant professor of strategy at the University of California, Los Angeles Anderson School of Management, and colleagues.
Conflicts of interest in medicine have been ubiquitous for many years, but a string of lawsuits, coupled with a crackdown by academic medical centers and public disclosure of industry payments, have brought renewed focus on how these relationships affect prescribing.
Today’s issue of JAMA is devoted to conflicts of interest in medicine and includes aviewpoint on what ProPublica has learned by publishing Dollars for Docs and a related tool calledPrescriber Checkup, which compares doctors to their peers based on how they prescribe drugs in Medicare.
The teaching hospital study focused on 19 centers in five states that restricted visits by drug reps in one or more ways: limiting access, limiting gifts or punishing those who broke the rules. Larkin’s team compared prescriptions by 2,126 doctors at those hospitals with 24,593 peers with similar characteristics who were not subject to the marketing limits. It examined more than 16 million prescriptions in total, using data from CVS Caremark, a large pharmacy benefit manager.
The researchers found significant changes in six of the eight drug classes studied and at nine of the 19 hospitals reviewed. The policies were put in place at different times from 2006 to 2011, but changes in prescribing started immediately and lasted for 12 to 36 months afterward.
Having a policy governing pharmaceutical marketing, known as “detailing,” was associated with a 1.67 percentage point decrease in market share for the average promoted drug. Before the policies, the average promoted drug had a market share of 19.3 percent. Those with tougher policies, including an enforcement component, appeared to have more significant results.
“These weren’t terribly onerous restrictions, yet at the same time, they changed prescribing in a way that has really significant cost implications,” Larkin said.
Among the centers that did not have statistically significant changes was Stanford University, one of the earliest adopters of restrictive policies. In 2010, ProPublica reported how Stanford was not enforcing its rules limiting the relationships between doctors and drug companies. It has tightened its oversight since. Stanford doctors prescribed fewer promoted drugs but not enough for the result to be significant.
“We were surprised that some of them [teaching hospitals] were not as significant as we expected them to be,” said Larkin, without singling out particular hospitals. “You can’t just put in a policy. You have to think about it carefully, think about the efforts that really matter and involve the [medical] community.”
The study had several limitations. First, it did not find that the policies caused the change in prescribing, only that there was an association between the two. Also, the study was observational, meaning that doctors were not randomly assigned to hospitals with and without policies. And the study took policies at their word, not looking at their implementation or follow through.
Dr. Howard Bauchner, JAMA’s editor in chief, said the study helps to crystalize the need to limit pharmaceutical company marketing in teaching hospitals “as a way of ensuring that there’s no influence, no inappropriate influence over prescribing.”
Bauchner said he isn’t bothered that the researchers only found significant results in fewer than half of the teaching hospitals studied. “Nothing is ever 100 percent effective,” he said. “To me that’s no different than a clinical trial. Not everyone benefits.”
Aneditorial that accompanied the research suggests that alternative approaches to educating doctors about drugs — besides relying on drug company promotion — need to be tested. “It has never been more important for physicians to come together to consider these alternatives, generate evidence about their effectiveness, and move the health care system toward solutions that lower costs for patients and minimize” conflicts of interest, wrote Colette DeJong and Dr. R. Adams Dudley of the University of California, San Francisco.
Every week in Des Moines, Iowa, the employees of a small nonprofit collect bins of unexpired prescription drugs tossed out by nursing homes after residents died, moved out or no longer needed them. The drugs are given to patients who couldn’t otherwise afford them.
But travel 1,000 miles east to Long Island, New York, and you’ll find nursing homes flushing similar leftover drugs down the toilet, alarming state environmental regulators worried they’ll further contaminate the water supply.
In Baltimore, Maryland, a massive incinerator burns up tons of the drugs each year — for a fee — from nursing homes across the Eastern seaboard.
If you want to know why the nation’s health care costs are among the highest in the world, a good place to start is with what we throw away. Across the country, nursing homes routinely toss large quantities of perfectly good prescription medication: tablets for diabetes, syringes of blood thinners, pricey pills for psychosis and seizures.
At a time when anger over soaring drug costs has perhaps never been more intense, redistributing discarded drugs seems like a no-brainer. Yet it’s estimated that American taxpayers, through Medicare, spend hundreds of millions of dollars each year on drugs for nursing home patients — much of which literally go down the tubes.
“It would not surprise me if as much as 20 percent of the medications we receive we end up having to destroy,” said Mark Coggins, who oversees the pharmacy services for Diversicare, a chain of more than 70 nursing homes in 10 states. “It’s very discouraging throwing away all those drugs when you know it can benefit somebody.”
No one tracks this waste nationwide, but estimates show it’s substantial. Colorado officials have said the state’s 220 long-term care facilities throw away a whopping 17.5 tons of potentially reusable drugs every year, with a price tag of about $10 million. The Environmental Protection Agency estimated in 2015 that about 740 tons of drugs are wasted by nursing homes each year.
This is, of course, part of a bigger problem. The National Academy of Medicine estimated in 2012 that the United States squanders more than a quarter of what it spends on health care — about $765 billion a year.
ProPublica is investigating the types of waste in health care that academics and politicians typically overlook. Our first installment examined the tens of millions worth of equipment and brand new supplies that hospitals jettison.
Today we look at the wasteful, and potentially harmful, ways nursing homes dispose of leftover meds — and how some states, like Iowa, have found a solution.
On a recent Wednesday in Des Moines, Ami Bradwell, a certified pharmacy technician, popped open the lids of several 31-gallon bins full of prescription drugs. In each were hundreds of what are known as “bingo cards” filled with rows of pills in sealed bubbles.
Experts say incineration is the least environmentally objectionable end-of-life option for unused drugs. But it’s also the most expensive destruction method — from 50 cents to a dollar per pound, paid for by the facilities themselves—which is why many nursing homes resort to flushing.
Nursing homes save the disposal fees in Iowa, because they can donate them to SafeNetRx, where they benefit needy patients like Max Armstrong.
The 82-year-old suffers from multiple chronic conditions — emphysema, congestive heart failure and more. The ailments were manageable until 2015, when he suffered blood clots in his leg and lung. Doctors put him on the generic blood thinner warfarin, but it “almost killed me,” he said, so he switched to Xarelto, a newer brand name drug that costs about $700 a month.
The total tab for the Xarelto and the other 14 medications Armstrong must take each month would cost at least $1,200, according to his daughter. Armstrong, whose savings took a hit during the financial crisis, lives on $1,158 a month in Social Security.
It’s “stupid” to throw away drugs that can keep so many other people healthy, Armstrong said. “There’s a lot of people out there in this world who need help.”
The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during hospital inspections.
This story was published on ProPublica on April 18, 2017. It was co-published with NPR’s Shots blog.
The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation’s hospitals that put patients’ health and safety at risk, under a groundbreaking proposal from federal health officials.
The Centers for Medicare and Medicaid Services wants to require that private health care 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 those accreditors, not the government.
There’s increasing concern among regulators that private accreditors aren’t picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.
In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity “raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies” during inspections, CMS officials wrote when they releaseddraft regulations including the proposed change on Friday.
The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool,Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.
Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.
But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS’ proposed rules are designed to fix this.
“We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements” publicly available, CMS officials wrote.
“It’s huge, absolutely,” says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. “Right now the public has very little information about the places where they’re putting their life on the line, and that’s just not acceptable. If you’re a good place, what are they afraid of?”
Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.
To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn’t fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.
State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commissionconducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise. 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 4,018 hospitals listed on the The Joint Commission’s website, more than 99 percent have full accreditation and only seven are on track to lose their “gold seal of approval.”
The Joint Commission said it is reviewing the CMS proposal and couldn’t comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. “We haven’t talked to our hospital partners,” says Gary Ley, its executive director. “It would be a major change for them also. It’s hard not to support the goals but we have to look at the execution.”
For its part, the American Hospital Association said it supports providing the public “useful information” about hospital quality, but has doubts that detailed inspection reports fit that description.
“It’s important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,” says Nancy Foster, AHA’s vice president of quality and patient safety, in a statement. “We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.”
Foster says it might be more useful to provide a one- or two-page “accurate summary” of inspection findings, with “key takeaways” and why they are important. “This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,” Foster says.
For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, theChicago Tribune reported how The Joint Commission gave its seal of approval to “medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.”
Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a "Top Performer in Key Quality Measures" by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it “is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.”
In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it “is proud of the care it provides patients at Shadow Mountain Behavioral Health.”
On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, 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 disclosed.
Consumers Union’s Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. “The information that’s available now is so minimal and would not really inform anyone about real quality of a hospital,” she says.
Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.
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.
Have you complained about a hospital to The Joint Commission or another accrediting body? We’d like to hear from you. Email charles.ornstein@propublica.org.
Tom Price doesn't appear to have suffered a financial hit when he fulfilled his pledge to sell off some assets as the new head of the Department of Health and Human Services.
On one transaction alone, Price made a profit of more than $150,000 on shares he held in a tiny Australian biotech company, according to his financial disclosures.
His purchases of that stock, which came while he was serving in Congress, were the subject of particular scrutiny during his confirmation hearings in January.
He was one of a handful of U.S. investors allowed to buy discounted shares in Innate Immunotherapeutics, which was working on an experimental multiple sclerosis drug.
Price invested about $10,000 in 2015 and another $50,000 to $100,000 in the company last summer, records show. He appears to have sold all those shares on two days in February, reaping between $265,000 and $550,000, according to forms he filed last month with the federal Office of Government Ethics.
Filers are required to show only a range of the value of any sold or purchased stock, meaning that his overall profit could range from $154,983 to as much as $489,981.
The forms show Price also sold shares worth a total of tens of thousands of dollars in about three dozen other companies involved in businesses including healthcare, technology and airlines.
While he served in Congress, Price reported trading hundreds of thousands of dollars' worth of shares in health-related companies while he voted on and sponsored legislation affecting the industry. He testified at his HHS confirmation hearings that his trades were lawful and transparent.
Democrats accused him of potentially using his office to enrich himself. ProPublica previously reported that his trading is said to have been under investigation by federal prosecutors.
Price testified during his confirmation hearings that the discounted shares in Innate Immunotherapeutics "were available to every single individual that was an investor at the time."
But, as The Wall Street Journalreported, the discounted shares were only available to American investors by invitation. Price learned of the company from his friend Rep. Chris Collins, R-N.Y., a company director and its largest shareholder.
Collins told the Journal he invited Price to buy, and Price did so in two purchases, one at 18 cents a share and another at 26 cents a share during the summer of 2016. When Price sold off his investment, Innate was trading at around 90 cents.
Before he was confirmed, Price pledged to sell off his holdings.
Price did not respond to a request for an interview.
Price has said before that his trades while he was in Congress were promptly disclosed, as required by law. He has rejected allegations that he ran afoul of insider-trading rules or used his position as chair of the House Budget Committee to get information or opportunities not available to normal investors.
Last week, ProPublica reported that on the same day his stockbroker bought him up to $90,000 of stock in six pharmaceutical companies, Price arranged to call a top U.S. health official, seeking to scuttle a controversial rule that could have hurt the firms' profits and driven down their share prices.
While in Congress, HHS Secretary Tom Price acted to help kill a rule that would hurt drug company profits shortly after his broker bought him up to $90,000 worth of pharmaceutical stock.
This article first appeared March 31, 2017 onProPublica.
On the same day the stockbroker for then-Georgia Congressman Tom Price bought him up to $90,000 of stock in six pharmaceutical companies last year, Price arranged to call a top U.S. health official, seeking to scuttle a controversial rule that could have hurt the firms' profits and driven down their share prices, records obtained by ProPublica show.
Stock trades made by Price while he served in Congress came under scrutiny at his confirmation hearings to become President Trump's secretary of health and human services. The lawmaker, a physician, traded hundreds of thousands of dollars' worth of shares in health-related companies while he voted on and sponsored legislation affecting the industry, but Price has said his broker acted on his behalf without his involvement or knowledge. ProPublica previously reported that his trading is said to have been under investigation by federal prosecutors.
On March 17, 2016, Price's broker purchased shares worth between $1,000 and $15,000 each in Eli Lilly, Amgen, Bristol-Meyers Squibb, McKesson, Pfizer and Biogen. Previous reports have noted that, a month later, Price was among lawmakers from both parties who signed onto a bill that would have blocked a rule proposed by the Obama administration, which was intended to remove the incentive for doctors to prescribe expensive drugs that don't necessarily improve patient outcomes.
What hasn't been previously known is Price's personal appeal to the Centers for Medicare & Medicaid Services about the rule, called the Medicare Part B Drug Payment Model.
The same day as the stock trade, Price's legislative aide, Carla DiBlasio, emailed health officials to follow up on a request she had made to set up a call with Patrick Conway, the agency's chief medical officer. In her earlier emails, DiBlasio said the call would focus on payments for joint replacement procedures. But that day, she mentioned a new issue.
"Chairman Price may briefly bring up ... his concerns about the new Part B drug demo, as well," she wrote. "Congressman Price really appreciates the opportunity to have an open conversation with Dr. Conway, so we really appreciate you keeping the lines of communication open."
The call was scheduled for the following week, according to the emails.
An HHS spokesman didn't respond to a request for comment from Price. DiBlasio and Conway didn't respond to questions about the phone call.
The proposed rule drew wide opposition from members of both parties as well as industry lobbyists and some patient advocacy groups. It was meant to change a system under which the government reimburses doctors the average sales price for drugs administered in their offices or inside clinics, along with a 6 percent bonus. Some health analysts say that bonus encourages doctors to pad their profits by selecting more expensive treatments.
Critics argued that the rule might cause Medicare enrollees to lose access to lifesaving drugs. Lawmakers worried the federal government was potentially endangering patients and turning them into guinea pigs in a wide-scale experiment in cost savings.
However, supporters of the rule said the experiment in payments was the kind of drastic action needed to rein in soaring health costs. "We are actively reforming every other aspect of our health-care system to pay for value except pharmaceuticals," Rep. Jan Schakowsky, D-Ill., said at the time. "Drug manufacturers are the only entity that can charge Medicare anything they want."
The six companies that Price invested in were steadfastly opposed to the rule. McKesson formally warned investors in a Securities and Exchange Commission filing that such a change could hurt share prices. The firms lobbied the government to kill the plan.
And at two of the six companies Price invested in, people who used to work for the congressman were part of the lobbying effort.
Price's former chief of staff, Matt McGinley, lobbied House members for Amgen, disclosure records show. Another former Price aide, Keagan Lenihan, lobbied on behalf of McKesson, where she was director of government relations at the time. Lenihan has since reunited with Price, returning to government to work as a senior adviser to her old boss at HHS.
Neither McGinley nor Lenihan responded to requests for comment.
Although Price said he wasn't aware of his broker's trades at the time they were made, he would have learned of his holdings no later than April 2016 when he signed and filed his latest financial disclosure forms. In earlier disclosures, Price signed forms listing his other health-related holdings, which included some drug stocks.
Price's personal intervention raises more questions about the overlap between his investments and his work as a member of Congress.
According to House ethics guidelines, "contacting an executive branch agency" represents "a degree of advocacy above and beyond that involved in voting" on legislation where a financial conflict of interest may exist.
"Such actions may implicate the rules and standards ... that prohibit the use of one's official position for personal gain," the guidelines state. "Whenever a Member is considering taking any such action on a matter that may affect his or her personal financial interests, the Member should first contact the Standards Committee for guidance."
Tom Rust, chief counsel for the House Ethics Committee, declined to comment, saying any consultations with members of Congress are confidential.
In December, after Trump was elected and named Price as his choice to lead HHS, Obama administration health officials scrapped their plan to change the drug reimbursement system. "The complexity of the issues and the limited time available led to the decision not to finalize the rule at this time," a spokesman said.
This story was co-published with Kaiser Health News, Stat and Vox.
When Louisiana resident Andrea Mongler wrote to her senator, Bill Cassidy, in support of the Affordable Care Act, she wasn't surprised to get an email back detailing the law's faults. Cassidy, a Republican who is also a physician, has been a vocal critic.
"Obamacare" he wrote in January, "does not lower costs or improve quality, but rather it raises taxes and allows a presidentially handpicked 'Health Choices Commissioner' to determine what coverage and treatments are available to you."
There's one problem with Cassidy's ominous-sounding assertion: It's false.
The Affordable Care Act, commonly called Obamacare, includes no "Health Choices Commissioner." Another bill introduced in Congress in 2009 did include such a position, but the bill died — and besides, the job as outlined in that legislation didn't have the powers Cassidy ascribed to it.
As the debate to repeal the law heats up in Congress, constituents are flooding their representatives with notes of support or concern, and the lawmakers are responding, sometimes with form letters that are misleading. A review of more than 200 such letters by ProPublica and its partners at Kaiser Health News, Stat and Vox found dozens of errors and mischaracterizations about the ACA and its proposed replacement. The legislators have cited wrong statistics, conflated health care terms and made statements that don't stand up to verification.
It's not clear if this is intentional or if the lawmakers and their staffs don't understand the current law or the proposals to alter it. Either way, the issue of what is wrong — and right — about the current system has become critical as the House prepares to vote on the GOP's replacement bill Thursday.
"If you get something like that in writing from your U.S. senator, you should be able to just believe that," said Mongler, 34, a freelance writer and editor who is pursuing a master's degree in public health. "I hate that people are being fed falsehoods, and a lot of people are buying it and not questioning it. It's far beyond politics as usual."
Cassidy's staff did not respond to questions about his letter.
Political debates about complex policy issues are prone to hyperbole and health care is no exception. And to be sure, many of the assertions in the lawmakers' letters are at least partially based in fact.
Democrats, for instance, have been emphasizing to their constituents that millions of previously uninsured people now have medical coverage thanks to the law. They say insurance companies can no longer discriminate against millions of patients with pre-existing conditions. And they credit the law with allowing adults under age 26 to stay on their parents' health plans. All true.
For their part, Republicans criticize the law for not living up to its promises. They say former President Obama pledged that people could keep their health plans and doctors and premiums would go down. Neither has happened. They also say that insurers are dropping out of the market and that monthly premiums and deductibles (the amount people must pay before their coverage kicks in) have gone up. All true.
But elected officials in both parties have incorrectly cited statistics and left out important context. We decided to take a closer look after finding misleading statements in an email Sen. Roy Blunt, R-Mo., sent to his constituents. We solicited letters from the public and found a wealth of misinformation, from statements that were simply misleading to whoppers. More Republicans fudged than Democrats, though both had their moments.
An aide to Rep. Dana Rohrabacher, R-Calif., defended his hyperbole as "within the range of respected interpretations."
"Do most people pay that much attention to what their congressman says? Probably not," said Sherry Glied, dean of New York University's Robert F. Wagner Graduate School of Public Service, who served as an assistant Health and Human Services secretary from 2010 to 2012. "But I think misinformation or inaccurate information is a bad thing and not knowing what you're voting on is a really bad thing."
We reviewed the emails and letters sent by 51 senators and 134 members of the House within the past few months. Here are some of the most glaring errors and omissions:
Rep. Pat Tiberi, R-Ohio, incorrectly cited the number of Ohio counties that had only one insurer on the Affordable Care Act insurance exchange.
What he wrote: "In Ohio, almost one third of counties will have only one insurer participating in the exchange."
What's misleading: In fact, only 23 percent (less than one quarter) had only one option, according to an analysis by the Kaiser Family Foundation.
His response: A Tiberi spokesperson defended the statement. "The letter says 'almost' because only 9 more counties in Ohio need to start offering only 1 plan on the exchanges to be one third."
Why his response is misleading: Ohio has 88 counties. A 10 percent difference is not "almost."
Rep. Kevin Yoder, R-Kan., said that the quality of health care in the country has declined because of the ACA, offering no proof.
What he wrote: "Quality of care has decreased as doctors have been burdened with increased regulations on their profession."
Why it's misleading: Some data shows that health care has improved after the passage of the ACA. Patients are less likely to be readmitted to a hospital within 30 days after they have been discharged, for instance. Also, payments have been increasingly linked to patients' outcomes rather than just the quantity of services delivered. A 2016 report by the Commonwealth Fund, a health care nonprofit think tank, found that the quality care has improved in many communities following the ACA.
His response: None.
Rep. Anna Eshoo, D-Calif., misstated the percentage of Medicaid spending that covers the cost of long-term care, such as nursing home stays.
What she wrote: "It's important to note that 60 percent of Medicaid goes to long-term care and with the evisceration of it in the bill, this critical coverage is severely compromised."
What's misleading: Medicaid does not spend 60 percent of its budget on long-term care. The figure is closer to a quarter, according to the Center on Budget and Policy Priorities, a liberal think tank. Medicaid does, however, cover more than 60 percent of all nursing home residents.
Her response: Eshoo's office said the statistic was based on a subset of enrollees who are dually enrolled in Medicaid and Medicare. For this smaller group, 62 percent of Medicaid expenditures were for long-term support services, according to the Kaiser Family Foundation.
What's misleading about the response: Eshoo's letter makes no reference to this population, but instead refers to the 75 million Americans on Medicaid.
Rep. Chuck Fleischmann, R-Tenn., pointed to the number of uninsured Americans as a failure of the ACA, without noting that the law had dramatically reduced the number of uninsured.
What he wrote: "According to the U.S. Census Bureau, approximately thirty-three million Americans are still living without health care coverage and many more have coverage that does not adequately meet their health care needs."
Why it's misleading: The actual number of uninsured in 2015 was about 29 million, a drop of 4 million from the prior year, the Census Bureau reported in September. Fleischmann's number was from the previous year.
Beyond that, reducing the number of uninsured by more than 12 million people from 2013 to 2015 has been seen as a success of Obamacare. And the Republican repeal-and-replace bill is projected to increase the number of uninsured.
His response: None.
Rep. Joseph P. Kennedy III, D-Mass., overstated the number of young adults who were able to stay on their parents' health plan as a result of the law.
What he wrote: The ACA "allowed 6.1 million young adults to remain covered by their parents' insurance plans."
Kennedy may have gotten to 6.1 million by including 3.8 million young adults who gained health insurance coverage through insurance marketplaces from October 2013 through early 2016.
His response: A spokeswoman for Kennedy said the office had indeed added those two numbers together and would fix future letters.
Rep. Blaine Luetkemeyer, R-Mo., said that 75 percent of health insurance marketplaces run by states have failed. They have not.
What he said: "Nearly 75 percent of state-run exchanges have already collapsed, forcing more than 800,000 Americans to find new coverage."
What's misleading: When the ACA first launched, 16 states and the District of Columbia opted to set up their own exchanges for residents to purchase insurance, instead of using the federal marketplace, known as Healthcare.gov.
Of the 16, four state exchanges, in Oregon, Hawaii, New Mexico and Nevada, failed, and Kentucky plans to close its exchange this year, according to a report by the House Energy and Commerce Committee. While the report casts doubt on the viability of other state exchanges, it is clear that 3/4 have not failed.
His response: None.
Rep. Dana Rohrabacher, R-Calif., overstated that the ACA "distorted labor markets," prompting employers to shift workers from full-time jobs to part-time jobs.
What he said: "It has also, through the requirement that employees that work thirty hours or more be considered full time and thus be offered health insurance by their employer, distorted the labor market."
What's misleading: A number of studies have found little to back up that assertion. A 2016 study published by the journal Health Affairs examined data on hours worked, reason for working part time, age, education and health insurance status. "We found only limited evidence to support this speculation" that the law led to an increase in part-time employment, the authors wrote. Another study found much the same.
In addition, PolitiFact labeled as false a statement last June by President Donald Trump in which he said, "Because of Obamacare, you have so many part-time jobs."
His response: Rohrabacher spokesman Ken Grubbs said the congressman's statement was based on an article that said, "Are Republicans right that employers are capping workers' hours to avoid offering health insurance? The evidence suggests the answer is 'yes,' although the number of workers affected is fairly small."
We pointed out that "fairly small" was hardly akin to distorting the labor market. To which Grubbs replied, "The congressman's letter is well within the range of respected interpretations. That employers would react to Obamacare's impact in such way is so obvious, so nearly axiomatic, that it is pointless to get lost in the weeds," Grubbs said.
Rep. Mike Bishop, R-Mich., appears to have cited a speculative 2013 report by a GOP-led House committee as evidence of current and future premium increases under the ACA.
What he wrote: "Health insurance premiums are slated to increase significantly. Existing customers can expect an average increase of 73 percent, while the average change due to Obamacare for those purchasing a new plan will be a 96 percent increase in premiums. The average cost for a new customer in the individual market is expected to rise $1,812 per year."
What's misleading: The figures seem to have come from a report issued before the Obamacare insurance marketplaces launched and before 2014 premiums had been announced. The letter implies these figures are current. In fact, premium increases by and large have been moderate under Obamacare. The average monthly premium for a benchmark plan, upon which federal subsidies are calculated, increased about 2 percent from 2014 to 2015; 7 percent from 2015 to 2016; and 25 percent this year, for states that take part in the federal insurance marketplace.
His response: None
Rep. Dan Newhouse, R-Wash., misstated the reasons why Medicaid costs per person were higher than expected in 2015.
What he wrote: "A Medicaid actuarial report from August 2016 found that the average cost per enrollee was 49 percent higher than estimated just a year prior — in large part due to beneficiaries seeking care at more expensive hospital emergency rooms due to difficulty finding a doctor and long waits for appointments."
What's misleading: The report did not blame the higher costs on the difficulty patients had finding doctors. Among the reasons the report did cite: patients who were sicker than anticipated and required a raft of services after being previously uninsured. The report also noted that costs are expected to decrease in the future.
His response: None
Sen. Dick Durbin, D-Ill., wrongly stated that family premiums are declining under Obamacare.
What he wrote: "Families are seeing lower premiums on their insurance, seniors are saving money on prescription drug costs, and hospital readmission rates are dropping."
What's misleading: Durbin's second and third points are true. The first, however, is misleading. Family insurance premiums have increased in recent years, although with government subsidies, some low- and middle-income families may be paying less for their health coverage than they once did.
His response: Durbin's office said it based its statement on an analysis published in the journal Health Affairs that said that individual health insurance premiums dropped between 2013 and 2014, the year that Obamacare insurance marketplaces began. It also pointed to a Washington Post opinion piece that said that premiums under the law are lower than they would have been without the law.
Why his response is misleading: The Post piece his office cites states clearly, "Yes, insurance premiums are going up, both in the health care exchanges and in the employer-based insurance market."
Rep. Susan Brooks, R-Ind., told constituents that premiums nationwide were slated to jump from 2016 to 2017, but failed to mention that premiums for some plans in her home state actually decreased.
What she wrote: "Since the enactment of the ACA, deductibles are up, on average, 63 percent. To make matters worse, monthly premiums for the "bronze plan" rose 21 percent from 2016 to 2017. … Families and individuals covered through their employer are forced to make the difficult choice: pay their premium each month or pay their bills."
What's misleading: Brooks accurately cited national data from the website HealthPocket, but her statement is misleading. Indiana was one of two states in which the premium for a benchmark health plan — the plan used to calculate federal subsidies — actually went down between 2016 and 2017. Moreover, more than 80 percent of marketplace consumers in Indiana receive subsidies that lowered their premium costs. The HealthPocket figures refer to people who do not qualify for those subsidies.
Her response: Brooks' office referred to a press release from Indiana's Department of Insurance, which took issue with an Indianapolis Star story about premiums going down. The release, from October, when Vice President Mike Pence was Indiana's governor, said that the average premiums would go up more than 18 percent over 2016 rates based on enrollment at that time. In addition, the release noted, 68,000 Indiana residents lost their health plans when their insurers withdrew from the market.
Why her response is misleading: For Indiana consumers who shopped around, which many did, there was an opportunity to find a cheaper plan.
Sen. Ron Wyden, D-Ore., incorrectly said that the Republican bill to repeal Obamacare would cut funding for seniors in nursing homes.
What he wrote: "It's terrible for seniors. Trumpcare forces older Americans to pay 5 times the amount younger Americans will — an age tax — and slashes Medicaid benefits for nursing home care that two out of three Americans in nursing homes rely on."
What's misleading: Wyden is correct that the GOP bill, known as the American Health Care Act, would allow insurance companies to charge older adults five times higher premiums than younger ones, compared to three times higher premiums under the existing law. However, it does not directly slash Medicaid benefits for nursing home residents. It proposes cutting Medicaid funding and giving states a greater say in setting their own priorities. States may, as a result, end up cutting services, jeopardizing nursing home care for poor seniors, advocates say, because it is one of the most expensive parts of the program.
His response: Taylor Harvey, a spokesman for Wyden, defended the statement, noting that the GOP health bill cuts Medicaid funding by $880 billion over 10 years and places a cap on spending. "Cuts to Medicaid would force states to nickel and dime nursing homes, restricting access to care for older Americans and making it a benefit in name only," he wrote.
Why his response is misleading: The GOP bill does not spell out how states make such cuts.
Rep. Derek Kilmer, D-Wash., misleadingly said premiums would rise under the Obamacare replacement bill now being considered by the House.
What he wrote: "It's about the 24 million Americans expected to lose their insurance under the Trumpcare plan and for every person who will see their insurance premiums rise — on average 10-15 percent."
Why it's misleading: First, the Congressional Budget Office did estimate that the GOP legislation would cover 24 million fewer Americans by 2026. But not all of those people would "lose their insurance." Some would choose to drop coverage because the bill would no longer make it mandatory to have health insurance, as is the case now.
Second, the budget office did say that in 2018 and 2019, premiums under the GOP bill would be 15-20 percent higher than they would have been under Obamacare because the share of unhealthy patients would increase as some of those who are healthy drop out. But it noted that after that, premiums would be lower than under the ACA.
