Aetna CEO Answers Burwell’s Call, Vows Support for Exchanges Amid Losses


SAN FRANCISCO — The head of Aetna Inc., the nation’s third-largest health insurer, said he supports insurance exchanges, even though he questioned their sustainability earlier this month and lost money in the marketplaces last year.
Aetna Chief Executive Mark Bertolini said U.S. Health and Human Services Secretary Sylvia Burwell called him Feb. 1 shortly after he made critical remarks during an earnings conference call. Before then, Aetna had struck a more upbeat tone compared to some rival insurers.

“The secretary called me that evening at home to say, ‘What happened?’” Bertolini said in an interview with Kaiser Health News. “Well, I told her you need to read the whole (earnings transcript), which she did and she calmed down. We like the program and we think it’s an appropriate effort. But we do need to make changes.”
In a wide-ranging interview, Bertolini left the door open to joining the California insurance exchange if the two sides can agree on premiums. Aetna had a chance to join Covered California when it launched in the fall of 2013, but opted to exit the state’s individual insurance market instead.
Regarding California’s private insurance market, Bertolini also said he had no regrets over recent rate hikes that have drawn the ire of state regulators who are now reviewing Aetna’s plan to acquire Humana Inc. for $37 billion.

Overall, Bertolini said he intends to continue working with the Obama administration and state officials but wants them to address some of the problems that are hampering enrollment under the Affordable Care Act, particularly among young people.
Government officials, he said, should allow more flexibility in rates and benefit design to attract younger and healthier consumers. Those enrollees are crucial to offset the higher medical costs of insuring older, chronically ill patients.
“Young people pay some amount of premium, pick a number, and have a $5,000 deductible and go to the doctor once a year and pay all in cash,” Bertolini said. “For people under 35, their definition of health is looking good in their underwear. How does that program support their view of what’s good health?”
Bertolini suggested introducing lower-deductible plans for young consumers, focused on staying healthy. Some state exchanges, including California, have acknowledged those concerns and offered some initial doctor visits that aren’t subject to the annual deductible. But California and other states also set standard deductibles, copays and other benefits, forcing insurers to compete more directly on price and making it simpler for consumers to compare plans. That runs counter to the industry’s call for more variety.
A spokesman for the U.S. Department of Health and Human Services declined to comment on Burwell’s conversation with Bertolini.
Industry criticism of public exchanges began to escalate in November when Stephen Hemsley, CEO of UnitedHealth Group Inc., said the company might stop selling Obamacare coverage after suffering substantial financial losses. Other insurers, including big Blue Cross Blue Shield plans, expressed concern about higher-than-expected medical costs among the exchange population.
“We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself,” Hemsley said in November.
Earlier this month, Aetna said it lost up to $140 million, or a negative margin of 3 percent to 4 percent, on individual coverage last year. The company said it expects to break even this year in the 15 states where it’s selling public exchange policies.
In California, Aetna has clashed repeatedly with the state Department of Managed Health Care over rate increases in the private market. The agency has deemed four rate hikes by Aetna unreasonable since 2013, but the company went ahead with each one anyway. California officials review premiums but have no authority to stop health insurance rate increases.
Shelley Rouillard, the agency’s director, accused Aetna of “price gouging” when it raised rates by 21 percent, on average, for some small businesses last year. “I can assure you rates are something that we will be looking at and considering as part of our review,” Rouillard said at a state hearing on the Aetna-Humana deal last month.
An agency spokeswoman said there was no timetable for a decision on the acquisition. Consumer groups oppose the Aetna deal and a similar merger between Anthem Inc. and Cigna Corp., saying they will result in fewer choices and higher costs.
Bertolini said those fears about consolidation aren’t justified and he said rate increases are necessary at times to cover rising medical costs.
“While California would like us to give away everything for free we can’t do that. We have to have a financially sustainable product,” Bertolini said.
Asked if he would be willing to make concessions on premiums to win state approval for the Humana deal, Bertolini said: “We’ll deal with that as we go through that process. We’re in the early stages.”
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Study Links Kindergartners’ Stumbles With Rocky Home Lives


Very young children who endure neglect, abuse and dysfunctional home lives go on to struggle as kindergartners, leaving them at risk for more difficult years as adolescents and adults, a new study finds.
Adverse childhood experiences before age 5 were linked with poor academic and behavioral performance in kindergarten, said researchers who examined a sample of about 1,000 urban children. Their study was reported in the journal Pediatrics this month.

“Relative to children with no ACEs, children who experienced ACEs had increased odds of having below-average academic skills including poor literacy skills, as well as attention problems, social problems, and aggression, placing them at significant risk for poor school achievement, which is associated with poor health,” the authors said.
The adverse experiences included varieties of maltreatment — psychological, physical or sexual abuse or neglect — as well as household dysfunction — such as maternal depression, substance abuse, incarceration or violence toward the mother.
Forty-five percent of the children in the study had no adverse experiences, 27 percent had one, 16 percent had two and 12 percent had three or more.
The researchers from children’s hospitals in New Jersey and Philadelphia analyzed data from a national group of participants in the Fragile Families and Child Wellbeing Study, drawing on the study’s follow-up interviews with mothers five years after their child’s birth and data on teacher-reported school performance near the end of the child’s kindergarten year.

Teachers rated about a quarter of the children below-average for literacy and math skills. Children with more adverse experiences generally showed worse academic, literary and behavior outcomes, the study said.
Dr. Manuel Jimenez, the study’s lead author and assistant professor of pediatrics, family medicine and community health at Rutgers Robert Wood Johnson Medical School, said that when he sees children having academic or behavioral difficulties, there are often deeper problems that originate at home. The analysis adds to a growing body of research that shows behaviors that start in early childhood can lead to dropping out of school, committing crimes and poor health in adulthood.
“This affects children’s ability to do well in school, the work world and the likelihood in ending up with trouble with the law or fitting into society. All those things come together and it’s a vicious cycle that repeats itself. And if we don’t intervene, then they evolve in less healthy ways and that repeats for the next generation,” said Debra Ness, president of the National Partnership for Women & Families.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Majority Of Young Men Don’t Know About Emergency Contraception, Study Finds


Less than half of young men have heard of emergency contraception, a recent study found, even though it’s available over the counter at drug stores and is effective at preventing pregnancy after sex.
The study, published in the March Journal of Adolescent Health, analyzed survey responses by 93 men between the ages of 13 and 24 who visited the adolescent medicine clinic at Children’s Hospital Colorado in Aurora for a physical exam, illness or injury between August and October 2014. Most had been sexually active. The computerized survey asked patients about their knowledge of contraceptives, and whether they had talked about birth control with their partners or health care providers.

Although 84 percent of the teenage boys and young men said they believed avoiding pregnancy was very or somewhat important, only 42 percent had heard of emergency contraception, according to the study. Those who knew about emergency contraception, also called the morning-after pill, were more likely to have talked with a health care provider about birth control in the past.
Far from being disappointed, Dr. Paritosh Kaul, an associate professor of pediatrics at the University of Colorado School of Medicine who co-authored the study, said he was “pleasantly surprised” at the 42 percent figure.
“That’s two-fifths of the boys, and … we don’t talk to boys about emergency contraception that often,” he said. “The boys are listening, and health care providers need to talk to the boys.”
“These guys believe they should be involved in sexual health decision making,” Kaul added. “And if they are then they’re more likely to talk with their girlfriends. They’re the missing half. It takes two to tango.”
If taken within five days of unprotected sex, emergency contraceptives can prevent ovulation, thus preventing pregnancy.

In 2013, the Food and Drug Administration approved one branded emergency contraceptive, Plan B One-Step, for sale over the counter without a prescription for all women. The following year, the agency said that generic versions of the pills could also be sold over the counter without age restrictions.
Eighteen percent of sexually active women reported in 2013 that they had used emergency contraception sometime in the previous two years, according to the Centers for Disease Control and Prevention. That figure is probably higher now that the drugs are more readily available, said Kelly Cleland, a researcher at Princeton University who is executive director of the American Society for Emergency Contraception.
Although the Colorado study is too small to be the basis for generalizations, it’s one of the few studies that looks at awareness or access since emergency contraceptives became available over the counter, Cleland said.
She said her organization has received complaints from consumers who have been denied emergency contraceptives at the pharmacy, including men who have either been told that men can’t buy it or that they have to have the ID card of the woman for whom they’re buying it, neither of which is true, said Cleland.
Women can get emergency contraceptives at no charge under the health law, but only with a doctor’s prescription. For women who don’t take that step, sharing the cost, which can run up to $50, is one important way for men to play a role, Cleland said. “EC is so expensive when the burden falls on women exclusively.”
Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Agonizing Limbo Of Abandoned Nursing Home Residents


A bad bout of pneumonia sent Bruce Anderson to Sutter Medical Center in Sacramento last May. As soon as he recovered, hospital staff tried to return him to the nursing home where he had been living for four years.
But the home refused to readmit him, even after being ordered to do so by the state. Nearly nine months later, Anderson, 66, is still in the hospital.

“I’m frustrated,” said his daughter, Sara Anderson. “You cannot just dump someone in the hospital.”
Anderson said her father, who has a brain injury that causes dementia-like symptoms, is confined to the hospital bed and frequently given anti-psychotic medications. She believes the nursing home, Norwood Pines Alzheimer’s Care Center, refused to readmit him because it wanted to make room for more lucrative and less burdensome residents.
“I didn’t have any question this was about money,” she said.
Bruce Anderson is the victim of a flawed readmission system for patients who want to return to their nursing homes after spending time in the hospital.
Nursing home residents are entitled to hearings under federal law to determine whether they should be readmitted after hospitalization. The state Department of Health Care Services holds the administrative hearings, but has said it is not responsible for enforcing the rulings.

But the state Department of Public Health, which oversees nursing homes, neglects to enforce the rulings and sometimes disagrees with them, according to advocates and court documents.
That leaves residents like Anderson, who won his hearing in July, with little recourse — and not many places to go. And since many nursing home residents have publicly-funded insurance, it means taxpayers are on the hook for hospital stays long after the patients are ready for discharge.
“Federal and state law have created a complicated and expensive process to ensure residents are not abandoned by their nursing homes,” said Tony Chicotel, a staff attorney at the nonprofit California Advocates for Nursing Home Reform. “It fundamentally doesn’t work.”

Chicotel said the outcome is “profoundly problematic” — vulnerable residents are abandoned by the nursing homes and then by the state.
Bruce Anderson, two other displaced nursing home residents and California Advocates for Nursing Home Reform are plaintiffs in a pending lawsuit against the California Health and Human Services agency.
Their suit, filed in federal court in San Francisco last November, alleges that the state is violating U.S. laws aimed at protecting nursing home residents from being “dumped” at hospitals. A hearing on the case is scheduled for next month.
Attorney Matthew Borden, who is representing the plaintiffs, said he wants the federal court to require California to establish a hearing process that complies with federal law and to enforce the rulings.
“We are not asking for the moon,” he said. “What is the point of a hearing if no one is going to enforce it? … This illustrates how futile this process is.”
The state’s Health and Human Services agency, which oversees both health departments involved, declined to comment, as did its attorneys at the California Department of Justice.
The defense lawyers filed a motion to dismiss the case, however, arguing that the plaintiffs haven’t presented evidence of a “systemic problem” with regard to residents who are not readmitted to facilities after winning their administrative hearings.

The defense motion also lays out several ways in which state officials could enforce administrative hearing orders, including civil penalties against nursing homes. But Chicotel, of California Advocates for Nursing Home Reform, said the state doesn’t avail itself of the enforcement mechanisms.
Deborah Pacyna, public affairs director of the California Association of Health Facilities, the trade association for nursing homes, said facilities can’t always take residents back after hospitalization — even if the administrative ruling is in the resident’s favor.
For example, nursing homes are prohibited by law from taking residents if they are dangers to themselves or others — or if the facility can’t provide adequate care for them, Pacyna said.
She said Bruce Anderson did pose a danger — that he had assaulted a staff member and law enforcement officers. The nursing home said in the administrative hearing that it believed Anderson would be better off in a psychiatric facility, according to the ruling.
“This is not about money,” she said. “This is about patient safety … The nursing home has to take into account the safety of the entire population.”
Regardless of motive, the refusal of nursing homes to readmit residents can put hospitals in a difficult situation. Patients can linger in the hospital for a year or more as staff members search for places that can accommodate their serious physical or behavioral needs, said Pat Blaisdell, vice president for the continuum of care at the California Hospital Association.

“It’s a major problem,” she said, noting that on any given day there are a few hundred people in hospital beds around the state who shouldn’t be there. That takes up valuable beds, staffing time and money that would be better spent on patients who genuinely need to be there.
Medi-Cal pays hospitals about $400 a day for these patients — far less than what it takes to provide care for them, Blaisdell said. Nursing homes also receive meager reimbursement from Medi-Cal, which Blaisdell said she believes is likely a factor when they decide not to readmit residents.
Whatever the reason, keeping patients hospitalized when they don’t need to be is medically bad for them, she said.
John Wilson, 61, is another one of the other plaintiffs in the lawsuit. He spent seven months at St. John’s Pleasant Valley Hospital in Camarillo after the hospital’s parent company, which owns the skilled nursing unit where he had resided, refused to readmit him to it. Wilson has ALS, a degenerative neurological disorder commonly known as Lou Gehrig’s disease, and he needs a ventilator to breathe.

Wilson’s son, Jeremy Wilson, said that in the past his father had gone to the hospital frequently for pneumonia, skin infections and other ailments, and each time the skilled nursing unit took him back. But last April, after Wilson got a bacterial infection and ended up in the intensive care unit, a social worker said he would not be accepted back into the nursing facility.
The family appealed the decision, and won its case in an administrative readmission hearing. But the facility still refused to readmit Wilson, his son said.
Jeremy Wilson said he was angry that the nursing home didn’t comply with the order — and that the state didn’t do anything about it. But after he pushed for months, the nursing home finally allowed his father to return, he said.
“He was basically in a jail for seven months,” the son said. “He couldn’t get in a wheelchair and go down into the garden. He was literally stuck in the room, and from a psychological standpoint, it took a great toll on him.”
Sara Anderson said she is still trying to get her father out of Sutter Medical Center in Sacramento. She, too, sees the toll it is taking on him. He has grown weaker and he misses his home at Norwood Pines — and playing bingo with the other residents, she said.
Anderson said the hospital staff is nice to him and he is receiving good care, but he really needs to be in a skilled nursing facility — not an acute care hospital.

She worries that it still may be a long time before her father is discharged, and that when he is, he will be sent someplace far from her home in San Joaquin County. Finding a place for him is very difficult, she said. “Places do not want to take someone like him … He is a hard sell.”
Beyond her father’s situation, Anderson said she wants the state to fix the way it handles nursing home readmission disputes. “This suit is really for the next family whose loved one gets dumped in the hospital,” she said.
Blue Shield of California Foundation helps fund KHN coverage in California.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Support For Sanders’ Single-Payer Plan Fades With Control, Cost Concerns

Americans are divided about the idea of creating a single-payer government health insurance system, as Democratic presidential candidate Bernie Sanders has proposed, but support shrinks when negative arguments are highlighted and alternatives are presented, according to a poll released Thursday.
In his insurgent primary campaign against Hillary Clinton, Sanders has been championing a Medicare-like single-payer plan for all citizens. The idea has been a popular proposal in the liberal wing of the party for decades. Clinton views it as politically infeasible and has been arguing that it is better to build on the Affordable Care Act than raze it in favor of an entirely new system. Republican candidates are all strongly opposed to the idea and would prefer to overturn the ACA.
The poll from the Kaiser Family Foundation found that 50 percent of Americans favored the single-payer idea, but support was highly partisan: seven of 10 Democrats and two in 10 Republicans liked it. (KHN is an editorially independent program of the foundation.) However, only 24 percent of people would like to establish such a plan if given other options, including expanding the existing Affordable Care Act, according to the poll. A majority of Democrats favor the incremental approach rather than creating a universal government plan.

Campaign-style attacks on a plan like the one proposed by Sanders could wither its general popularity, the poll found. Support was reduced by nearly half when people were told that a single-payer plan would increase taxes or “give the government too much control over health care.” Support also dropped substantially after people were told a government plan would require eliminating or replacing the existing health care law.
Some of those opposed to a single government plan could be swayed by positive arguments, such as it would guarantee all Americans have insurance as a basic right or that the plan would eliminate premiums, copays and other costs borne by employers or individuals. At most, 13 percent were converted to favoring the idea, leaving 30 percent still opposed.
The words used to describe a single-payer plan also affected opinions, the poll found. “Medicare-for-all” was the most popular, with 64 percent of Americans responding positively. “Guaranteed universal health coverage” appealed to 57 percent of people. Only 44 percent liked “single-payer health insurance system” and 38 percent liked “socialized medicine.”
“Most Americans think that if guaranteed universal coverage through a single government plan was put into place, uninsured and low-income people would be better off, but there is little consensus among the public about how it would impact their care personally,” the pollsters wrote.
On a separate issue, the poll reported that the majority of the public was well informed about how the Zika virus spread, amid reports of birth defects in babies born to infected mothers in South and Central America. Three-quarters of people knew the virus spreads through mosquito bites and more than half were aware that it can spread through sex. Seven in 10 people knew Zika cannot spread through handshakes.
The discovery of high levels of lead in the water supply of Flint, Michigan, has fueled broad concerns about the safety of public water supplies, according to the poll. Seventy-seven percent of people said they were worried about water for low-income areas and 47 percent were concerned about their own water supply.
The poll was conducted from Feb. 10 through Feb. 18 among 1,202 people. The margin of error for the full sample was +/- 3 percentage points.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

With Special Tax Suspended, Medical Device Firms Reap Big Savings


U.S. manufacturers of medical devices started 2016 with a windfall — a two-year suspension of a controversial tax on their revenue.
Medical devices include a wide range of products and machines used in medical care, such as tongue depressors, endoscopes and MRI scanners, for example. Manufacturers said the tax on devices hurt their business. The Congressional Research Service estimates companies paid out $2.4 billion in 2014.
“When this tax went into place, it forced us to make cuts and sustain those cuts,” said George Montague, chief financial officer of Minnesota-based Smiths Medical. His firm takes in more than $1 billion a year for its specialty medical products.
Smiths Medical had paid $10 million a year in medical device taxes, Montague said, “and so now we’re getting that funding back.” He insisted the money will go into building the business.

“We’re making significant investment in our product portfolio — in improving our product portfolio,” Montague said. “And what this enables us to do is accelerate some of that investment.”
The medical technology industry has branded the device tax a job-killer, though that claim has been disputed. Montague said Smiths Medical will now be adding new jobs, but he doesn’t know how many.
Minnesota is home to a concentration of device makers, and U.S. Rep. Erik Paulsen, R-Minn., is a leading opponent of the tax. He said suspending it for two years could provide a major boost to Minnesota’s economy.
“There are estimates that because of Minnesota’s high concentration in this sector — essentially the largest in the world in a concentrated environment — that Minnesota would be paying 25 percent of the tax,” Paulsen said. “That’s a big deal to our economy.”
Bob Paulson is CEO of NxThera, a small firm in Minnesota that makes devices involved in the treatment of urological conditions. His company had only been paying the device tax since November, he said, when NxThera started selling products in the United States. The tax made it harder to find financing, he said, because investors balked at putting their money into an industry that’s been singled out to pay a tax. Thanks to the tax hiatus, he said, he now plans to enlarge his staff of 43 researchers and sales people.
“It absolutely means additional money that we can invest in both of those areas,” he said.
Still, some industry analysts questioned whether suspending the tax will significantly boost the number of jobs created.
The Congressional Research Service concluded the tax was having fairly minor effects on employment, changing payrolls by no more than two-tenths of 1 percent. Still, the same report called the tax difficult to justify and noted that such excise taxes are typically put in place to discourage a particular behavior, such as smoking.
Jason McGorman, a senior analyst with Bloomberg Intelligence, said the suspension won’t really change what big companies are doing, but will help their bottom lines. Big, publicly traded firms also might return the money to shareholders by buying up their own shares, he said.
“Smaller companies felt a bigger tax bite than the giants, so they are more likely to put the tax savings back into the business,” McGorman said.
Industry analyst Brooks West, of Piper Jaffray, said device makers would be smart to reinvest the windfall.
“Politically, they better spend this money on R-and-D,” West said, “or the government can look at this and say, you know, ‘Look, if you just pass this on to the shareholders, we’re going to reimpose the tax.’ ”
But Rep. Paulsen said he doubts the tax will return. He’s optimistic the two-year tax suspension will become a permanent repeal.
This story is part of a reporting partnership with Minnesota Public Radio, NPR and Kaiser Health News.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Candidates’ Drug-Price Plans May Miss The Mark


Most of the people running for president say they want to do something about the rising cost of prescription drugs. But most of their proposals probably won’t work because they don’t address the dynamics behind these price increases.
“There’s no magic bullet,” said John Rother, president and CEO of the National Coalition on Health Care, a nonpartisan research group. Solving the problem “will require a whole range of policies.”
Democrats Hillary Clinton and Vermont Sen. Bernie Sanders each have drug price proposals. Among Republicans, Donald Trump has addressed the issue, as has Sen. Marco Rubio of Florida, Sen. Ted Cruz of Texas and Ohio Gov. John Kasich.
It’s pretty obvious why the candidates are all talking about drug prices. Public opinion polls routinely show it as a top issue the public wants addressed. The October monthly tracking poll from the Kaiser Family Foundation found strong majorities of both Democrats and Republicans cited as their top health priorities “making sure that high-cost drugs for chronic conditions … are affordable to those who need them,” and “government action to lower prescription drug prices.” (Kaiser Health News is an editorially independent program of the foundation.)

And the public is correct to worry about drug prices. Drug costs are the fastest growing part of the nation’s health care budget, and account for nearly one of every five dollars spent on employer health insurance benefits.
But it turns out that some of the most visible examples of what some people view as drug industry greed are not what is actually driving those increases.
For example, “pharma bro” Martin Shkreli, the indicted former head of Turing Pharmaceuticals, bought an important but little-used drug (with no generic competition) and increased its price by 5,000 percent (from $13.50 to $750 per pill) overnight. He made even more enemies by invoking his Fifth Amendment right not to incriminate himself at a recent hearing of the House Oversight and Government Reform Committee, then calling its members “imbeciles” in a tweet after leaving the hearing room.
“He is such a perfect villain,” said Rother. “But there are other” companies that are buying up drugs for which patent protections have expired and jacking up costs, including Valeant, which was also called before Congress to justify its actions.
Still, for all the headlines these price hikers have garnered, “they’re not the ones driving the overall upward costs,” said Rother. That’s because while the anecdotes are shocking, the drugs in question tend to be used by small patient populations, so their total cost is not that much to the health system.
Similarly, said Rother, much attention has been paid to extremely expensive “specialty” drugs to treat complex conditions like cancer or multiple sclerosis. The final products frequently cost from tens to hundreds of thousands of dollars for a course of treatment or even a single dose.
But again, with some exceptions, these drugs are not the principal problem. That’s partly because the number of patients who rely on them for treatment is small relative to the entire population. It’s also partly because most specialty drugs are taken for a short period of time rather than indefinitely. Although, pointed out Rother, “with more and more people in high-deductible health plans,” even asking patients to pay a small percentage of the cost can put the drugs out of reach.
So what IS driving up drug spending? Some specialty drugs — particularly Sovaldi and others that can treat and even cure hepatitis C — can be used by millions of patients, so their $80,000-to-$100,000 price tags quickly make an impact. Those drugs alone were estimated to have added a half a percentage point to the 2014 health spending inflation rate. The drugs’ expense has had such a large impact on state Medicaid programs, which provide health coverage for low-income people, that many have started rationing it.
But by far the biggest impact, said Rother, has come from traditional pharmaceutical companies raising prices on their products across the board. In January, for example, Pfizer raised prices on nearly its entire portfolio. Most of the increases are between five and 20 percent.
So what are candidates proposing?
One popular idea (advocated by Clinton, Sanders and Trump) is to let the federal Medicare program negotiate prices for all, or at least the most expensive drugs. That approach was specifically banned when the GOP Congress added the Part D drug benefit to Medicare in 2003.
While that sounds like a logical way to save money, most experts who have looked at the issue say it might not. The Congressional Budget Office has said that lifting the ban on negotiation “would have a negligible effect” on cost because the federal government was unlikely to obtain significantly lower prices than private drug benefit providers. Even the Obama administration, which proposed allowing Medicare to negotiate for very high-cost drugs as part of its fiscal 2017 budget, estimates no savings from the provision. The only way Medicare negotiation would save money is if the program decided to cover some drugs and not others (which is what the Department of Veterans Affairs does). But that would be sure to trigger an enormous political backlash in Medicare.
Another popular proposal, also among the ideas offered by Clinton, is to cap how much patients have to pay out of pocket for their drugs. A half a dozen states have taken steps in this direction.
But that doesn’t actually lower drug prices, “it’s just a cost shift,” said Alissa Fox of the Blue Cross and Blue Shield Association. “You’re really just requiring everyone else (in the insurance pool) to pay those costs,” which would boost premiums.
Sanders, meanwhile, has been pushing to allow Americans to buy cheaper drugs from other industrialized countries, particularly Canada, for almost as long as he’s been in Congress. His website points out that drug spending in Canada (which has price controls) is 40 percent lower than in the U.S.
But while the idea of letting U.S. consumers piggyback other countries’ controlled prices is popular with the public, it’s not just drugmakers who oppose it. Health officials in every administration from President Bill Clinton to President Barack Obama have warned that the safety of drugs from other countries — even those originally made in the U.S. — cannot be guaranteed.
So what might help?
“Most of this issue involves trade-offs,” said Rother. “You do need incentives [for drugmakers] to produce new drugs.”
Dana Goldman, a health economist at the University of Southern California, agreed. “It’s patient rights versus patent rights,” he said at a recent forum on the issue. While patients want cheap and easy access, he said, “you need incentives to get companies to take the risk in innovation.”
Some other ideas candidates and policymakers have suggested include limiting what drugmakers spend on marketing to patients, something that is not even allowed in many other countries. Other targets include making it harder for drug companies to delay generic drug competition and requiring drugmakers to devote a certain percentage of revenue to research and development.
All, by the way, have been proposed in Congress before. None have come close to passage.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Latino Youth In California See Significant Rise In Psychiatric Hospitalizations


Psychiatric hospitalizations of Latino children and young adults in California are rising dramatically — at a much faster pace than among their white and black peers, according to state data.

While mental health hospitalizations of young people of all ethnicities have climbed in recent years, Latino rates stand out. Among those 21 and younger, they shot up 86 percent, to 17,813, between 2007 and 2014, according to the Office of Statewide Health Planning and Development. That’s compared with a 21 percent increase among whites and 35 percent among African Americans.
No one knows for certain what’s driving the trend. Policymakers and Latino community leaders offer varying and sometimes contradictory explanations. Some say the numbers reflect a lack of culturally and linguistically appropriate mental health services for Latinos and a pervasive stigma that prevents many from seeking help before a crisis hits.
“Often, they wait until they are falling apart,” said Dr. Sergio Aguilar-Gaxiola, a professor at the University of California, Davis Medical School and director of the university’s Center for Reducing Health Disparities.

Others blame stress from the recent recession, family disintegration and an influx of traumatized children fleeing poverty and violence in Central America.
Still others suggest the trend might actually be positive, reflecting an increasing willingness among Latino parents to seek treatment for themselves and their children, at least when they are in crisis.
Among Latino adults, psychiatric hospitalizations rose 38 percent during the same period. Similar hospitalizations of black adults increased 21 percent, while hospitalizations of white adults remained flat.
Margarita Rocha, the executive director of the nonprofit Centro la Familia in Fresno, said mental health issues are starting to be discussed more publicly in the Latino community.
“That’s helping people to come forward,” she said.

Ken Berrick, CEO of the Seneca Family of Agencies, which serves children with emotional disturbances in a dozen counties, agreed. Because more Latinos are now getting mental health services, children are more likely to be identified as requiring hospitalization, he said.
“I know for a fact that access to service is better now,” said Berrick, whose operation has a crisis stabilization unit in Alameda County, Calif.
Kids’ psychiatric hospitalizations overall rose nearly 45 percent between 2007 and 2014, regardless of ethnicity, a pattern experts attribute to various factors including a shortage of intensive outpatient and in-home services, schools’ struggles to pay for mental health services through special education and a decline in group home placements.
“Those kids have to be treated somewhere,” said Dawan Utecht, Fresno County’s mental health director, of the move to keep kids out of group homes.
“If they don’t get those services in a community setting, they’re going to go into crisis.”
The rise among Latino youths is remarkable in part because hospitalization rates for that population historically have been relatively low.
Latino children remain much less likely to receive mental health treatment through Medi-Cal, the state and federal coverage program for poor and disabled residents. Between 2010 and 2014, less than 4 percent of Latino children received specialty mental health services through the traditional Medi-Cal program. That’s compared with 7 percent of eligible black and white children, according to state data. The numbers don’t include those enrolled in managed care.

(Asian Americans and Pacific Islanders seek treatment at a rate even lower than Latinos. Although hospitalizations are also increasing rapidly among that population, the raw numbers remain relatively small.)
Leslie Preston, the behavioral health director of La Clínica de La Raza, in East Oakland, says that the shortage of bilingual, bicultural mental health workers limits Latino kids’ access to preventive care, which could lead to crises later on.
“Everybody’s trying to hire the Spanish-speaking clinicians,” she said. “There’s just not enough clinicians to meet that demand.”
Access to care can be even harder for recent immigrants. Spanish-speaking children who have been referred for a special education assessment, which can help them become eligible for mental health services, sometimes wait months or years before someone tests them, she said.
“The families don’t know the system,” she added. “They don’t know their rights.”
Other clinicians point to relatively low health insurance coverage among Latinos, particularly those without legal status, and a cultural resistance to acknowledging mental illness.
Dr. Alok Banga, medical director at Sierra Vista Hospital in Sacramento, said some immigrant parents he encounters don’t believe in mental illness and have not grasped the urgency of their children’s depression and past suicide attempts. Many are working two or three jobs, he said. Some are undocumented immigrants afraid of coming to the hospital or having any interaction with Child Protective Services.
But the biggest problem, from his perspective, is the shortage of child psychiatrists and outpatient services to serve this population.
“The default course for treatment falls on institutions: hospitals, jails and prisons,” he said.
Jeff Rackmil, director of the children’s system of care in Alameda County, said sheer population growth — particularly, an increase in Latino children insured under Medi-Cal — may also be part of the explanation for the rise in hospitalizations.
Yet the state’s Latino population aged 24 and under increased less than 8 percent between 2007 and 2014, which doesn’t nearly explain an 86 percent increase in hospitalizations.

Some California communities are working to bring more Latino children into care and to reduce the stigma associated with mental illness.
At Life Academy of Health and Bioscience, a small, mostly Latino high school in East Oakland, students grow up amid pervasive violence and poverty. “We’re just told to hold things in,” said 17-year-old Hilda Chavez, a senior.
Students often don’t seek help because they fear discussing mental health problems will earn them a label of “crazy,” Chavez said.
Last year, the school, in conjunction with the Oakland-based La Clínica de La Raza, started a program to interest students in careers in mental health care. The program provides training in “first aid” instruction to help people in crisis, and places students in internships with mental health organizations.
Nubia Flores Miranda, 18, participated in the program last year and now is majoring in psychology at San Francisco State University. Miranda said she became interested in a career in mental health after she experienced depression and anxiety during her freshman year at Life Academy.
Seeing a school counselor “changed my life around,” she said.
But she saw that her peers were wary of seeking help from counselors at the school, most of whom were white and lived in wealthier, safer neighborhoods. Once, when a classmate started acting out at school, Miranda suggested she talk to someone.
“She told me she didn’t feel like she could trust the person — they wouldn’t understand where she was coming from,” she said.

The shortage of services is especially evident in the Central Valley, where many agricultural workers are Latino. Juan Garcia, an emeritus professor at California State University, Fresno, who founded a counseling center in the city, says the drought and economic downturn have exacerbated depression, anxiety, substance abuse and psychotic breaks among Latinos of all ages.
“The services to this population lag decades behind where they should be,” he said.
In Fresno County, psychiatric hospitalizations of Latino youth more than tripled, to 432, between 2007 and 2014. Hospitalizations of their white and black peers about doubled.
Liliana Quintero Robles, a marriage and family therapy intern in rural Kings County, also in the state’s Central Valley, said she sees children whose mental health issues go untreated for so long that they end up cutting themselves and abusing alcohol, marijuana, crystal meth and OxyContin.
“There’s some really, really deep-rooted suffering,” she said.
Out in the unincorporated agricultural community of Five Points, about 45 minutes from Fresno, almost all of the students at Westside Elementary School are low-income Latinos. When principal Baldo Hernandez started there in 1981, he’d see maybe one child a year with a mental health issue. These days, he sees 15 to 30, he said.
He blames dry wells and barren fields, at least in part.
“I’ve had parents crying at school, begging me to find them a home, begging me to find them a job,” he said.
In some parts of the Valley and other places, the closest hospitals that accept children in psychiatric crises are hours away. Children can be stuck in emergency room hallways for days, waiting for a hospital bed.
“It makes for a very traumatized experience for both families and children,” said Shannyn McDonald, the chief of the Stanislaus County behavioral health department’s children’s system of care.
Recently, the county expanded its promotora program, which enlists members of the Latino community to talk to their peers about mental health.
In the small town of Oakdale, a slim, energetic 51-year-old promotora named Rossy Gomar spends 60 to 70 hours a week serving as cheerleader, educator and sounding board for many of the Latino women and children in the town.

Gomar’s office in the Oakdale Family Support Network Resource Center is cluttered with open boxes of diapers and donated children’s toys and clothing.
“Look at my office,” she laughs. “We don’t fit.”
Gomar says many of the women she works with don’t recognize that they are depressed or abused. Children see their parents’ problems and don’t know where to turn for help.
“There are many young people who don’t have any hope,” she said.
But little by little, she has seen some good results.
One 17-year-old client is a student at Oakdale High School. The girl, whose name is being withheld to protect her privacy, said that earlier this year, problems at school and a break-up with her boyfriend had her struggling to get out of bed each morning. She began drinking, using drugs and thinking about suicide. She was scared to talk to her parents, she said, and kept everything inside.
One day, she walked into Gomar’s office and started crying.
“She told me ‘Everything is ok. We want you here,’” the girl said. “When I was talking with her, I felt so much better.”
The California Wellness Foundation supports KHN’s work with California ethnic media.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Dueling Star Ratings May Confuse Some Home Health Patients


Patients looking for home health care services will be impressed if they check out the federal government’s ratings of Brookdale Senior Living. Four of the company’s home health agencies — in Florida, North Carolina, Ohio and Rhode Island — each earned five stars, the top quality score, primarily based on Medicare’s assessment of how often patients got better.
But further research may lead to confusion. Medicare also posts stars to convey how patients rate agencies after their care is over. There, these same four Brookdale agencies earned no more than two stars.
“We understand that we have work to do on our patient perception results,” Kristin Puckett, a Brookdale spokeswoman, said in an email. “It is vital that our patients’ perception of their care is as positive as the outcomes from the quality care we provide.”

Such contradictory results between how patients view home health agencies and how the government rates them are hardly unusual. One in five agencies had clinical and patient ratings that differed by two stars or more, a Kaiser Health News analysis of government records shows.
Skilled home health services, where Medicare sends nurses, aides, and physical and occupational therapists to people’s houses, are becoming more important amid pressures to keep homebound patients from going to the hospital. To help doctors and patients select among more than 12,000 agencies, Medicare last year published star ratings for clinical quality on its Home Health Compare website, and in January it added star ratings to reflect the views of patients.
Medicare was liberal in giving top marks based on patients’ opinion scores, awarding four or five stars to 74 percent of agencies it rated. Of those, 2,152 agencies got five stars.
But in encapsulating clinical quality measures, Medicare used a different formula that ensured three-star ratings would be most common. Only 27 percent of agencies received four or five stars. Just 286 agencies received the maximum five stars.
In a statement, the Centers for Medicare & Medicaid Service said the different star ratings should not be confusing. “CMS stresses that website users should look at all of the different types of measures available for a given provider type, including for home health care agencies,” the statement said. “By providing both clinically based and survey-based measures, CMS hopes to make available to the public a range of perspectives and information that consumers can evaluate to help inform their decision about an agency.”

As the number of quality metrics has proliferated, star ratings follow other Medicare efforts to distill sometimes complex quality assessments into a consumer-friendly format. Medicare also assigns stars for dialysis center quality, hospital patient experience and several aspects of nursing home care.
Some of the differences between home health care patient experience and clinical quality stars can be chalked up to the fact that the two domains focus on different facets of home health care. The clinical quality measures look at how quickly the agency began care; how much patients’ mobility improved, getting in and out of bed and bathing; how much pain and shortness of breath decreased; and how many patients end up in the hospital.
The patient surveys examine how well health care workers explained to patients how to take care of themselves and whether they treated patients with gentleness, courtesy and respect. The questionnaires also probe whether the workers checked patients’ medications for side effects and properly explained how and why they were being taken.
“We’re really talking about very different sets of metrics,” said Teresa Lee, director of the Alliance for Home Health Quality and Innovation, a nonprofit research group. “It’s unfortunate, but maybe it’s the truth that patient experience and clinical quality of care do not go hand in hand.”
Adding to potential confusion, 41 percent of the star ratings summing up patient views are not reliable — by the government’s own admission — because fewer than 100 surveys were returned, records show. Home Health Compare warns consumers in footnotes to use the scores “with caution as the number of surveys may be too low to accurately tell how an agency is doing.” Medicare did not assign stars for agencies if fewer than 40 surveys were returned.
Brookdale’s Puckett said it has been challenging to get more patients to return the surveys, which she characterized as “complex,” particularly for the very ill. “It is important to point out that our patient population has an average age of 86 and often relies on family members, powers of attorney and/or guardians to complete” the survey, she said.
Some elder care experts have broader reasons to question the ratings.
Dr. Joanne Lynn, a geriatrician at the Altarum Institute, a nonprofit research and consulting firm, said much of a patient’s health was beyond the control of home health workers, who can visit as infrequently as once every two weeks.
“Medicare-covered home health services are so limited, and what they are measuring includes a number of things that, for many people, are not fixable,” she said, referring to metrics assessing how often patients got better in their daily activities.
Instead, she said, poor ratings for an agency may reflect an absence of other important services in a region. “If you’re in an area that doesn’t have a lot of advanced care planning, has a yearlong waiting list for Meals on Wheels, and no doctors who are able to visit people at home, you’re going to be stuck with sending sick people back to the hospital,” Lynn said.
Margaret Murphy, associate director of the Center for Medicare Advocacy, a nonprofit that aids Medicare beneficiaries seeking health services, said she fears that agencies that avoid particularly sick patients may end up looking better in the ratings.
“We find that agencies don’t want to take those people on,” she said. “They can get someone who has just come out of a hospital, maybe after a heart attack and they need a little bit of watching to get back on their feet, maybe they need a little bit of therapy. But they’re going to go back to their regular life, as opposed to someone with Parkinson’s, who is losing strength and losing balance. They are a big burden on agencies.”
It is not clear how many patients use Medicare’s star ratings and whether those who do, understand them. Lee said, “If you have patients who are very sick, the question is to what extent will they be in a position, because of their health, to really look extensively at this kind of information.”
Share Your Experience: Is there anything you would like to share about your reaction to this article and your experiences with a skilled home health agency. Your comments may inform future KHN coverage on this issue. Write us at Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

As Rural Hospitals Struggle, Some Opt To Close Labor And Delivery Units


A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, North Carolina, it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable. The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed. Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.
“It was kind of scary for a while,” Murphy remembered. But with Murphy and two other family physicians trained in obstetrics as well as experienced nurses staffing the 25-bed hospital’s labor and delivery unit, the situation was manageable, and both mother and baby were fine.
Things are different now. Alleghany hospital — like a growing number of rural hospitals — has shuttered its labor and delivery unit, and pregnant women have to travel either to Winston-Salem or to Galax, Virginia, about 30 minutes away by car, weather permitting.
“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, said Murphy, who teaches at the Cabarrus Family Medicine Residency Program in Concord, North Carolina. (Although not essential, women typically see the physician they expect will handle their delivery for prenatal care.)
About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.
“The fact that closures continue happening — over time that means the nearest hospital gets further and further away,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who coauthored the study published in the January issue of Health Services Research.
There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

“A labor and delivery unit is functionally no different than an intensive care unit,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. Staffing levels are high in obstetrics, often one nurse for every patient, and the rooms are cluttered with monitors, infusion pumps and other equipment.
It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and rely instead on local family physicians, but it can be difficult to get enough to fully provide services for a hospital, too. Nurses with obstetrics experience also can be scarce.
Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be difficult because insurance payments are often low. Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, said Kozhimannil. Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she said.
Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.
Encouraging medical professionals to move to rural areas is key, they say. A bipartisan bill introduced in Congress last year, for example, would require the federal government to designate maternity care health professional shortage areas. Such designations exist for primary care, mental health and dental care. The National Health Services Corps awards scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage area. Once they get to a community and put down some roots, the hope is they’ll stay.
Expanding the use of midwives and birthing centers could be cost effective since they are generally less expensive than physicians and hospital obstetric units. Although birthing centers and home births are on the rise, more than 98 percent of the 4 million babies that were born in 2014 made their arrival at a hospital.
“You can deal with lower volume and still be sustainable,” said Shah.
“Finding strength in numbers, small rural hospitals are increasingly banding together to share resources, said Kozhimannil. For example, since it’s difficult to keep rural staff trained in rare complications, small rural hospitals sometimes pool resources to buy a mobile simulation unit to train people on handling postpartum hemorrhage, the leading cause of maternal mortality.
Kozhimannil sees great opportunity in the ongoing national dialogue about health reform but says much of the research to date has focused on reforming health care in urban settings.
“That’s why it’s crucial to have rural people at the table,” she said.
Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.