President’s Task Force Aims To Help End Discrimination In Mental Health Coverage

Tucked in remarks the president made Tuesday on the opioid epidemic was his announcement of a new task force on mental health parity — aimed at ensuring that people with mental illnesses and substance abuse problems don’t face discrimination in the health care system.
Despite a landmark 2008 law intended to do just that, enforcement has been paltry, and advocates say discrimination has continued.
“The goal of the task force is to essentially develop a set of tools, guidelines, mechanisms so that it’s actually enforced, that the concept is not just a phrase — an empty phrase,” President Obama said during a panel discussion at the National Prescription Drug Abuse and Heroin Summit in Atlanta, Georgia. “We’ve got to let the insurance carriers know that we’re serious about this.”

Advocates say parity has long been an “empty phrase” and it has taken the administration far too long to address the problem. They say insurers have been subverting the law in subtle ways, and the government has not aggressively acted to stop them.
“It’s better late than never, and you can’t not be grateful for the fact that we’re finally implementing a law that was passed nearly a decade ago,” said former congressman Patrick Kennedy, one of the authors of the parity law. “But it’s troubling that it’s occurring in the last year of the presidency, and that it took the administration this long to address a problem that’s been with us for many years.”
In a 2015 survey by the National Alliance on Mental Illness, an advocacy group for people with mental illness and their families, many patients said they were denied payment because treatment was deemed “not medically necessary” twice as often for mental health as for other medical conditions. Only a handful of states, including California and New York, have been investigating whether insurers are complying with the parity law. Meanwhile, the federal government has taken few if any public enforcement actions, as Kaiser Health News reported last year.
For years, Kennedy has been traveling the country speaking about the lack of enforcement of the federal mental health parity law he helped create. One problem, he has said repeatedly, is that the administration has been hesitant to enforce a law against insurers, who were a key partner in implementing the Affordable Care Act.
“Even this administration, which is pro-consumer and liberal, has a tough time doing anything but dancing around issues of enforcing the law because they’re afraid to step on the insurers’ toes,” Kennedy said.
Tuesday’s announcement, he said, was also meager. “If the administration really wanted to be front and center on this they could have done it at the White House at a summit that would have gotten all kind of attention.”
Instead, he said, it was buried in an announcement of new programs and funding for opioid addiction. Also announced Tuesday were the final parity rules for patients with coverage under Medicaid and the Children’s Health Insurance Program (CHIP).
Despite the complaints of advocates and patients, insurers argue they have long been complying with parity.
“Our industry has long supported mental health parity and implementation of those requirements so that consumers have access to care when they need it,” Clare Krusing, a spokesperson for America’s Health Insurance Plans, the industry’s main trade group, said in a written statement. “Suggesting that coverage decisions drive the mental health challenges we face does a disservice to the ongoing efforts to improve the country’s health system for those who need behavioral health care.”
The interagency task force, which will be chaired by the White House’s Domestic Policy Council, will aim to identify and promote best practices for state and federal agencies to ensure that insurers are complying with the parity law. It will consist of heads of the departments of Treasury, Justice, Labor and Health and Human Services, among others, and will be responsible for delivering a report to the President by October 31, 2016.
“I think anything the White House does to acknowledge the obstacles to treatment of mental illness is a step in the right direction. But frankly, another task force is a far cry from much-needed enforcement,” said Meiram Bendat, a Los Angeles-based lawyer who has filed several lawsuits against insurers alleging violations of the parity law.
People with mental illness and their advocates have long been aware of exactly what the problems are, he said. But rooting them out will require the task force to be “keenly attuned to social and institutional bias against patients with behavioral health problems. And that bias frequently takes the form of insurance companies effectively limiting care only to crisis and refusing to acknowledge the pervasive and long-term nature of these disorders.”
Provider groups widely applauded the creation of the task force.
“What we’re hoping is that the task force will increase the visibility of the issue and highlight its significance,” said Dr. Renée Binder, president of the American Psychiatric Association, which has identified wide variation in how well insurers are complying with the law.
“We would welcome the opportunity to meet with the task force as part of its outreach charge,” she said.
But even if parity is successfully implemented, Benjamin Miller, director of the health policy center at the University of Colorado School of Medicine, said it may be “too little, too late.”
“It’s simply not enough to have mental health parity – even with this change in law, there will still be access issues for patients.”
That’s because mental health providers often don’t have appointments readily available or won’t accept these patients’ insurance coverage, he said.
“While mental health parity rights a wrong, it does not change the fundamental delivery of care, which is sorely needed for increasing access to mental health,” Miller said.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

A Crisis With Little Data: States Begin To Count Drug-Dependent Babies


How do fix a problem if you don’t know its size?
Many states — including some that have been hardest hit by the opioid crisis — don’t know how many of their youngest residents each year are born physically dependent on those drugs.
Pennsylvania is one of those states. Ted Dallas, head of Pennsylvania’s Department of Human Services, calls the information he’s working with “reasonably good.”
“Data is never pristine when you’re dealing with 2.7 million people,” he said. “Do I think it gives you a good picture of the issues that are out there? Yes.”
Between 2013 and 2014, about 3,700 babies on Medicaid in Pennsylvania were born with neonatal abstinence syndrome, Dallas said. The statistics show that 31 died before their first birthday — and neonatal abstinence syndrome likely played a role in at least some of those deaths.
But it’s not all the data Dallas would like to have. The statistics are two years old, he said, and only deal with babies who are covered by Medicaid, the government’s health insurance for the poor and disabled. That’s just a slice of Pennsylvania’s nearly 13 million people. More comprehensive, statewide numbers, he said, would have to come from Pennsylvania’s Department of Health — and that agency isn’t keeping track.

With more complete information, Dallas says, the state would be able to better deploy resources as it tries to solve a health problem that’s getting worse. With the right resources, there is an upside to this aspect of the opioid crisis: Babies with neonatal abstinence syndrome who get the right care usually do recover. But their care is expensive, and takes time.
“These babies are very work-intensive,” said Dr. David Wolf, who works in the neonatal intensive care unit in Pinnacle Health’s Harrisburg Hospital. “Our nurses are on the front lines; they have to deal with the minute-to-minute symptoms.”
Cuddling or rocking the babies nearly nonstop is key to successful treatment, Wolf said, along with adjusting medication doses frequently in the first 48 hours of the child’s life, to wean these newborns off opioids with as little discomfort as possible.
Each infant’s stay in the hospital can stretch past two or three weeks, and can cost $10,000 or much more. Then the babies need follow-up visits.
Pediatricians say that if the right agencies get real-time information, the babies are likely to get better care, and it’s more likely that hidden roots of the epidemic can be identified and addressed.
To make good decisions, health officials need basic information: Which infants are affected? How many, where, and why?
Pennsylvania might look to Tennessee’s tracking efforts. Tennessee reacted quickly when doctors started seeing a lot more cases of neonatal abstinence syndrome in 2012, recalled Dr. Michael Warren, a pediatrician and public health specialist with the Tennessee’s Department of Health.
“We were hearing from hospitals across the state, that they were really, really full,” Warren said, “and in some cases, bursting at the seams.”
It’s now mandatory for doctors and hospitals to report cases of neonatal abstinence syndrome within 30 days, and Tennessee made it simple for them to do so.
“If you’ve ordered from Amazon or an online service and you’ve been able to do that, you can navigate this system with ease,” Warren said. “And truly, at the end of it, you click ‘submit’ and that case is reported to us at the Department of Health.”
The data that started rolling into Tennessee shattered a number of stereotypes, Warren found.
“I think sometimes there’s a tendency to say these are just those moms who are using illicit drugs or buying those drugs on the street,” he said. “But what the surveillance system has actually allowed us to see, is that, in the majority of our cases, Mom is getting at least one substance that is prescribed to her by a health care provider.”
As a result, the state alerted doctors to the issue, recommending they try to change their prescribing habits, and more often offer alternatives to opioids, especially to pregnant patients. The evidence-based shift in prescribing recommendations only came about because health officials had solid data they could share.

When a public health crisis emerges, real-time data are especially important. Policymakers can use the information just as Tennessee did — to tailor solutions to the root causes. Otherwise solutions may miss the mark, or, if the data are old, come after the problem has festered and grown.
Pennsylvania Department of Human Services Secretary Ted Dallas acknowledged his state is missing out.
“If we had better data, generally, my theory would be we could make better decisions,” he said.
Just as I was wrapping up this story, Pennsylvania’s health department called. Starting in July, officials there plan to start collecting data about all babies who are born dependent on opioids.
The system to collect the information is still being developed, but neonatal abstinence syndrome will be added to the Pennsylvania’s list of reportable diseases, meaning that every time doctors diagnose a baby with the condition, they’ll be required to notify the state.
This story is the fourth in our four-part series, “Treating the Tiniest Opioid Patients,” a collaboration produced by Kaiser Health News, NPR and local NPR member stations.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Fantasy Sports Fueling A Rise In Online Gambling Addiction


Poison comes in many forms for addicts: Alcohol and drugs usually come first to mind, but gambling — often overlooked — is of increasing concern to state officials and rehab centers.
The number of problem gamblers has grown in recent years with an explosion of betting opportunities available at the touch of a smartphone screen. That is particularly true during this month’s annual “March Madness” college basketball tournament.
The state’s Office of Problem Gambling, part of the Department of Public Health, recorded 36,000 calls to its hotline last year — the highest number since it began public awareness efforts in 2003, said Terri Sue Canale-Dalman, who heads the agency. The number of problem gamblers in California is estimated to have reached 1 million.

The average gambler loses about $38,000 a year and is $20,000 in debt, Canale-Dalman said. And the damage is not only monetary: Relationships are often lost and some gamblers suffer a decline in mental and physical health.
Jason, a resident of Culver City, knows what it’s like to be seduced by high stakes. To his family and friends, Jason was a winner. He frequently reaped thousands of dollars through various forms of gambling: blackjack and sports betting were his favorites. Those who heard his stories thought him a lucky man.<10 years. Jason did win quite a bit, but he lost even more – a sum, he said, that many people earn over an entire lifetime.
“Gamblers are very good at not showing their cards,” said Jason, who requested his last name not be used because of the sensitivity of the subject. “I didn’t share my losses or horror stories. Most gamblers won’t.”
He also lost time — valuable time he now realizes would have been better spent with his wife and children.
For state health officials, stories like Jason’s aren’t new — but they’re hearing them more often now.
One reason: there are more ways to gamble than ever before.
In the digital age, table poker and slot machines are beginning to take the back seat. Instead, online gambling and fantasy sports are becoming more popular. With easy access from a computer, tablet or phone, daily fantasy sites such as New York’s FanDuel and Boston-based DraftKings have become the newer, hipper go-to platforms for people seeking the adrenaline rush that comes with sports betting. Mostly unregulated for the nearly 10 years they have been in existence, daily fantasy sports has become a controversial topic. The California legislature is considering legislation to clarify its legal standing and help address the problem behavior surrounding it.
Traditionally, participating in fantasy sports meant drafting athletes to create a team that would last an entire season. Now, daily fantasy sports contests are more immediate, offering leagues that last a weekend or a day. With that, opportunities to wager — and problem gamblers — have multiplied.
“We’re seeing a monumental shift,” said Dr. Eric Geffner, who has treated gambling addiction in Los Angeles since 1998. “What started as a pastime to relax and have a few beers with friends … has become full hardcore gambling.”
Many people are attracted to daily fantasy sports sites because they believe their sports knowledge can help them win, Geffner said.
Over the years, Geffner has seen hundreds of problem gamblers walk through his Westwood office. This time of year is particularly busy because March Madness offers a big pool of games to bet on, he said.
Daily fantasy sports, now a billion-dollar industry, was exempted from a federal law that outlawed Internet gambling in 2006. But state regulators are starting to scrutinize it. In the past few months, fantasy sports companies have been fighting in some states to remain in operation.
On March 21, DraftKings and FanDuel suspended their operations in New York pending a legal battle with the state’s attorney general. In California, a bill working its way through the state legislature would authorize and regulate daily fantasy sports sites.
The legislation, authored by Assemblyman Adam Gray (D-Merced), would allow these companies to operate in California after obtaining a license and paying an annual fee. The purpose of the legislation is to protect consumers, who currently assume all the risk.
The bill would prohibit an operator from allowing players to establish more than one account and would ban any advertising aimed at people under 21.
It would also require the state’s Department of Justice to develop an online self-exclusion form for problem gamblers who ask to be banned from gambling activities. The operators would have to make these forms available on their sites by July 2017.
Gray’s bill cleared the state Assembly in January and is now awaiting Senate action.
The daily sports fantasy industry does not consider itself to be in the gambling business. Industry representatives argue that unlike gambling, which is largely a matter of chance, daily fantasy sports require research and an ability to evaluate players and matchups.
But they are cognizant of problem behavior and willing to cooperate, said Peter Schoenke, chairman of the Fantasy Sports Trade Association. He said the industry is working with 20 states to help pass legislation that will clarify the legal status of daily fantasy sports.
“It’s not good for the industry to have those (problem) behaviors go unchecked,” Schoenke said. “We are being proactive and working to get bills passed that work for everyone.”
A spokeswoman for FanDuel said the site has trained staff in place to look for compulsive behavior by players. The number of contests a player can enter in a given time period is also limited, according to the site.
Jason, now in his mid-40s, never used DraftKings or FanDuel, but he has heard plenty about the sites from younger gambling addicts who, like him, are currently in treatment at Beit T’Shuvah, a rehabilitation center in Los Angeles whose name means “house of return” in Hebrew.

Yael Landa, the center’s gambling treatment program director, said Beit T’Shuvah treats a variety of addictions through residential and outpatient services. At any given time, about 120 people are enrolled in the center, 15 percent of whom are gamblers. Quite a few are in their early to mid-20s.
“We hear all kinds of stories from people of all ages,” Landa said. “People who owe a lot of money, people who’ve lived a double life. Some face severe financial wreckage.”
I. Nelson Rose, a law professor and gambling expert at Whittier Law School, said young adults’ attraction to gambling is not surprising: temptation is all around them. When gambling becomes convenient, common sense dictates that the number of problem gamblers grows, Rose said.
“Why in the world would you play a slot machine if you are carrying the world’s greatest games on your smartphone?” he said. “Warning signs vary,” she said. “This isn’t like alcohol. You can’t smell or see something right away.”
Michael Barbosa, 57, of Pleasant Hill, believes the lack of obvious physical symptoms might be a reason why gambling addictions are too often disregarded as a disease. He lost four marriages because of his addiction to card games and poker. He stole money from his mother and at one point ended up on the street.
In 2013, he started a rehabilitation program at HealthRight 360, a residential treatment facility in San Francisco. That’s where he learned that being addicted to gambling is not much different than being addicted to a drug. When he attempted to stop cold turkey, he’d get fevers.
“It made me physically sick,” Barbosa said. He also fell victim to depression, which he still struggles with today. “It all goes hand in hand,” he said.
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.

Pregnant And Addicted: The Tough Road To A Healthy Family


Amanda Hensley started abusing prescription painkillers when she was just a teenager. For years, she managed to function and hold down jobs. She even quit opioids for a while when she was pregnant with her now 4-year-old son. But she relapsed.
Hensley says she preferred drugs like Percocet and morphine, but opted for heroin when short on cash.
By the time she discovered she was pregnant last year, she couldn’t quit.
“It was just one thing after another, you know — I was sick with morning sickness or sick from using,” said Hensley, who is 25 and lives in Cleveland. “Either I was puking from morning sickness or I was puking from being high. That’s kind of how I was able to hide it for a while.”

Hensley said she was ashamed and hurt, and she wanted to stop using but didn’t know how. She had friends who would help her find drugs — even after they found out she was pregnant. But finding help to get sober and protect her child proved much more difficult, though.
The number of people dependent on opioids is increasing and that includes women of child-bearing age, like Hensley. Researchers estimated that every 25 minutes a baby was born dependent on opioids in 2012, the most recent year for which data are available.
By the time Hensley was about six months pregnant, she was living on couches, estranged from her mother and her baby’s father, Tyrell Shepherd. Her son went to live with her mother.
That’s when Hensley reached out for help. One moment, she dialed to get her fix. The next, she called hospitals and clinics.
“Nobody wants to touch a pregnant woman with an addiction issue,” she said.

Shepherd wasn’t happy when he realized Hensley was taking opioids while pregnant. “If you don’t care about yourself,” he said, “have enough common decency to care about the baby you’re carrying. Be adult. Own up to what it is you’re doing and take care of business. Regardless of how bad you’re going to feel, there’s a baby that didn’t ask to be there.”
After being rejected by two hospitals and several clinics, Hensley let herself go into withdrawal and then went to the emergency department of MetroHealth System, Cleveland’s safety-net hospital.
Under the auspices of a state-supported program, Hensley was prescribed Subutex — an opioid replacement drug that has helped her stop abusing drugs.
Her baby girl Valencia was born three months later. Mom and baby had their own room at the hospital, where nurses encouraged snuggling and breastfeeding. The nurses were also on hand to drop liquid morphine into Valencia’s mouth when her legs started shaking and her screams turned frantically high-pitched — the baby, too, had to be slowly weaned off of opioids.
Hensley cries as she remembers those early days: “She wouldn’t latch on — we couldn’t get her to feed. I couldn’t get her to stop crying. She was very fussy and I realized, ‘I did that to her. I took her choice away.’ And that’s one thing I still need to work through because I haven’t forgiven myself for that.”
Hensley hasn’t abused opioids in nine months, and Valencia is now about 6 months old. She has chubby baby cheeks and clear brown eyes the size of saucers.

During a recent visit Valencia kept cooing and smiling — especially when her mother was nearby.
“She started saying mamma,” Hensley said. “So now, at night when she wakes up, that’s what I hear: ‘Mamma, ma, ma, mama.’ ”
It’s been a journey. Hensley said only within the past few months has she stopped having dreams about using opioids.
Most physicians who specialize in addiction treatment agree that Hensley and her baby received the appropriate care. According to the American Congress of Obstetricians and Gynecologists, women who are pregnant should have medically-assisted opioid therapy that at least temporarily replaces the drugs they are abusing with opioids that are more stable, like methadone. Withdrawal should be discouraged during pregnancy if opioid-assisted therapy is available.
Quitting opioids cold turkey is dangerous for the infant and could increase the risk of preterm labor or fetal death.
Dr. Stephen Patrick, a neonatologist at Vanderbilt University’s School Of Medicine, said the medical community really needs to focus on providing access to medically assisted care for substance abuse.
“I think it’s time for us to reshape how we view addiction in the United States,” he said. “It is a medical condition — it is not a moral failing.”

Patrick has seen first-hand how difficult it is for women to find this medical help. At Vanderbilt and in other communities he’s visited around the U.S., he said, he’s seen women travel for hours to receive treatments for opioid-use disorder. It’s a particularly a problem in rural communities.
Dr. Jennifer Bailit, at MetroHealth, directs the mother’s program that helped Hensley, and was her obstetrician. It’s a tough problem to tackle, Bailit said.
“These are difficult patients. They are complicated and they have complex social needs,” Bailit said. “Many practitioners are just not equipped to deal with the breadth and depth of the kind of issues that come with them.”
In the past few years, MetroHealth has become a go-to place for pregnant women in Northeast Ohio, treating more and more patients. The hospital cared for a handful of pregnant women with opioid addiction in 2002. Last year, it saw 160 women, and many of them traveled some distance to reach the facility.
In addition to the sort of opioid replacement therapy that Hensley received, the hospital has a whole package of services to support mothers before and after the baby is born. The hospital assigned Hensley a social worker, and set her up with intense outpatient therapy — three days a week for six months. Hensley still checks in with a doctor at the hospital once a month to get her medications.
The support has helped the whole family recover. Valencia is hitting all her developmental milestones — like rolling over. And Shepherd has really taken to being a dad, regularly feeding the baby, changing diapers, and creating silly noises to make her laugh.
Hensley and Shepherd have picked out their wedding rings and have begun discussing where to have the ceremony. Hensley has gone back to cosmetology school, and the couple is also talking about when they can bring Hensley’s older son home.
This story is the third in our four-part series, “Treating the Tiniest Opioid Patients,” a collaboration produced by Kaiser Health News, NPR and local NPR member stations.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Supreme Court Asks For More Information In Birth Control Case

An apparently deadlocked Supreme Court is asking lawyers in a closely watched health law case to provide more information on how women working for religious employers might be able to get insurance coverage for contraception without violating the rights of their bosses.
The order also included a request for information about a scenario that might be a possible compromise in the case.
At issue in Zubik v. Burwell is an “accommodation” created by the Obama administration to a provision of the Affordable Care Act that otherwise requires most employers to provide female workers access to coverage of FDA-approved contraception with no copay.

Houses of worship are exempt from the requirement to provide contraceptive coverage, but religiously affiliated organizations (such as hospitals, universities and social service agencies) are required to submit information to their insurer or the government stating their religious objection. The insurer is then required to provide the coverage, under the accommodation.
The religious organizations that are suing, however, claim that the act of notifying the government or their insurance companies facilitates the coverage being provided, making them “complicit” in what they consider sinful.
The eight Supreme Court justices at last week’s oral arguments appeared evenly divided over whether the requirement represented a “substantial burden” on the organizations’ religious freedoms. (All but one lower court said it did not.) A 4-4 tie in the case (the seat of the late Justice Antonin Scalia remains vacant) would leave the lower court rulings intact unless the court opts to take up the issue after Scalia’s seat is filled. It also would create an unusual situation in which the rules would be enforced in most areas of the country, but not all.
The order issued Tuesday asked lawyers on both sides of the case to “file supplemental briefs that address whether and how contraceptive coverage may be obtained by petitioners’ employees through petitioners’ insurance companies, but in a way that does not require any involvement of petitioners beyond their own decision to provide health insurance without contraceptive coverage to their employees.” The final deadline for the new briefs is April 20.
As for the potential compromise, the justices asked the lawyers specifically if the religious organizations might inform their insurers when initially contracting for insurance that they do not wish to offer contraceptive coverage. At that point, the insurance company, “aware that petitioners are not providing certain contraceptive coverage on religious grounds — would separately notify petitioners’ employees that the insurance company will provide cost-free contraceptive coverage, and that such coverage is not paid for by petitioners and is not provided through petitioners’ health plan.”
Interestingly, those on both sides of the case say they were heartened by the latest turn of events.
“I find it encouraging that they’re asking for more information about how to ensure that women get contraception in their health plans,” said Brigitte Amiri, senior staff attorney for the American Civil Liberties Union. Seeking a potential compromise, she said, “seems to recognize that taking contraception out of health plans is harmful.”
David Cortman, senior counsel for the Alliance Defending Freedom and the attorney representing two of the religious organizations suing the government, said he also finds the request to be “a positive development.”
“The court addressed the very arguments that we’ve been making all along, of being complicit,” he said, and the justices appear to be making an effort to find some way to ensure that the benefits are provided, but the organizations are not required to violate their religious tenets in order for that to happen.”
Cortman would not say whether the potential compromise raised in the order would be acceptable to his clients. “If it is truly outside of our health insurance plan and doesn’t make the client complicit, that’s what we’ve suggested,” he said.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

A Nurse’s Lesson: Babies In Opioid Withdrawal Still Need Mom


HARTFORD, Conn. — Carolyn Rossi has been a nurse for 27 years, and she’s been fiercely protective of infants in her intensive care unit — babies born too soon, babies born with defects and, increasingly, babies born dependent on opioids.
Rossi works in the neonatal intensive care unit (NICU) at the Hospital of Central Connecticut near Hartford. Like many hospitals across the country, it has seen the number of babies born with neonatal abstinence syndrome go up dramatically in recent years. The National Institute of Drug Abuse reports more than 21,000 infants in the U.S. were born in withdrawal from opioids in 2012, the most recent year for which data are available. The hospital says each baby costs roughly $50,000 to treat.
These fragile and fitful babies present new challenges for hospitals. There’s research that suggests they may do best when they can be held for hours, by their mothers, in a quiet, private room as they go through the process of being weaned off the drugs. But delivering that care means changing hospital systems and attitudes about addiction among doctors and nurses.
“It was a lot about taking babies away from moms,” Rossi said, describing the way she first learned to care for babies in withdrawal. The nurses saw their role, she said, as “trying to protect the baby from the mother, basically. Like we were going to cure the baby but not cure the mother and the family.”
It wasn’t the best strategy. The babies can often be soothed best by their mothers. But mothers are struggling, too.

“So, [a mother] comes in with a stigma,” said Kate Sims, who directs the hospital’s women and children’s services. “She’s feeling guilt herself. And unfortunately, as best as we are as providers and nurses, we’re also judgmental.”
Sims said that feeling — that lack of trust between a mother and a nurse — can push that mom away, making treating the baby even harder.
So the hospital has started to retrain its nurses to think differently. The biggest change? Treating mom as a mom, and not as an addict. That means recognizing that addiction isn’t a moral failure, and that many people who are addicted come from a lifetime of trauma. Rossi said it’s been hard for nurses who are baby specialists to be mom specialists, too.
“It’s a big culture change for me personally, and I know for the NICU nurses that are in here. You really do believe you’re doing the right thing until something like this comes along.”
Along with changing a culture of nursing, it’s changing a hospital’s approach, too. Dr. Annmarie Golioto, chief of pediatrics and the head of the hospital’s nursery, says a bright, loud, bustling intensive care unit is a hard environment for a baby going through withdrawal. So she’s gotten approval to use a few rooms just outside the intensive care unit — quiet, monitored spaces for the baby and mother to stay for as long as the baby needs it.
“We’ve had to figure out, how can we use our rooms differently?” says Golioto. “How can we use our space differently? And how we can partner with mom differently to have that relationship with her to say, ‘We expect you to stay here with your baby and take care of the baby after you’ve been discharged.'”
Golioto hopes the new setting could shorten recovery times and decrease the amount of morphine a baby needs to ease withdrawal. She’s also hopeful these moves will inspire some mothers to think differently about their newborns.
“The thinking was, ‘My baby is being taken care of. There are nurses there. There are doctors there. I don’t need to be here. They’re getting everything they need,’ ” says Golioto. “What we’re trying to change the thinking is, ‘No, they’re not getting everything they need if you’re not here. Because they need you.’ ”
Nurse Rossi says she only needed to see the change in attitude and approach work once to see the culture shift pay off. It was back in December, and she gave a mother a room to stay in for more than a month while her baby went through withdrawal.
“She was just thrilled. And she wasn’t here 24/7. She couldn’t be here 24/7,” says Rossi. “She was here as much as she could and, just knowing that she had the flexibility, for me, helped me understand that she is a mom, she is a great mom, she wants to be a better mom.”
Nearly every aspect of the opioid epidemic worsened in 2014, according to the government’s latest figures. And even though this hospital’s programs are just a few months old, it’s hoping that this culture change will, at the very least, give at risk moms and babies a better start.
This story is second in our four-part series Treating the Tiniest Opioid Patients, a collaboration produced by NPR, local member stations 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.

Mortgages For Expensive Health Care? Some Experts Think It Can Work.


A Massachusetts Institute of Technology economist and Harvard oncologist have a proposal to get highly effective but prohibitively expensive drugs into consumers’ hands: health care installment loans.
Writing last month in the journal Science Translational Medicine, the authors liken drug loans to mortgages, noting that both can enable consumers to buy big-ticket items requiring a hefty up-front payment that they could not otherwise afford.
Some consumer advocates and health insurance experts see it differently.
“Isn’t this why we have health insurance?” asked Mark Rukavina, a Boston-based health care consultant whose work has focused on affordability and medical debt. “Insurance used to protect people from financial ruin for these unpredictable, costly occurrences. Now, with large deductibles, we’ve got coverage for preventive care but not for treatment.”

Andrew Lo, a financial economist at MIT’s Sloan School of Management, and Dr. David Weinstock, an oncologist at the Harvard-affiliated Dana-Farber Cancer Institute, agree that insurance would be a better option. But for many consumers that isn’t enough protection these days.
“This is a private sector stopgap way to deal with something right now,” said Lo.
Their proposal calls for the loans to be financed by a pool of investors who would buy bonds and equities issued by an organization that makes the loans to consumers.
While it’s “distasteful” to talk about patients mortgaging their lives for treatment, Lo said, they hope the proposal will spur change.
The health care installment loans that Lo, Weinstock and their co-author Vahid Montazerhodjat, a former MIT doctoral student who was working with Lo, propose would be aimed at helping people afford “transformative” therapies that cure potentially lethal conditions such as cancer or hepatitis C. They’re not designed to pay for maintenance drugs that help people deal with chronic illness. It’s easier for insurers to cover maintenance drugs because they’re purchased over an extended period of time, they said.
In contrast, breakthrough hepatitis C drugs Sovaldi and Harvoni, for example, can cure people of the liver-destroying disease in a few months, but the price tag of $84,000 or more has led many insurers to limit coverage to people whose disease has significantly progressed to show signs of liver damage.
“There are miraculous treatments like Harvoni, but they’re out of reach” for many people, said Lo.
Someone who wanted that Harvoni treatment might take out a health care loan with a nine-year term at an annual interest rate of about 9 percent, the authors suggest. In a twist on conventional loans, if a therapy doesn’t work or the patient relapses or dies, the patient isn’t obligated to repay the loan.

Are sick patients good loan prospects? Lenders might want to assess not only loan applicants’ creditworthiness but also their health to determine whether the applicant is likely to live long enough to pay it off.
The study authors say that requiring repayment only if the treatment works will protect patients and provide an incentive for the development of more effective drugs.
That’s a wrongheaded approach, said A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design.
Medical treatment isn’t always straightforward. Even highly “transformative” drugs such as Sovaldi aren’t guaranteed to work, Fendrick said, and other factors come into play. For example, about 10 percent of people who were prescribed Sovaldi for hepatitis C didn’t finish their course of treatment, Fendrick said, referring to an analysis by the CVS Health Research Institute.
“In this situation, the person who does the right thing and gets the good outcome is penalized and has to pay the money back,” he said. Instead, he argued, patients who follow their doctor’s recommendations and “do what you’re supposed to do” should not be held liable for the loans.
The proposal doesn’t address drug prices, except to say that the potential for increase due to higher demand for previously unaffordable therapies needs to be addressed.
Price increases are a real concern, said Paul Ginsburg, director of public policy at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The health law has made it easier for people to afford expensive drugs. It expanded Medicaid coverage to millions of lower income adults and capped at roughly $7,000 the amount consumers generally spend annually out-of-pocket for care.
“It’s helped people, but it’s also driven prices higher,” he said. From a drug company’s perspective, “It just means that more people can afford this drug, so we can charge more for it.”
Lo said the MIT Laboratory for Financial Engineering and the Dana-Farber Cancer Institute will host a conference this winter to bring together drug manufacturers, insurers, patient advocates, financial engineers and others to discuss strategies to make expensive drug therapies more affordable. Health care loans will be on the agenda, he 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.

When Medicare Advantage Drops Doctors, Some Members Can Switch Plans


Eliza Catchings has been seeing doctors at the Christie Clinic in central Illinois since 1957. But just after receiving this year’s WellCare Medicare Advantage member card, the insurer told her the clinic was leaving WellCare’s provider network and she would have to choose new doctors.
“I was terrified,” said Catchings, 79, who gets care for diabetes and heart problems. But she was helped by a little-noticed change in federal policy.
Medicare Advantage plans sold by private insurers are an alternative to traditional Medicare, but they cover services only from doctors, hospitals and other providers that are in the insurer’s network. Although providers are allowed to drop out of the plans any time, members can usually change only during the annual sign-up period in the fall. There are exceptions, but until recently losing a provider was not among them.
After insurers dropped hundreds of providers in 2013, the Centers for Medicare and Medicaid Services (CMS) issued rules giving people a “special enrollment period” to change plans or join regular Medicare if there was a “significant” change in their provider network. The policy took effect last year and applies only to Medicare Advantage members, not to the plans CMS oversees in the health law’s marketplaces.

Yet officials didn’t explain what they considered significant or what would trigger the option.
In the past eight months, Medicare officials have quietly granted the special enrollment periods to more than 15,000 Medicare Advantage members in seven states, the District of Columbia and Puerto Rico based on provider cuts. These decisions offer important details about how members can get permission to follow their doctors who leave their plans.
The number of beneficiaries affected has ranged from 344 members who lost access to 125 physicians and hospitals (3 percent of the network) in a New West Health Services plan in southwestern Montana to 7,830 members of MMM Healthcare and PMC Medicare Choice, which dropped 268 providers (about 5 percent) in Puerto Rico. Richard Shinto, president and CEO of InnovaCare, which runs both Puerto Rican plans, said poorly performing doctors were dropped so that the plans could improve their star ratings from CMS.
Those insurers notified CMS about the changes, as required by the government, to make sure the smaller network met minimum standards and members’ needs.
But Medicare Deputy Administrator Sean Cavanaugh said beneficiaries can also call the government’s help line, 800-Medicare, to request permission to leave their plans because they lost their doctors. In rare situations, Cavanaugh said, individual beneficiaries have been allowed to switch plans.
“What we’re looking for is whether their selection of a plan was based on a network and the presence of certain physicians and that their selection would’ve been different” without those physicians, he said.
Yet Medicare does not publicize the option, and few beneficiaries may know about it. Representatives who answered calls last week to Medicare’s toll-free number said nothing could be done.
Catchings sought help from Jen Tayabji of the Champaign County Health Care Consumers advocacy group, who then contacted Erin Weir at AgeOptions, the Area Agency on Aging in suburban Chicago.
They took examples of five Wellcare members who could not find new doctors to CMS, which then granted a special enrollment period to several hundred Christie Clinic patients and told WellCare to send them letters.
Miguel Torres, WellCare’s senior director for Illinois field sales and marketing, said Christie Clinic terminated its WellCare contract in three rural counties and the company is still trying to replace the 100 doctors the insurer lost. Creating “a competitive network” is a constant focus, he said, “to ensure that our members get the care closest to their homes.”
Now Catchings can stay with her long-time doctors at the Christie Clinic. “Everything’s the same,” she said, except one thing — she has a Medicare Advantage plan from Coventry.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Contratistas Agrícolas Se Resisten A Requisitos Del Obamacare


El Obamacare está poniendo a la industria de la agricultura en estado de tensión.
Muchos contratistas que proveen trabajos en granjas y que ahora pueden ofrecer seguro médico a sus trabajadores se están quejando en voz alta del costo para sus negocios, que ya tienen de por sí un bajo margen de ganancia.
Algunos están preocupados porque los formularios que deben llenar con el gobierno federal bajo la Ley de Cuidado de Salud pondrá a los problemas de inmigración en un primer plano. Cerca de la mitad de la fuerza de trabajo agrícola en Estados Unidos es indocumentada.
“Definitivamente va a haber algunas repercusiones”, dijo Jesse Sandoval, un contratista de trabajadores agrícolas de Stockton, California. “Creo que va a haber algunas cosas que no podrán ser ignoradas”.
Sandoval vino a una conferencia educativa sobre contratistas agrícolas —esencialmente dotaciones de trabajadores del campo coordinadas por agencias— realizada en el San Joaquin County Agricultural Center en Stockton, en el otoño. Hombres de hombros anchos, vestidos con chaquetas de mezclilla y sombreros de vaquero, se sentaron en la audiencia, escuchando una letanía de conferencias sobre leyes y normas que regulan su industria, incluyendo el mandato del Obamacare para los empleadores.

El año pasado, empleadores con 100 o más empleados de tiempo completo tuvieron que ofrecer seguro de salud a sus trabajadores o pagar una fuerte multa. Este año, empleadores que tienen de 50 a 99 personas a tiempo completo deben cumplir con este mandato.
Sandoval tiene cerca de 100 trabajadores en su nómina de pagos (payroll). Cuando los granjeros necesitan una cuadrilla para recolectar guindas, zapallos o espárragos, lo llaman y él les envía trabajadores. Tiene que ofrecerles seguro de salud este año, y se está resistiendo por el precio. A $300 por mes por empleado, estaría enfrentando una factura mensual de $30.000.
Sandoval dijo que no puede absorver el gasto. “Los números no están ahí”, dijo. “Mi margen de ganancia es del 10 por ciento, ¿y tengo que aumentar un 10 por ciento los gastos? Bueno, eso no funciona”.
Entonces, como muchos contratistas, está pasando la factura a los agricultores, que a su vez la pasan a los trabajadores agrícolas. En virtud de la Ley de Cuidado de Salud, los empleados pueden verse obligados a contribuir con el 9.5 por ciento de sus ingresos en primas de salud.
Pero para los trabajadores agrícolas que cosechan naranjas o duraznos a $10 por hora, eso todavía es demasiado. Agostin García, de Fresno, California, dijo que los dos contratistas para los que trabaja cerca de Fresno le ofrecieron seguro directamente. Pero cuando vio el precio, los rechazó.
“Para mí, que soy el único en mi casa que trabaja”, dijo. “Hay cinco de nosotros en la familia. Simplemente no funcionaría. O yo pago el seguro de salud, o pago el alquiler y las cuentas”.
García dijo que sólo una parte de sus compañeros de trabajo se han inscrito para la cobertura. Dijo que cuando los contratistas de trabajo agrícola reparten folletos que explican la cobertura, la página en la que los trabajadores rechazan está justo en la parte superior.
“Creo que lo hacen de manera intencional”, dijo García. “Ellos cumplen con las leyes al decir, ‘Yo ofrecí’”. Pero saben que nadie va a aceptarlo, saben que nadie va a pagar esas cantidades”.
El costo del Obamacare no es lo único que preocupa a las personas de la industria agrícola. Algunos están preocupados por los problemas de inmigración.
Los empleadores tienen que presentar nuevos formularios al IRS, tanto si sus trabajadores aceptan o no el seguro de salud.

La abogada Kaya Bromley dijo que esto hará las cosas más difíciles para algunos contratistas que suelen hacer la vista gorda cuando los trabajadores les dan documentos fraudulentos. “Ahora que hay más transparencia debido a todos los informes, creo que vamos a tener muchos más datos sobre el número de trabajadores ilegales o indocumentado que tenemos”, dijo.
Bromley dijo que entre los contratistas para los que ella hace consultoría, ha visto una serie de estrategias cuasi-legales e incluso ilegales para eludir el mandato de la ley de salud.
“He oído de empleados que eligen dejar el trabajo porque quieren estar ‘bajo el radar’. También he oído hablar de los empresarios que están instando a que se vayan, o al menos lo favorecen”, dijo. “Y les advierto a todos que van a estar en serios problemas”.
Los contratistas de trabajadores agrícolas dicen que están atrapados en un Catch-22. Técnicamente, los inmigrantes que se encuentran en Estados Unidos ilegalmente no son elegibles para los beneficios del Obamacare. Sin embargo, los empleadores no pueden admitir que cualquiera de sus empleados pueden estar trabajando de manera ilegal, por lo que tienen que ofrecer el seguro o enfrentar multas del IRS, tal vez incluso una demanda por discriminación.
“Es algo grande. Y nadie está hablando de la enormidad de esto”, dijo Bromley. “Cuando se juega, y comiencen las sanciones es cuando la gente va a empezar a tener la religión al respecto”.
Golinda Vela Chávez ayuda a gerenciar una empresa contratista en Salinas, California. Para ella, hablar del Obamacare le produce frustración, por el complejo sistema de inmigración del país.
Dijo que Estados Unidos no refuerza las fronteras, y luego no deja que la gente trabaje. “Y de repente, el empleador es malo”, dijo.
Contratistas se preguntan cómo se supone que deben cumplir con la Ley de Cuidado de Salud cuando todavía hay tanta contradicción en el sistema de inmigración. “Nuestro gobierno, lo único que hace es hablar de ello, pero no soluciona nada, eso hace que todo sea peor”, dijo Chávez.
La Ley de Cuidado de Salud es como un cortador de galletas, dijo, y las complejidades de la industria de la agricultura simplemente no encajan.
Esta historia fue producida por Kaiser Health News, un programa editorial independiente perteneciente a la Kaiser Family 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.

Pharmaceutical Company Has Hiked Price On Aid-In-Dying Drug


When California’s aid-in-dying law takes effect this June, terminally ill patients who decide to end their lives could be faced with a hefty bill for the lethal medication. It retails for more than $3,000.
Valeant Pharmaceuticals, the company that makes the drug most commonly prescribed by physicians to aid patients who want to end their lives, doubled the drug’s price last year, one month after California lawmakers proposed legalizing the practice.
“It’s just pharmaceutical company greed,” said David Grube, a retired a family doctor in Oregon, where physician-assisted death has been legal for 20 years.
The drug is Seconal, or secobarbital, its generic name. Originally developed in the 1930s as a sleeping pill, it fell out of favor when people died from taking too much or from taking it in combination with alcohol. But when intended as a lethal medication to hasten the death of someone suffering from a terminal disease, Seconal is the drug of choice.
“It works very quickly and very gently,” says Grube, who is also the national medical director for Compassion and Choices, an advocacy group. “People fall asleep with no complications. It’s a very gentle passing.”
In 2009, Grube remembers the price of a lethal dose of Seconal — 100 capsules — was less than $200. During the next six years, it shot up to $1,500, according to drug price databases Medi-Span and First Databank. Then Valeant bought Seconal last February and immediately doubled the price to $3,000.

Most drug companies justify such hikes by pointing to high research costs. But Grube says that’s not the case with Seconal. It’s been around for 80 years.
“It’s not a complicated thing to make, there’s no research being done on it, there’s no development,” he says. “That to me is unconscionable.”
Valeant bought several other drugs at the same time it bought Seconal, raising some of those prices as much as 500 percent. That sparked a congressional investigation into its pricing practices. (The company’s CEO resigned Monday).
“Valeant sets prices for drugs based on a number of factors,” the company said in a statement, including the cost of developing or acquiring the drug, the availability of generics and the benefits of the drug compared with costly alternative treatments. “When possible, we offer patient assistance programs to mitigate the effects of price adjustments and keep out-of-pocket costs affordable for patients.”
The most likely explanation for raising the price of Seconal is the lack of generics, says Mick Kolassa, founding partner of Medical Marketing Economics, a firm that advises drug companies on how to price and market their drugs.
Seconal went off patent in the early 1990s. There were some generics for a while, but then demand shrank and manufacturers abandoned them.
“So that meant when the current company bought it, they didn’t have any generic competition, simply because the market got so small that it left,” Kolassa said. “So in situations like that, a company can acquire it and raise the price.”
Kolassa says it’s also possible that the demand for even the brand-name drug is so low that it’s hard to recoup the costs of making and selling it.
“Here’s a company that said, ‘Well, we can raise the price, keep it on the market and make some money with it. Or we can walk away and the product goes away,’” he said.
Whatever the explanation, what cancer patients like Elizabeth Wallner see is a drug company taking advantage. She has one word to describe the pharmaceutical executive who decided to double the price of Seconal: “Scumbag.”
Wallner was diagnosed with Stage 4 colon cancer five years ago. It spread to her liver and lungs. She always thought that if her suffering became too unbearable, she would consider ending her life. But she never thought about the price tag of the lethal drug.
“You’re going to make money off my death,” she said.
She’s most worried about her son.
“You are literally, at that point, taking the money from children,” she said. “Everything I have, if I’m going to die tomorrow, everything I have will be left to my son who will be 20 years old and almost 100 percent on his own.”
Under the California aid-in-dying law, it is optional for health insurance companies to cover the costs of the practice. Most private insurers plan to do so, according to the California Association of Health Plans.
So does the state’s Medicaid program.
But for patients who aren’t covered, there is a cheaper alternative: a three-part drug cocktail that can be mixed by a compounding pharmacy for about $400.
Grube says the cocktail works just as well, but doctors usually don’t prescribe it because of the hassle some patients have to go through to get it. Seconal, on the other hand, is a ready-made pill, routinely available at most retail drugstores.
He says advocacy groups are working on campaigns to reduce drug costs and to educate doctors and patients about the law.
“My dream is that any Californian who will choose aid in dying would have few burdens or barriers to jump through,” Grube said.
Katie Orr contributed reporting from Sacramento.
This story is part of a partnership that includes KQED, 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.