Baltimore Draws 10-Year Blueprint To Cut Racial Health Disparities

Baltimore officials presented a 10-year plan Tuesday that sharply highlights the poor health status of African-Americans and aims to bring black rates of lead poisoning, heart disease, obesity, smoking and overdoses more in line with those of whites.
“We wanted to specifically call out disparities” in racial health, said Dr. Leana Wen, who became the city’s health commissioner early last year. “And we have a moonshot. Our moonshot is we want to cut health disparities by half in the next 10 years.”
Black Baltimore leaders praised Wen for putting disparities squarely in the conversation even as they acknowledged the difficulty of achieving the plan’s goals.
“It’s a big challenge. There’s no debating that,” said Diane Bell-McKoy, CEO of Associated Black Charities, a Maryland nonprofit. “She takes a step forward more so than anybody else I’ve seen because she calls it out. Most of the time we find code words for it. We don’t call it out.”
Violence last year following the death of Freddie Gray, a black man who died after being injured in police custody, exposed Baltimore’s health divide as well as its criminal justice differences, officials said. Gray’s family had won a settlement for alleged lead-paint poisoning, which is blamed for low test scores and cognitive challenges among thousands of Baltimore children.

“What happened last year with Freddie Gray put Baltimore in the national media spotlight,” said Helen Holton, a Baltimore councilwoman who represents a portion of the city’s west side. “That made people stop and take notice of what had been going on and stop treating it as business as usual.”
The health plan, called Healthy Baltimore 2020, was first reported by the Baltimore Sun. Officials plan to track blood-lead levels, overdose deaths, child fatalities, healthy-food availability and other indicators year by year. It’s called Healthy Baltimore 2020 because officials have set ambitious goals to achieve before 10 years is up, Wen said.
Tentative targets include cutting youth homicides by 10 percent and disparities in obesity, smoking and heart-disease deaths by 15 percent — all by 2020.
Tactics include more programs to reduce street violence, expanded anti-smoking campaigns, more home visits for pregnant women and increased access to naloxone, which blocks the effects of heroin.
The blueprint is “an ongoing document” that will be amended with community participation and results closely scored, Wen said.
“Our community is sick of us overpromising and underdelivering,” she said.
Baltimore officials have made substantial progress in reducing lead poisoning, lowering teen pregnancy and cutting infant mortality.
But as in many other areas, Baltimore is still divided by health. Residents of Gray’s west-side neighborhood of Sandtown-Winchester live 10 years less on average than Marylanders in general. Poor neighborhoods have far higher rates of heart disease, diabetes, addiction, HIV infection and other illness than more prosperous parts of the city.
Black leaders emphasized that Baltimore’s health won’t improve unless policymakers address deeper causes of illness such as poverty, unemployment and poor housing.
“It is affirming to see someone in Dr. Wen’s role address the uncomfortable truths behind health inequities,” said Debbie Rock, CEO of LIGHT Health and Wellness, which offers health and other community services on Baltimore’s west side. “This is a great platform to also address upstream factors” such as low incomes, she said.
Holton compared the health blueprint to a Justice Department report this month alleging a pattern of excessive force and violation of constitutional rights by the Baltimore Police Department.
Both documents address racial differences and offer challenges for improvement, she said.
“You can travel 5 miles from one neighborhood to another and it’s like you are in two different communities” in health levels, Holton said. “Freddie Gray was like the tipping point. Let’s take this and make it a teachable moment of how to be better moving forward.”Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Cardiac Rehab Improves Health, But Cost And Access Issues Complicate Success

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CHARLOTTESVILLE, Va. — Mario Oikonomides credits a massive heart attack when he was 38 for sparking his love of exercise, which he says helped keep him out of the hospital for decades after.
While recovering, he did something that only a small percentage of patients do: He signed up for a medically supervised cardiac rehabilitation program where he learned about exercise, diet and prescription drugs.
“I had never exercised before,” said Oikonomides, 69, who says he enjoyed it so much he stayed active after finishing the program.
Despite evidence showing such programs substantially cut the risk of dying from another cardiac problem, improve quality of life and lower costs, fewer than one-third of patients whose conditions qualify for the rehab actually participate. Various studies show women and minorities, especially African Americans, have the lowest participation rates.
“Frankly, I’m a little discouraged by the lack of attention,” said Brian Contos, who has studied the programs for the Advisory Board, a consulting firm used by hospitals and other medical providers.

Now, though, advocates say cardiac rehab may gain traction, partly because the federal health care law puts hospitals on a financial hook for penalties if patients are readmitted after cardiac problems. Studies have shown that patients’ participation in cardiac rehab cut hospital readmissions by nearly a third and saved money.
The law also creates incentives for hospitals, physicians and other medical providers to work together to better coordinate care.
Cost Undermines Participation
Oikonomides, who lives in Charlottesville, went for three decades without another heart attack after his first, but recently had bypass surgery because of blockages in his heart.
He is again rebuilding his strength at the University of Virginia Health System. “I attribute my 30 good years of life to cardiac rehab,” he said recently while pedaling on a stationary bike in a light-filled gym at one of the university’s outpatient medical centers, a heart monitor strapped to his chest.
But many patients still face hurdles.
Uninsured patients simply can’t afford cardiac rehab. And for those with some form of coverage, “the No. 1 barrier is the cost of the copayment, which is frustrating,” said Dr. Ellen Keeley, a cardiologist at UVA, who strongly encourages her patients to enroll.
Medicare and most private insurers generally cover cardiac rehab for patients who have had heart attacks, coronary bypass surgery, stents, heart failure and several other conditions. Most coverage is two or three hour-long visits per week, up to 36 sessions.
Insured patients usually must make a per visit copay to participate. For regular Medicare members, that runs about $20 a session, although many have private supplemental insurance that covers that cost. For patients with job-based insurance — and enrollees in the alternative to traditional Medicare called Medicare Advantage — out-of-pocket costs can range from nothing per session to more than $60 a pop.
“Some insurers say a copay for a specialty visit is $50, whether that means going to a neurosurgeon once in their life or whether that’s three times a week for cardiac rehab,” said Pat Comoss, a consultant in Harrisburg, Pa., who trains nurses to work in these programs.

More than a year ago, federal Medicare officials met with insurers after advocates voiced their concern that higher copays were keeping patients from cardiac rehab, said Karen Lui, a legislative analyst for the American Association of Cardiovascular and Pulmonary Rehabilitation, the profession’s trade group.
“To their credit, they dug in and talked with plans that had much higher copays, such as $100 per session,” said Lui. Medicare officials told insurers that a $50 copay per session is the upper limit a plan should charge,” he added.
UnitedHealth, with nearly 3 million members in Medicare Advantage plans, said patient payments for cardiac rehab vary widely. About 12 percent of members pay nothing, while 23 percent pay $50 a session. Another large insurer, Humana, has a similar range, with copays running up to $60 a session.
Nationally, the weighted average payment now for Medicare members in private plans is just a bit more than the $20 that patients in traditional Medicare pay, said Dale Summers, director of the Center for Medicare & Medicaid Services’ division of finance and benefits.

Preventing The Next Heart Attack
Aside from cost, another big reasons so few patients participate is many are never referred to a program. Some hospitals are addressing this disconnect by building automatic referrals into their discharge system.
Patients may be reluctant to attend cardiac rehab, especially if they had not been physically active before their heart problem.
To counter that, Gary Balady, director of preventive cardiology at Boston Medical Center stresses its importance with his patients. He tells them that about 15 percent of heart attack patients may experience another one within a year.
“One of first things we say [in cardiac rehab] is we are here today to work together to prevent the next heart attack,” he said.
At the University of Virginia medical center, heart attack patients are given an appointment to come back to a special clinic within 10 days of discharge. Over the course of about an hour, patients meet with an exercise physiologist, a cardiologist, a nutritionist and a pharmacist — and all in the same exam room.
At the visit, the medical professionals answer questions, go over the patient’s medications, make diet tips and recommend cardiac rehab. Kathryn Ward, manager of UVA’s cardiology clinics, says up to 100 patients a month were referred to the clinic in its first year. Of those, 71 percent enroll, she said, well over the national average.
Other Barriers
Still, patients face other barriers to this kind of care, including time constraints, or having to travel long distances to the nearest program.
And existing programs aren’t enough to accommodate all patients who are eligible. A recent study in the Journal of Cardiopulmonary Rehabilitation and Prevention surveyed 812 existing cardiac rehab programs in the U.S., finding that even if they were expanded modestly and operated at capacity, they could still only serve 47 percent of qualifying patients.
“We have patients who are an hour away from any cardiac facility and they can’t afford the gas money or the time,” said UVA cardiologist Keeley.

Take Kathryn Shiflett of Culpeper, Va. At age 33, the last thing she expected was a heart attack.
But one night in late March, she felt pain in her arm — pain that spread to her jaw — and she felt nauseated. After tests at a local hospital, she was transferred by ambulance to UVA, where cardiologists opened a blocked artery in her heart.
Shiflett, a medical worker with two children, traveled back to UVA a week later for her clinic appointment, and was encouraged to participate in cardiac rehab.
Shiflett found the program appealing because she wants to be active and prevent a repeat of her heart attack. But she lives an hour away. In addition to the distance, she isn’t sure she can make any of the sessions. Cardiac rehab classes are during working hours. The latest starts at 3 p.m.
“I’m not sure I can get there by then,” Shiflett said.
One answer for patients like Shiflett could be a home-based program, which are less common, but drawing increased interest.
“There are a whole plethora of different ways to provide cardiac rehab outside traditional center model,” said Mark Vitcenda, senior clinical exercise physiologist at the University of Wisconsin Hospital and Clinics in Madison.
At his program, patients can start in a supervised program at a center for two or three sessions, then can choose whether to continue in a home-based model, with occasional visits to the center. About 30 to 40 percent of Wisconsin program patients choose the home-based option, he said, with most being younger, working patients with lower medical risk.
“If we can lower the barriers of transportation and cost, patients are able to be more involved,” 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.

Did It Hurt Or Help? Researchers Analyze Ohio’s 2011 Abortion Law

Did a law regulating drug-induced abortions keep women safe or block them from access to this procedure?
A study published Tuesday in the journal PLOS One suggests an Ohio law limiting how women can obtain a medical abortions may have led to a higher rate of complications. But the law’s defenders said these conclusions should be viewed with skepticism, and that researchers detected more need for follow-up care because the law resulted in more careful patient monitoring, unearthing problems they say were already there.
The findings add to the ongoing national debate over abortion, and whether and how to regulate it.
The study, conducted by researchers from the University of California, San Francisco, analyzed the now five-year-old law. Similar measures are on the books in Texas and North Dakota.
Ohio’s law requires that women receiving a so-called “medication abortion” take the pills in accord with protocols established in 2000 when the procedure was approved by the federal Food and Drug Administration.
Here is how the procedure works: Women in the early stages of pregnancy take a two-pill regimen — mifepristone and then, a day or two later, misoprostol — to induce abortion. It typically causes some level of cramping and bleeding. Both dosage amounts were set by the agency and had to be taken at a doctor’s office before the pregnancy reached seven weeks.
Research in the ensuing years suggested smaller doses of the pills are equally effective, and that women can take the misoprostol dose at home, on their own. That brings down the number of needed doctor’s visits to the initial mifepristone trip and a follow-up after, to verify the abortion in fact took place. In response, many physicians in states without such statutory requirements prescribed an “off-label” form of the treatment, rather than the one that had been sanctioned by the FDA or by the Ohio law.
The FDA updated its original medication abortion protocols in March. So, the Ohio law, which says doctors must adhere to the agency’s rules, now aligns with this revamped regimen, meaning women only have to see a doctor twice, can take smaller doses and have 10 weeks to get a medication abortion.
This reflects a concern many doctors had put forth: that tying the law to this 16-year-old standard of care placed an undue burden on women, requiring them to visit the doctor more often, take larger doses and get the procedure done earlier in their pregnancy — within seven weeks. That, they said, could have a chilling effect, especially as those laws were often passed in tandem with other restrictions, like requiring hospital admitting privileges for the doctors performing abortions, and having facilities providing them meet certain building standards.
But the new alignment between the FDA and best practice is not necessarily permanent, so laws like Ohio’s still raise a red flag, said Ushma Upadhyay, an associate professor of obstetrics, gynecology and reproductive health at UCSF, and the study’s lead author. As science progresses, researchers and health professionals may discover more effective or more convenient ways to administer medication abortion. For instance, clinical trials are underway to expand the timeframe in which the procedure is safe. Because medical best practices change more quickly than FDA approval, she added, women who live where these laws are still on the books could, in the future, face a similar gulf between the best care option and what, under the law, doctors are allowed to do.
“There’s an increasing number of restrictions on all abortions, including medication abortion,” Upadhyay said. “Often they’re under the guise of improving health and safety for women. And what is needed is more evidence.”
In this study, researchers used information from four major abortion providers in Ohio to examine medication abortions, looking at about 1,200 cases before the law and nearly 1,600 after.
Their findings: Once the law was in effect, women were three times as likely to need extra medical care after the procedure, such as follow-up visits or more medication. Women more frequently experienced side effects like nausea and vomiting. They faced higher costs — likely, the researchers said, because they had to take larger amounts of medication. A standard medication abortion can cost between $300 and $800. In addition, they were far less likely to seek out the medication abortion option. The incidence rate for this procedure dropped from 22 percent of women in 2010 to about 5 percent in 2014, a dip the study authors attributed to greater difficulty in paying or meeting the requirements for a medication abortion.
“Between the cost, and the extra trips and the shorter time period, it didn’t make it feasible” to have a medication abortion, said Heather Boonstra, director of public policy for the Guttmacher Institute, which researches reproductive issues. That, she added, put states with these restrictions out of step with women’s preferences.
“Observationally, what you see across the nation over time is an increased use of mediation abortion,” said Boonstra, who did not help with the study. “That trend continued in other parts of the nation, whereas you saw this significant drop in Ohio.”
The researchers also note that those consequences do not appear uniformly distributed. Women covered by Medicaid, the federal-state insurance plan for low-income people, were less likely to receive follow-up care than their privately-insured counterparts. It is unclear why that was the case, Upadhyay said, but it is possible those women needed follow-up treatment and were not able to get it, thanks to barriers like needing childcare, working multiple jobs or not being able to find transportation to the clinic.
Americans United for Life, an anti-abortion advocacy group that has presented evidence in support of laws such as Ohio’s medication abortion measure, dismissed the research as biased. “When considering a study, you have to consider the source,” said Clarke Forsythe, the group’s acting president and senior counsel, in a statement.
AUL is reviewing potential legislation to push next year, said Kristi Hamrick, an organization spokeswoman, and medication abortion will likely remain a subject of conversation, she said, adding that the organization is concerned about the drug’s potential consequences. “I suspect we will be talking about this for a while,” Hamrick said.
However, research has found that, while medication abortion is somewhat riskier than its surgical counterpart, complications are very rare.
While women needed extra medical care, it is not clear the abortion laws put them at risk, Upadhyay noted. Most got an extra dose of medication, or had the abortion performed through the more common, invasive procedure, she said. But the abortion process as a whole was “a lot more burdensome” without needing to be, she said. And the increased requirements for getting the procedure meant women faced more barriers toward getting health care generally.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

‘America’s Other Drug Problem’: Copious Prescriptions For Hospitalized Elderly

SANTA MONICA, Calif. — Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.
A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.
And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.
“This is actually a little bit alarming,” Bailey said.
He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal’s breathing.
An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.
“This is America’s other drug problem — polypharmacy,” said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. “And the problem is huge.”

The medical center, where Bailey also works, is intended specifically for treating older people. One of its goals is to ensure that elderly patients are not harmed by drugs meant to heal them.
That work falls largely to Bailey, a clinical pharmacist specializing in geriatric care.
Some drugs can cause confusion, falling, excessive bleeding, low blood pressure and respiratory complications in older patients, according to research and experts.
Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.
Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable “adverse drug events” occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).
And even if a drug doesn’t cause an adverse reaction, that doesn’t mean the patient necessarily needs it. A study of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.
“There are a lot of souvenirs from being in the hospital: medicines they may not need,” said David Reuben, chief of the geriatrics division at UCLA School of Medicine.
Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.

University of California, San Francisco researcher and physician Ken Covinsky, said many doctors who prescribe drugs in hospitals don’t consider how long those medications might be needed. “There’s a tendency in medicine every time we start a medicine to never stop it,” Covinsky said.
When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don’t have a family member or a caregiver to help, the consequences can be disastrous.
One 2013 study found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.
UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital’s geriatric unit to improve care and reduce readmissions among older patients.
Speaking from his hospital bed at UCLA’s Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.
Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.

“I’m very confused about it, to tell you the truth,” he said after talking to Bailey. “It’s complicated. And if the pills are not right, you are in trouble.”
Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.
Over a six-month stretch after Bailey started working in UCLA’s Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.
Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.
“As you know, our elderly are already at risk for an accumulation of drugs in their body,” he told the group. “If you put a drug that has a really long half-life, it is going to last even longer in our elderly.”
The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey’s services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.
Bailey said he tries to answer several questions in order to determine what’s best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?
One of his go-to references is known as the Beers list — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.
When he’s not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients’ medication lists are accurate and up to date. He also monitors patients’ new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.
“Medications only work if you take them,” Bailey said dryly. “If they sit on the shelf, they don’t work.”

That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.
Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.
Bailey said he’s constantly weighing the risks versus the benefits of medications for elderly patients like Cal.
“It is figuring out what they need,” he said, “versus what they can survive without.”
This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.
KHN’s coverage of aging and long-term care issues is supported by a grant from The SCAN Foundation, and its coverage of late life and geriatric care is supported by The John A. Hartford 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.

Patients, Fearing Pricey Follow-Ups, May Shy Away From Some Colon Cancer Tests

This week, I answered a grab bag of reader questions about insurance coverage for colorectal cancer screening, hospital facility fees and the tax treatment of annual fees charged by concierge medical practices.
Q. A stool-based DNA test to screen for colon cancer is available that is readily paid for by health plans, including Medicare. But if I have a positive Cologuard test result, I’d have to pay several hundred dollars for a regular diagnostic colonoscopy. Doesn’t this discourage people from getting screened for colon cancer, which is the goal, after all?
A. Patient advocates point to several reasons people may be discouraged from getting tested for colorectal cancer, including the “ick” factor and the time it takes to prepare for and get a colonoscopy, the most common screening test. “But the number one factor is always cost,” said Caroline Powers, director of federal relations at the American Cancer Society Cancer Action Network.
Commercial insurers and the Medicare program cover cancer screenings that are recommended by the U.S. Preventive Services Task Force without requiring any payment by patients. The task force, an independent panel of medical experts, recommends colorectal cancer screening for people from age 50 to 75.

Several different types of tests get the thumbs up from the task force, including colonoscopy, in which a flexible tube with a camera is snaked through the colon from the rectum to look for polyps and other abnormalities, and stool-based tests, including the DNA test you mention, which looks for genetic mutations associated with cancer or polyps.
But, as you point out, there’s a potential hitch. If you get a positive test result from a DNA test or other screening method, you’ll need to get a follow-up colonoscopy to check whether the test result was correct.
Patient advocates have argued that the follow-up colonoscopy should be provided without cost sharing by patients, and doctors tell them that some private insurers are beginning to handle the process that way, Powers said. But in the Medicare program that follow-up test is still considered diagnostic, and seniors are responsible for any deductible and coinsurance charges. Patient advocates continue to lobby for a change to that policy.
“From a public health perspective, it goes against everything we’re trying to do,” Powers said.
Q. I have carpal tunnel syndrome in both wrists. I visited a hand surgeon at his office who gave me a cortisone shot in my right wrist. His bill was $450, of which my insurance covered $420. But I also received another bill from the hospital with which his practice is affiliated that included a $1,702 facility fee for which I have a $400 co-payment. This seems so unfair. What can I do to avoid owing that charge?
A. There may not be much you can do after the fact. As hospitals continue recent efforts to purchase physician practices, hospital facility fees are increasingly common. In 2014, a third of doctors were either employed by a hospital or worked in practices that were at least partly owned by a hospital, an increase from 29 percent in 2012, according to a study by the American Medical Association. Even if the doctor’s office is located across town, the physician practice essentially becomes part of the hospital, and patients are typically billed for both physician services and hospital facility charges.

Starting next year, some hospital facility charges will no longer be allowed. Under the Bipartisan Budget Act of 2015, the Medicare program will no longer pay hospital facility fees for outpatient services at physician offices that aren’t located on the hospital campus. However, the change will apply only to practices that hospitals acquire after Nov. 15, 2015, and doesn’t affect commercial insurers at all.
The best way to protect yourself from unexpected facility fees is to get details from the physician’s office before you visit, said Richard Gundling, senior vice president at the Healthcare Financial Management Association, a group for professionals in health care finance. That way, you can make an educated decision about whether to proceed before you get a surprise bill. “The patient should always ask, ‘What is my out-of-pocket cost for this visit?’”
Q. My husband’s family physician is a member of MDVIP, one of many “concierge” practices in which a doctor or group of doctors generally charge an annual fee for faster appointments, more access to the doctor, more time with him during appointments, and preventive services during the annual wellness visit that aren’t included in a regular Medicare annual wellness visit. Is the annual fee of $1,650 tax deductible?
A. The annual fee is generally tax deductible, said Roy Harris, general counsel at MDVIP. That annual fee covers the cost of an executive physical every year for members, often a checkup with extra bells and whistles such as additional tests or screenings. If people itemize their medical expenses on their income taxes, they can generally deduct the expense as a physical exam. Even if they don’t itemize, many people get reimbursed from their flexible spending accounts or health savings accounts for the annual fee after getting their physical, Harris said.
Mark Luscombe, principal federal tax analyst at Wolters Kluwer Tax and Accounting, a software and information services company, agreed, although he noted that the Internal Revenue Service hasn’t weighed in specifically on this issue.
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.

A Young Woman Dies, A Teen Is Saved After Amoebas Infect The Brain

Doctors describe 16-year-old Sebastian DeLeon as a walking miracle — he is only the fourth person in the U.S. to survive an infection from the so-called brain-eating amoeba.
Infection from Naegleria fowleri is extremely rare but almost always fatal. Between 1962 and 2015, there were only 138 known infections due to the organism, according to the Centers for Disease Control and Prevention. Just three people survived. This summer, two young people, one in Florida and one in North Carolina, became infected after water recreation. Only one had a happy ending.
DeLeon is a 16-year-old camp counselor. The Florida Department of Health thinks he got the infection while swimming in unsanitary water on private property in South Florida before his family came to visit Orlando’s theme parks.
So many things had to go right for DeLeon to survive. On a Friday, he had a bad headache. The next day, his parents decided this was way more than just a migraine and took him to the emergency room at Florida Hospital for Children.

Doctors persuaded the family to do a spinal tap to rule out meningitis, even though he didn’t have a stiff neck, the telltale symptom. Sheila Black, the lab coordinator, looked at the sample and assumed she saw white blood cells. But then she took a second, longer look.
“We are all detectives,” Black said. “We literally had to look at this and study it for a while and watch for the movement because the amoeba can look like a white cell. So unless you’re actually visually looking for this and looking for the movement, you’re going to miss it.”
That movement triggered the alarm: This was an amoeba case. And that’s when the pharmacy reached out to a small Orlando drug company called Profounda, which has a drug called Impavido that was originally developed as a cancer treatment and approved by the FDA in 2016 to treat the tropical parasitic disease leishmaniasis. It has been used in several cases to treat amoeba infections as well.
Profounda CEO Todd MacLaughlin got the call from the pharmacy, but he was out of town so his son drove the drug to Florida Hospital.
“Within 12 minutes he had picked up the product and was on the way to the hospital,” MacLaughlin said. “Everybody was in the right place at the right time.”
DeLeon was given the drug along with others. Doctors put him into a coma and lowered his body temperature to give the drugs time to work and slow the infection.
Dr. Humberto Liriano was emotional talking about the experience. They knew the odds were not in DeLeon’s favor when he was placed into a coma.
“The family when they came to me, immediately within four hours, I had to tell them to say their goodbyes,” Liriano said. “I had to tell them, ‘Tell him everything you want to tell your child, because I don’t know from the time I put him to sleep to the time I take the tube out, [if he will] wake up.’ ”
DeLeon’s mother, Brunilda Gonzalez, thanked doctors at a press conference.
“We are so thankful that God has given us the miracle through this medical team and this hospital for having our son back and having him full of life,” Gonzalez said. “He’s a very energetic, adventurous, wonderful teen. We’re so thankful for the gift of life.”
Central Florida has coped with amoeba infections before, including the death of Jordan Smelski, who died at the same hospital where DeLeon was saved. Smelski’s parents started a foundation to raise awareness of the disease in the medical community and to advocate for hospitals to stock the drug in case of an infection.
Profounda says seven hospitals have taken it up on stocking the drug at no cost, charging them only when the drug is used. The drug costs $48,000 for a full round of treatment. MacLaughlin said the company will provide the drug free if someone doesn’t have insurance.

DeLeon will soon head to South Florida for rehab, and doctors are optimistic he’ll make a full recovery.
But in North Carolina, an 18-year-old Ohio woman died from the amoeba in mid-June, stoking fear in the community. She had been rafting at the U.S. National Whitewater Center in Charlotte, which is among a handful of facilities in the country that have man-made rapids coursing through concrete channels. Its CEO, Jeff Wise, pointed out the lower part of the channel in mid-July.
“This is the bottom pond,” he said, “where all of the water in our essentially 12 million-gallon system rests while it’s ready to be pumped back up into the top pond, where it’ll float back down through the channels.”
But there was no whitewater between late June and Aug. 10, because CDC tests found the amoeba after the woman died.
Mecklenburg County Health Director Dr. Marcus Plescia encouraged people to keep perspective.
“This organism, Naegleria fowleri, is actually quite a prevalent or commonly occurring organism in open bodies of water,” he said. “We find it in lakes. We find it in ponds. It’s very common for people to come into contact with, but it’s very uncommon for people to develop this kind of infection with it.”
It’s harmless if swallowed, because stomach acid kills it. But if it’s in water forced up the nose, it can cause the brain infection, which is difficult to diagnose and treat.
The Whitewater Center uses city water that it treats with UV radiation, a filtration system and some chlorine. Still, it’s a large, open body of water, and exists in a regulatory no-man’s land because it’s neither swimming pool nor local river or lake.
North Carolina Gov. Pat McCrory said the state should reexamine whether the center should be treated like a swimming pool. But testing for the amoeba is not part of swimming pool regulations, because chlorine used in pools is effective at killing it. And the county and the state don’t have the ability to test for it. It’s usually up to the CDC.
As part of its lease agreement with the county, the center does weekly tests for common contaminants such as fecal coliform bacteria.
County health leaders point out that people are much more likely to die from drowning or boating accidents in area lakes and rivers than they are from Naegleria fowleri. In fact, there have already been at least eight of those deaths in the greater Charlotte area this summer.
But people just don’t get as worked up about those. David Ropeik, a risk management consultant in Concord, Mass., explains why.
“We worry about things not only based on the likelihood of them happening but the nature of the experience itself,” Ropeik said. “The odds may be low of brain-eating amoeba eating your brain, but the nature of a brain-eating amoeba eating your brain sounds pretty scary, doesn’t it?”
Ropeik is the author of “How Risky Is It, Really?” He says the media coverage of rare risks is part of the problem.
“Anything that makes a risk feel scarier like, ‘This is the zombie amoeba!’ is going to subconsciously interest journalists as something that will get people’s attention,” he said. “Because the viewer, reader, listener is likely to pay attention to a story that could portend their death.”
Dr. Jennifer Cope, an infectious disease epidemiologist at the CDC, said 11 out of 11 tests for the amoeba were positive at the rafting center, which does sound alarming. She called that significant but noted this is the first time the CDC has encountered the amoeba in this type of setting.
Whitewater Center CEO Wise says roughly 1.5 million people have rafted there over the past decade, and this is the first health issue it has had tied to what’s in the water.
The CDC says there are ways to make the water less conducive to the amoeba’s growth, including bulking up the amount of chlorine. The Whitewater Center worked with consultants to figure out a more effective way of doing that, and it reopened this month with a revamped chlorination system. So far, county health leaders say it is working the way it is supposed to.
This story is part of a partnership that includes WMFE, WFAE, 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.

Screening Positive For Depression Doesn’t Mean You’ll Get Treatment, Study Finds

Getting treatment for depression may sometimes be a regular part of health care for the “worried well” that leaves those who cannot afford it to suffer by themselves.
A new study published Monday in JAMA Internal Medicine illustrates that phenomena. Most Americans who screen positive for depression don’t receive treatment — while most who did receive treatment don’t actually have the condition.
“Over the last several years there has been an increase in prescription of antidepressants,” said Mark Olfson, professor of psychiatry at the Columbia University Medical Center and lead author of the study. “In that context, many people assumed that under-treatment of depression is no longer a common problem.”
But Olfson found the opposite to be true after analyzing data from Medical Expenditure Panel Surveys in 2012 and 2013 that includes questionnaires screening for depression. Of the 46,417 adults surveyed, 8.4 percent answered in ways that suggested they had depression, but only 28.7 percent of them received any treatment for it.
“The findings highlight that there are continuing challenges in aligning depression care with patient needs,” he said.

Adults in the lowest income group were five times more likely to be depressed compared with those in the highest income group. But they, along with uninsured adults, racial and ethnic minorities, and men, were also less likely to receive treatment.
On the other hand, among the 8.1 percent of adults who received treatment for depression, only 29.9 percent of them had depression and 21.8 percent of them had serious psychological distress. And those with either less serious or no depression were more likely to receive antidepressants. It’s a problem of overprescription, Olfson said, because studies have shown that antidepressants are not any more effective for patients with mild depression than a placebo.
“Being a little less aggressive in medication in mild depression would be beneficial,” he said. “There are simpler forms of psychological interventions that can be adapted for primary care.”
Rather than relying on these drugs, the patients can be given other treatments ranging from counseling and exercise to yoga.
In addition, researchers concluded that those with serious psychological distress are more likely to be treated by psychiatrists instead of general medical professionals, but this trend does not translate to older patients, African Americans, the uninsured or those with less education.
“Some when they have depression don’t believe they require treatment or that they could benefit from treatment,” Olfson said. “People are visiting doctors but the attention is to current, pressing medical problems.”

But these doctor visits can be used as an opportunity for increasing access to treatment for depression to disadvantaged populations. Olfson found that most people with untreated depression make at least one visit to a primary care doctor annually. If depression screening and mental health services can be integrated into primary care, Olfson said, there will be better access and awareness about the illness.
“If you give them a referral to a mental health clinic, they simply won’t go if they don’t think they have a mental health disorder,” he said. “By embedding the services within primary care, it becomes more accessible and less stigmatized.”
It’s an idea Benjamin Cook, director of the Health Equity Research Lab and assistant professor at Harvard Medical School, agrees on, but he said increasing access for minorities would require professionals who speak their languages and understand what type of treatment they are open to. Cook was not involved in the study.
“(For example) African Americans and Latinos prefer antidepressants less than whites,” Cook said. That might be an underlying reason “not to go for mental health treatment, why they might not stay at treatment for as long.”
This integration of services would also benefit patients who are over treated — those who receive antidepressants when they don’t need to. Olfson said many primary care doctors expressed frustrations in finding mental health professionals particularly in small and rural areas, so prescribing antidepressants might become their go-to when they don’t have resources. If there is a mental health professional right in the clinic, patients might get access to more services that a general doctor cannot offer such as counseling and psychotherapy.
“Depression really is a serious condition and we’re finding that so many Americans aren’t receiving care,” he said. “I hope that it (this study) brings attention to this situation.”Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Protecting California’s Seniors From Surprise Hospital, Nursing Home Bills

Californians with Medicare coverage would no longer be surprised by huge medical bills stemming from “observation care” in hospitals under legislation that state lawmakers approved overwhelmingly last week and sent to Gov. Jerry Brown to sign into law.
The sticker-shock can happen when people go to the hospital but health care providers are not sure what’s wrong. If the patient is not sick enough to be formally admitted, but still not healthy enough to go home, they can stay in the hospital for “observation care,” which Medicare considers an outpatient service. That can mean higher out-of-pocket expenses for the patient.

Hospitals can bill observation patients for a larger share of the cost of any treatment and tests than admitted patients. Any routine medications they usually take at home may not be covered at all in the hospital. In some parts of the country, Medicare observation patients have been charged exorbitant prices for prescription drugs, including $18 for one baby aspirin.
And because observation patients have not spent the required minimum of three straight days as an admitted patient, Medicare will not cover their follow-up nursing home expenses after discharge. Observation care doesn’t count.
But patients may not even know they have been placed on observation care status when they’re lying in a hospital bed.
“I don’t think the average person knows the difference,” said Sen. Ed Hernandez (D-West Covina).
Hernandez introduced the legislation requiring hospitals starting Jan. 1 to tell all patients if they are getting observation care.
The state’s observation care notice would not necessarily spell out the details, but it would warn patients that their status could affect what their insurance will cover.
After they get the notice, Medicare observation patients can try to ask their doctors to change that status. If their doctor prescribes nursing home care, they’ll have to pay the bill, but can try appealing to Medicare for reimbursement, or they can go home and recover on their own.
Members of private Medicare Advantage plans should ask their plans about their observation care policies, since they can vary.
The number of Medicare observation patients at the nation’s hospitals doubled since 2006 to nearly 1.9 million in 2014, according to the most recent statistics from the Centers for Medicare & Medicaid Services.
In California, the number of people hospitalized for observation, regardless of their type of health insurance, was 417,366 in 2015, also more than twice as many as in 2006. The rate rose far faster than the percentage of patients admitted to the hospital (14 percent, to 3.54 million) during the same time, according to the California Office of Statewide Health Planning and Development.
Hospital officials have blamed the increase, in part, on stepped-up enforcement of the strict criteria Medicare has set for hospital admissions to avoid paying for unnecessary treatment. Medicare won’t pay anything for admitted patients who instead should have been placed in observation.
“We hope this legislation takes care of the problems we have seen associated with patients not being aware that they are actually not admitted into the hospital even though they are physically located in the hospital,” said Bonnie Castillo, associate executive director for the California Nurses Association, which represents more than 90,000 nurses and is a leading advocate for the bill.
Among those patients is Lois Frarie, a 96-year-old retired teacher from Monterey. She spent four days in the hospital, including two as an observation patient, after she fell and fractured her elbow and pelvis requiring surgery four years ago. When a hospital review committee switched her status to observation, she didn’t even move to a different room.
“She had no clue this was going on,” said her niece, Sherry Smith.
It wasn’t until Frarie was about to be discharged from the hospital to a nursing home to regain her strength that her family found out Medicare would not cover her care because she didn’t have a three-day hospital admission. Before the nursing home would accept her, her family had to pay $7,000 up front. When she returned home three months later, she owed more than $19,000.
Smith appealed to Medicare for reimbursement on her aunt’s behalf, an effort that only ended last year. Officials eventually agreed only to pay for the ambulance that brought Frarie to the hospital.
The legislation also would require the nation’s first minimum nurse-to patient staffing ratios in observation care units for hospitals that have separate units for those patients.
“We are still the only state that has these very specific mandated ratios for every unit of the hospital that have to be adhered to every minute of every day,” said Jan Emerson-Shea, a spokeswoman for the California Hospital Association, which represents 400 hospitals. Those staffing rules, however, excluded observation care units.
“We wanted to make sure hospitals didn’t use observation care as a loophole to avoid any of the minimum nursing staffing requirements,” said Sen. Hernandez.
If Gov. Brown signs the legislation, as many expect, Hernandez said California’s observation care notice could be combined with a federal observation care notice that hospitals also must use next year.
While the federal notice provides more details in a standardized form, it is only for Medicare patients and only after they’ve spent 24 hours in observation. To comply with the state requirements, California hospitals would have to give it as soon as possible to all observation patients, no matter what health insurance they have.
Although the state hospital association neither opposed nor supported the Hernandez legislation, the observation notice is important, said Debby Rogers, the association’s vice president of clinical performance and a former emergency room nurse.
“Our goals are to make decisions in the best interest of the patients, and providing notification of their status we think helps them, and at the same time informs them if there are risks,” Rogers said.
But a notice alone is not enough, said Bonnie Burns, a training and policy specialist at California Health Advocates, a Medicare advocacy group based in Sacramento.
“It is a baby step that at least tells them there is a problem,” Burns said. “The issue for many beneficiaries is that the time spent in observation doesn’t let them access the Medicare nursing home benefit. The better fix would be to allow people to use their Medicare benefit if they have been under observation.”
Contact Susan Jaffe at Jaffe.KHN@gmail.com or @susanjaffe
KHN’s coverage of late life and geriatric care is supported by The John A. Hartford Foundation.
KHN’s coverage of aging and long-term care issues is supported by The SCAN 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.

FAQ: Hospital Observation Care Can Be Costly For Medicare Patients

This story has been updated.
Some seniors think Medicare made a mistake. Others are stunned when they find out that being in a hospital even for a couple of days doesn’t always mean they were actually admitted.
Instead, they received observation care, considered by Medicare to be an outpatient service. The observation designation means they can have higher out-of-pocket expenses and fewer Medicare benefits. Yet, a government investigation found that observation patients often have the same health problems as those who are admitted.

Medicare officials are working to finalize a notice that will inform patients that they are receiving observation care. That is required under a federal law that went into effect in August, and hospitals will likely begin using the notices in January. Some states already require that patients be told about their status.
More Medicare beneficiaries are entering hospitals as observation patients every year. The number doubled since 2006 to nearly 1.9 million in 2014, according to figures from the Centers for Medicare & Medicaid Services. At the same time, enrollment in traditional Medicare grew by 5 percent.
Here are some common questions and answers about observation care and the coverage gap that can result. (Seniors enrolled in Medicare Advantage should ask their plans about their observation care rules since they can vary.)
Q. What is observation care?
A. Hospitals provide observation care for patients who are not well enough to go home but not sick enough to be admitted. This care requires a doctor’s order and is considered an outpatient service. The hospitalization can include short-term treatment and tests to help doctors decide whether the patient meets the medical criteria for admission. Medicare officials have issued the so-called “two-midnight rule:” Patients whose doctors expect them to stay in the hospital through two midnights should be admitted. Patients expected to stay for less time should be kept in observation.
Q. What effect does observation status have on patients’ care and expenses?
A. Because observation care is provided on an outpatient basis, patients usually also have co-payments for doctors’ fees and each hospital service, and they have to pay whatever the hospital charges for any routine drugs the hospital provides that they take at home for chronic conditions such as diabetes or high cholesterol.
Observation patients cannot receive Medicare coverage for follow-up care in a nursing home, even though their doctors recommend it. To be eligible for nursing home coverage, they must have first spent at least three consecutive days (or through three midnights) as an admitted patient, not counting the day of discharge.
Q: Why are more Medicare patients receiving observation care instead of being admitted?
A. Medicare has strict criteria for admissions as an inpatient and usually won’t pay anything for admitted patients who should have been in observation care. Partly in response to stepped up enforcement of these rules, hospitals in recent years have been placing more patients in observation.
Q. Will the cost of my maintenance drugs be covered when I am in the hospital?
A. No, Medicare does not pay for these routine drugs for patients in the hospital in observation care. Some hospitals allow patients to bring these medications from home. Others do not, citing safety concerns.
If you have a separate Medicare Part D drug plan, the coverage decision will be up to the insurer. If the plan covers your maintenance drugs at home and agrees to cover them in the hospital, it will only pay prices negotiated by the plan with drug companies and in-network pharmacies. Most hospital pharmacies are out-of-network. So even if your plan covers these drugs, you may be left paying most of the bill. However, you can ask hospitals if they would consider waiving the charges.
Medicine to treat the symptoms that brought you to the hospital may be covered as an outpatient service under Part B.
Q: How do I know if I’m an observation patient and can I change my status?
A. The only way to know for sure is to ask. “Unless people are in an observation unit, the difference between observation and inpatient care is basically indistinguishable,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy.
Q. Can I change my status in the hospital?
A. If your doctor says you are too sick to go home and you are receiving services that can be provided only in a hospital, ask your doctor to admit you to the hospital by changing your status to inpatient. However, even if your doctor does that, you can be switched back to observation status during your hospital stay.
Q. What can I do if I’m already in a nursing home and I find out Medicare won’t cover my nursing home care?
A. You have two options, Edelman said. You can agree to pay the bill but continue to seek coverage through a Medicare appeal or you can leave the nursing home.
If you opt to stay in the nursing home, follow these steps to see if Medicare will reimburse you, she said. Ask the nursing home to fill out a form called the “Notice of Exclusions from Medicare Benefits Skilled Nursing Facility.” The form will show what services you need, the estimated cost and the reason why Medicare will probably not pay. The facility will check off the first reason, “no qualifying 3-day inpatient hospital stay.” Then you can check off the form’s option one, asking the facility to submit it to Medicare along with documentation supporting your need for these services. You will not be billed until Medicare issues a decision.
If Medicare does not pay the bill, you will receive information on how to appeal that decision. Although Medicare officials caution that hospital patients cannot appeal their observation status, the “notice of exclusion” applies to the nursing home charges and clearly states in bold type: “I understand that I can appeal if Medicare decides not to pay.”
For more information on filing an appeal, visit the Center for Medicare Advocacy’s observation care website.
This is an updated version of a article first published Sept. 4, 2014.
This article was produced by Kaiser Health News with support from The SCAN 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.