Spot the signs of ovarian cancer

Each year, about 22,000 women in the U.S. get ovarian cancer. It’s also the fifth leading cause of cancer death among U.S. women. Early diagnosis is the key to survival, and the key to early diagnosis is recognizing the symptoms of ovarian cancer:

  • Bloating
  • Pelvic or abdominal pain
  • Trouble eating or feeling full quickly
  • Urgency or frequency of urination

Women have unique health concerns, including certain types of cancers and high rates of chronic disease. Medicare covers many services to address these concerns, like a yearly “Wellness” visit, bone mass measurement, cervical cancer screenings, mammograms, and cardiovascular screenings. Medicare also covers other preventive services, so talk to your doctor about risk factors and to schedule your next screening.

Currently there’s no effective screening test for ovarian cancer, and it can be very hard to identify ovarian cancer early. The signs and symptoms of ovarian cancer aren’t always clear and may be hard to recognize. It’s important to pay attention to your body and know what’s normal for you. If you notice any changes in your body that last for 2 weeks or longer and may be a sign or symptom of ovarian cancer, talk to your doctor and ask about possible causes. Symptoms may be caused by something other than cancer, but the only way to know is to see your doctor, nurse, or other health care professional.

Make sure to ask your doctor about your level of risk for ovarian cancer at your “Welcome to Medicare” visit or your next yearly “Wellness” visit.

September is National Ovarian Cancer Awareness Month, a perfect time for you to learn more about this disease and know the symptoms. Visit the Centers for Disease Control for more information on ovarian cancer.

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Another Way For Anti-Vaxxers To Skip Shots For Schoolkids: A Doctor’s Note

Dr. Tara Zandvliet was inundated with calls and emails from parents last year, after California passed a law nixing personal beliefs as an exemption from school vaccinations. Suddenly, many parents sought exemptions for medical reasons.

Someone even faked two medical exemption forms purportedly written by the San Diego pediatrician, copying a legitimate document she’d provided for a patient and writing in the names of students she’d never treated, she said. She learned of the forgeries only when the school called for verification.

Only 1 in 10 families contacting her for such exemptions could cite a legitimate reason, such as a severe allergic reaction to a previous vaccine, Zandvliet said. Of those kids with valid health problems, she estimates, only about a third merited the exemption.

Families who oppose mandated immunization for schoolchildren may be seeking medical exemptions to get around the new state law, which requires kindergartners entering public and private schools to be fully vaccinated regardless of families’ personal beliefs, according to a study published Tuesday in JAMA, the Journal of the American Medical Association.

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Before the 2016-17 school year, parents who opposed vaccination, or anti-vaxxers as they are often called, could enroll their unvaccinated children in school citing the personal belief exemption, based on religious or philosophical convictions, for example.

After a rampant measles outbreak originating at Disneyland in 2014 that resulted in 147 cases reported across seven states, California scrapped the personal belief exemption. The law, which was hotly contested by some parents, left in place waivers for medical reasons.

Such a stringent policy is fairly unusual. Eighteen states have personal belief exemptions and 47 allow parents to opt out of vaccinations for their children based on religious beliefs, according to the National Conference of State Legislatures. Besides California, Mississippi and West Virgina allow exemptions based on medical concerns alone.

Michigan also recently tackled this issue and required families seeking an exemption to meet personally with local public health departments. After instituting the new rules, state officials reported that the number of waivers fell 35 percent.

The increase in California medical waivers suggests that anti-vaccine parents may be finding doctors willing to exempt their kids from the mandate, according to the researchers.

The study, which used data from the California Department of Public Health, shows that the number of medical exemptions among kindergartners, though small, tripled to 2,850 in 2016 from the previous year. Meanwhile, the number of exemptions for personal beliefs was about four times lower in 2016 than in the year before. (They did not plunge to zero in part because some pre-kindergartners had exemptions that were grandfathered in under the law.)

The state’s law, however, gives doctors more wiggle room to authorize medical exemptions — for example, for children with a family history of adverse reactions to vaccines.

Paul Delamater, an assistant professor at the University of North Carolina-Chapel Hill and lead author of the JAMA study, said this reason is inconsistent with the recommendation from the American Academy of Pediatrics. The academy states that medical exemptions should be reserved for students who could truly be harmed by vaccination, such as those with a weak immune system because of chemotherapy or a known dangerous reaction to a vaccine ingredient.

Many of the California counties with the biggest increases in medical exemptions since the law took effect are in Northern California, including Shasta, Plumas, Sonoma and Marin. Some with high percentages of personal belief exemptions before the law had among the greater increases in medical waivers afterward, Delamater said.

In one Southern California county, Orange, the number of medical exemptions went from 92 in the 2015-16 school year to 348 in 2016-17, according to state data. Meanwhile the number of personal belief exemptions decreased from 1,270 to 269 in the same period.

“The medical exemption increase is concerning,” said Catherine Flores-Martin, executive director of the California Immunization Coalition, a public-private partnership that promotes vaccinations and co-sponsored the state’s vaccine law.

Flores-Martin said health professionals expected a short-term rise in medical exemptions because parents previously may have obtained the easier-to-get personal belief exemptions for children who actually qualified medically. But the rise in medical exemptions is greater than she had anticipated, and Flores-Martin said some doctors may be inappropriately offering them to parents on a broad basis.

“It would be unusual for a child to be exempted from every vaccine forever, because that’s pretty extreme. You see patterns [of such exemptions] in some of these schools. I don’t think that’s a coincidence.”

Her group is encouraging people to contact the Medical Board of California if they encounter doctors writing medical exemptions for conditions like asthma that aren’t included under the state law.

“It really isn’t up to the parents,” Flores-Martin said. “Some doctors may feel emboldened if they … feel they can do that without scrutiny or consequence. It’s an issue that physicians need to address with their peers, and we’re going to help start that conversation. It’s up to the doctors to behave professionally.”

Many parents who don’t want vaccinations for their children, including some vocal opponents from affluent, well-educated regions of the state, say they are concerned that  vaccines are linked to autism, despite overwhelming scientific evidence that this is not the case.

Zandvliet, the San Diego doctor, tries to take a judicious approach. Unlike some other doctors, she doesn’t charge extra for writing exemptions. She does, however, require families asking for an exemption to provide medical documentation of the child’s condition before she’ll write one.

Although she said she has not yet written a permanent medical exemption for all vaccines, she has written “medical exemptions lite,” which spare the students from one or more vaccines for a limited period. Sometimes, she will write these for students with siblings who experienced an adverse reaction to the vaccine, although she acknowledges there are no studies showing that it’s useful to do so.

For families seeking exemptions without a health reason, perhaps because they’re misinformed or philosophically opposed to vaccines, Zandvliet takes the opportunity to educate them. Sometimes, she succeeds in getting reluctant parents to partially vaccinate their children, or to spread out vaccines over a longer period than the U.S. Centers for Disease Control and Prevention recommends.

“If we stop listening as doctors, we’re going to turn people off,” Zandvliet said. “Doctors are saying, ‘If you won’t go by the CDC schedule for vaccinations, get out of my office.’ So they didn’t vaccinate, and they didn’t protect that child.”

Pamela Kahn, president-elect of the California School Nurses Organization, who works in Orange County, said California has a strong record on vaccinations and there is only so much school nurses can do to educate parents who oppose them.

“Overall, the vaccine rates are really high in the state of California after this law went into effect,” Kahn said. “When you compare the amount of kids that were exempt between both pools, we’re still way ahead of the game.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Health Industry, Public Health

Tags: Doctors, Vaccines

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California, Other States To Extend Obamacare Sign-Up Beyond Federal Limit

California and several other states will exempt themselves this year from a new Trump administration rule that cuts in half the amount of time consumers have to buy individual health insurance under the Affordable Care Act.

In California, lawmakers are contemplating legislation that would circumvent the rule in future years, too.

The Trump administration’s rule gives people shopping for 2018 coverage on the federal exchange 45 days to sign up, from Nov. 1 through Dec. 15.

But in California and some of the other states that run their own exchanges — Colorado, Minnesota, Washington and Massachusetts, as well as the District of Columbia — consumers purchasing insurance for themselves this year will have extra time to make decisions.

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In Colorado, for example, the sign-up period is from Nov. 1 to Jan. 12. In Minnesota, it will start Nov. 1 and run through Jan. 14. In Washington state, it is Nov. 1 through Jan. 15.

Consumers shopping for coverage in California’s exchange, Covered California, will still have the full three months they’ve had in recent years, starting on Nov. 1 and ending Jan. 31. Californians shopping for individual market plans outside the exchange will have those same three months to make up their minds.

“We want to make sure our consumers have the time they need to find the best plan that fits their needs,” said James Scullary, a spokesman for Covered California.

The rule that truncated the enrollment period for the federal exchange, published in April by the Centers for Medicare & Medicaid Services (CMS), gives state-based exchanges the ability to extend the amount of time allowed by tacking a “special” enrollment period onto the 45 days set by the federal government.

Because that flexibility is limited to 2018 coverage, California legislators are taking an extra step to keep the three-month enrollment period for 2019 and beyond. Assemblyman Jim Wood (D-Healdsburg) introduced legislation last week that would ensure a three-month enrollment window for consumers seeking coverage in 2019 and subsequent years.

“When the Trump administration issued its new … rules cutting the ACA’s open enrollment period in half, we knew we had to act,” Wood said. “Californians have enjoyed a three-month enrollment period for years, and this change could catch people off guard and not allow them to sign up in time. That would be a travesty.”

Health policy experts say the federal rule is a political attempt to undermine the viability of the Obamacare insurance exchanges.

“It’s no big secret that the Trump administration isn’t a big fan of the Affordable Care Act or the individual market that it created,” said Dylan Roby, associate professor of Health Services Administration at the University of Maryland. “There’s just this general intent of the administration to reduce enrollment, reduce … subsidies and make it a little bit harder for people to enroll.”

The shortened enrollment window was part of a so-called market stabilization rule rolled out by the Trump administration that also offers insurance companies concessions, including the flexibility to sell some health plans that cover less of the enrollees’ cost of care than currently required by the ACA.

California’s insurance commissioner, Dave Jones, expressed concern about the impact of a shortened enrollment period in a letter to the federal government in March, before the rule was finalized.

Jones’ letter cited research that shows younger people tend to sign up for health insurance toward the end of open enrollment, and that putting up barriers to their enrollment could reduce the number of healthy people in the insurance pool.

That would “needlessly destabilize the market” and would “result in increased premiums for those who do enroll in coverage,” the insurance commissioner said.

Shana Alex Charles, an assistant professor of health sciences at California State University-Fullerton, said the pushback by California lawmakers against federal attempts to shorten the enrollment period underscores the state’s commitment to having a marketplace that “actually makes sense.”

“If you want to maximize enrollment, you need to make sure people can get their paperwork together, and have the mindset and the time for people to complete the application,” she said.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Insurance, The Health Law

Tags: Obamacare Plans, Open Enrollment, Trump Administration

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Yemen’s cholera epidemic hits 600,000, confounding expectations

GENEVA (Reuters) – Yemen’s cholera outbreak has infected 612,703 people and killed 2,048 since it began in April, and some districts are still reporting sharp rises in new cases, data from the World Health Organization and Yemen’s health ministry showed on Tuesday.

The overall spread of the epidemic has slowed in the past two months, with the daily number of new suspected cases cut to around 3,000 in recent days.

However the epidemic, the most explosive on record in terms of its rapid spread, has continually confounded expectations. Soon after it began, WHO saw a worst-case scenario of 300,000 cases within six months.

But by the end of June, WHO was hoping 218,000 cases might be the halfway mark. In late July it said the spread had peaked after infecting 400,000.

Epidemics normally decline as quickly as they arise, so the peak of the disease – which is spread by contaminated food and water – should be roughly half the eventual total caseload.

But the decline in the epidemic has been bumpy, and the number of new cases rose in two of the past four weeks.

WHO spokesman Tarik Jasarevic said some of the most affected areas, such as Sanaa City and the governorates of Hajjah and Amran, had seen falls in the numbers of new cases.

But there had been a “sudden and significant increase” in the number of suspected cases reported from 12 districts, in the governorates of Hodeidah, Al Jawf, Al Mahwit, Ibb, Dhamar, Al Bayda and Aden.

“WHO is currently investigating the reason for this increase. A key aim of the investigation will be to determine whether the numbers are accurate and whether the spike in suspected cases is, in fact, caused by cholera or another diarrhoeal disease like rotavirus,” Jasarevic said.

Save the Children, a charity running cholera treatment centers, said last Friday that suspected cases in Hodeidah governorate had jumped by 40 percent in three weeks amid heavy rains and a heatwave, and in some districts weekly caseloads were double their previous peaks.

The United Nations has said the epidemic is man-made, driven by a civil war that has left 15.7 million people without clean water or sanitation.

Reporting by Tom Miles, Editing by Mark Trevelyan

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Bad blood over Obamacare fight lingers as Congress returns

WASHINGTON (Reuters) – When the U.S. Congress returns from summer vacation on Tuesday, for the first time in years gutting Obamacare will not be the main order of business on the healthcare agenda.

But leftover hard feelings in the wake of the long, partisan Obamacare wars could poison other issues.

Among them will be a measure to keep federal funding flowing to an insurance program that helps millions of children and pregnant women. The Children’s Health Insurance Program (CHIP) must be reauthorized by a vote of Congress by Sept. 30. If that does not happen, the program is expected to run out of money.

Another issue will be stabilizing the individual insurance market created under the 2010 Affordable Care Act, former Democratic President Barack Obama’s signature domestic policy achievement. In recent months, the Trump administration has worked to undermine it and insurers have raised premiums by double digits or exited the market.

Republicans in Congress spent six months trying to make good on a seven-year campaign promise to repeal and replace Obamacare, also a top campaign promise by President Donald Trump, while Democrats remained unanimously opposed.

The effort, which inflamed partisanship and exposed deep divisions within the Republican Party, ended with a dramatic failed Senate vote in July, leaving the law in place, but damaged.

Reauthorization of CHIP is typically not contentious. The program has bipartisan support. But lobbyists and industry officials said that any healthcare effort in Congress could become partisan in this political climate.

“Anything having to do with healthcare after the process we’ve gone through is subject to being controversial,” one health industry lobbyist said last week.

Serving as a backdrop for Congress’ deliberations, including hearings scheduled for Wednesday and Thursday, will be Trump and his Twitter account.

In several tweets, Trump has chastised lawmakers, sometimes by name, for failing to deliver on their promise to get rid of Obamacare. If that continues, already-rocky relations between Trump and fellow Republicans could worsen.

Several congressional aides, lobbyists and industry officials said they were skeptical that lawmakers would be able to move past the bitter months-long Republican push to gut Obamacare and somehow achieve bipartisan cooperation on healthcare.

The Obamacare markets’ problems have worsened amid conflicting messages from Trump and the Republicans’ effort to dismantle the healthcare law. Republican aides and lobbyists said there was little appetite to try once more to repeal and replace it.

They said Republicans, controlling the White House, House of Representatives and Senate, were unlikely to take up the repeal-and-replace effort for the remainder of 2017.

Trump’s administration has moved to undercut Obamacare, slashing its advertising budget by 90 percent and backing off enforcement of the so-called individual mandate, the requirement that everyone purchase insurance or pay a fine.

Editing by Kevin Drawbaugh and Matthew Lewis

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Novartis names drugs chief as CEO to deliver return to growth

ZURICH (Reuters) – Novartis (NOVN.S) CEO Joe Jimenez will step down on Feb. 1 and hand over to drug development chief Vas Narasimhan to decide the fate of $50 billion in assets and make good on a pledge to return the Swiss company to sales growth.

Jimenez, who will have been at the helm for eight years when he retires, has hived off animal health, vaccines and over-the-counter drugs businesses at Novartis to focus on generally more profitable prescription medicines, particularly in cancer.

But sales have been hit as top-selling drugs such as blood cancer treatment Gleevec have lost patent protection, while eye business Alcon has lagged expectations and generics arm Sandoz has faced intense pressure on prices in the United States.

Novartis got a boost last week, when the United States approved its $475,000-per-patient Kymriah treatment for young people with B-cell acute lymphoblastic leukemia, one of a series of new drugs it expects to revive sales growth starting next year.

Jimenez, 57, said on Monday now was a good time to move on.

“I really believe a leader has to be in place at the beginning of that growth phase to see it through,” he told reporters on a call. “And that wouldn’t be me, given that I‘m already eight years into my tenure.”

Narasimhan, 41, is among a new generation of youthful leaders at Novartis, including head researcher Jay Bradner at the Novartis Institutes For Biomedical Research.

Together, they have sought to improve the company’s way of moving drugs from the laboratory into commercial products, something they acknowledge has not always worked efficiently.

“That’s going to continue to be the focus of the company: To translate that innovation into commercial success,” said Narasimhan, a U.S. citizen.

Analysts said Narasimhan’s skills as a Harvard-trained medical doctor and former McKinsey consultant may be the blend Novartis needs to balance research and business.

“The appointment … brings deep medical and commercial knowledge plus strong communication, and we expect this fresh start to be taken very well by the markets,” said David Evans, a Kepler Cheuvreux analyst.

FILE PHOTO: CEO Joseph Jimenez of Swiss drugmaker Novartis arrives to address the company’s annual news conference in Basel January 29, 2014. REUTERS/Arnd Wiegmann

DECISIONS

But there will be plenty in Narasimhan’s in-tray.

His appointment comes as Novartis is reviewing Alcon for a possible sale that could bring in $25-$35 billion.

Slideshow (2 Images)

He must also decide what to do with its $10 billion stake in its over-the-counter (OTC) drugs venture with GlaxoSmithKline (GSK.L). Novartis faces a deadline of March 2018 to decide whether to exercise a sell option for its 36.5 percent stake.

Narasimhan will have to weigh up too what to so with Novartis’s $14 billion stake in cross-town rival Roche (ROG.S), which the company has said could be sold.

Novartis shares have lagged the Stoxx European Health Care Index .SXDP by around 9 percent during Jimenez’s tenure. At 1025 GMT, they were down 0.9 percent at 80.10 Swiss francs.

Having held various roles at Novartis since 2005, Narasimhan became global head of drug development and chief medical officer in 2016.

Jimenez said his departure would not affect a strategic review of Alcon, with an update due by year’s end.

“We’re going to consider all options ranging from keeping the business up to a capital markets exit,” he said. “There really is no change, so don’t read anything into it.”

He also hailed last week’s U.S. approval of Kymriah, the first so-called CAR-T therapy to win the U.S. Food and Drug Administration’s blessing.

“We started this five years ago, it was a big bet, a lot of people thought we were crazy and it’s paying off,” Jimenez said. “We have big plans.”

Reporting by John Miller; Editing by Muralikumar Anantharaman and Mark Potter

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Shingles: A Link to Vasculitis?

Action Points

  • Herpes zoster (HZ, shingles) is associated with increased risk of giant cell arteritis (GCA), but the infrequency of HZ in GCA patients suggests it is only one potential trigger for GCA.
  • Remember that GCA is a type of vasculitis affecting older individuals that is characterized by headache, scalp tenderness, and jaw claudication, and its complications can include vision loss, aortic aneurysms, and cardiovascular events.

Having a history of shingles was associated with an increased risk of developing giant cell arteritis (GCA) among individuals older than 50, a retrospective analysis of medical and pharmacy claims from two administrative databases showed.

Among patients from a Medicare 5% random sample who developed GCA, 6% had a history of herpes zoster (HZ), as did 3.1% of those included in the Truven MarketScan Commercial Claims and Encounters database, according to Jeffrey R. Curtis, MD, of the University of Alabama at Birmingham, and colleagues.

In a fixed-effects model analysis that included both groups, the adjusted hazard ratios for GCA were 1.44 (95% CI 1.14-1.82) for individuals with a history of uncomplicated HZ and 2.08 (95% CI 1.57-2.76) for those with previous HZ having complications such as cranial nerve involvement, the researchers reported online in Arthritis & Rheumatism.

“We observed a strong association between HZ and incident GCA — with complicated HZ increasing GCA risk by twofold and uncomplicated HZ increasing GCA risk by nearly 1.5-fold,” they stated.

GCA is a type of vasculitis affecting older individuals that is characterized by headache, scalp tenderness, and jaw claudication. It can have complications including vision loss, aortic aneurysms, and cardiovascular events.

The pathophysiology is thought to involve abnormal interactions between the blood vessel wall and the immune system, with dendritic cells recruiting CD4+ T cells and macrophages that ultimately form granulomas.

Reactivation of varicella zoster virus also results in vasculopathy with features similar to those seen in GCA such as the presence of multinucleated giant cells, and some studies have found evidence of varicella in GCA biopsy specimens.

However, few epidemiologic data are available linking HZ with GCA, and the potential mechanisms are as yet uncertain. It also is not known if the use of antivirals or the shingles vaccine might influence the risk of GCA.

Therefore, to more fully examine the relationship between HZ and GCA, the investigators analyzed outcomes from 2006 to 2013 in the two large national databases that included almost 17 million individuals.

Among the 1.25 million patients in the Medicare sample, 5.3% had a documented history of shingles, as did 2.1% of the 15.4 million in the MarketScan sample.

In the Medicare group, antiviral treatment had been given in 53% of complicated HZ and 72.5% of uncomplicated cases, while in the MarketScan group, antivirals had been used by 58% and 77.2%, respectively.

Few patients in either group had received the shingles vaccine, with rates ranging from 1.3% to 4% in MarketScan and 2.2% to 7.1% in Medicare.

Median duration from the HZ event to diagnosis of GCA ranged from 177 to 361 days in the MarketScan sample and 593 to 651 days in the Medicare group.

In unadjusted analyses, complicated HZ was associated with a 2.61-fold increased risk of GCA, while uncomplicated HZ had a 1.68-fold increased risk.

After adjustment for sex, steroid exposure, and antiviral and vaccine use, the hazard ratios in the Medicare group were 1.99 for complicated HZ and 1.42 for uncomplicated HZ, while in MarketScan the hazard ratios were 2.16 and 1.45, respectively.

In the Medicare group, a marginally significant protective effect against GCA was seen for antiviral treatment (HR 0.67, 95% CI 0.46-0.99), but no association was seen for the MarketScan group. Use of the shingles vaccine had no association with the development of GCA in either sample.

The authors emphasized that an observational study such as this does not imply causality, but the relationship between HZ and GCA is supported by findings of a temporal association, a “dose response,” with the higher risk being seen after complicated HZ, and the use of two independent databases.

However, they pointed out that only a minority of patients with GCA in both samples had a history of HZ, so any potential association is for a limited proportion of affected individuals. “This may suggest that altered immunity, such as immunosenescence, may be the critical mechanism underlying GCA pathogenesis and also predispose to HZ infection,” they wrote.

Given the potentially severe consequences of GCA, if HZ is indeed a trigger, treatment with antivirals and vaccine use might help prevent the disease, although the data in this study were unclear. Antiviral use was reportedly lower among complicated cases, but that may have been because treatment was given on an inpatient basis, or was delayed. As to vaccination, no benefit was seen, but few patients had received the vaccine, which is only about 50% effective and its protective effects wane with time.

“Additional studies examining pathophysiological mechanisms linking HZ and GCA as well as the potential benefits of antivirals or vaccination are warranted,” Curtis and colleagues concluded.

The authors reported no financial conflicts.

2017-09-03T12:00:00-0400

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Why One California County Went Surgery Shopping

SANTA BARBARA, Calif. — Retiree Leslie Robinson-Stone and her husband enjoyed a weeklong, all-expenses-paid trip to a luxury resort — all thanks to the county she worked for.

The couple also received more than a thousand dollars in spending money and a personal concierge, who attended to their every need. For Santa Barbara County, it was money well spent: Sending Robinson-Stone 250 miles away for knee replacement surgery near San Diego saved the government $30,000.

“The only difference between our two hospitals is one is expensive and the other is exorbitant,” said Andreas Pyper, assistant director of human resources for Santa Barbara County, referring to the local options.

Frustration with sky-high hospital bills and a lack of local competition is common to many employers and consumers across the country after years of industry consolidation. Fed up with wildly different price tags for routine operations, some private employers are steering patients they insure to top-performing providers who offer bargain prices. Santa Barbara County, with about 4,000 employees, is among a handful of public entities to join them.

The county has saved nearly 50 percent on four surgery cases since starting its out-of-town program last year, officials said. The program is voluntary for covered employees.

At a Scripps Health hospital in the San Diego area, the county paid $61,600 for a spinal fusion surgery that would have cost more than twice as much locally. It avoided two other operations altogether after patients went outside the area for second opinions.

Typically, employers are seeking deals through “bundled payments” — in which one fixed price covers tests, physician fees and hospital charges. And if complications arise, providers are on the hook financially. Medicare began experimenting with this method during the Obama administration.

Santa Barbara County is among about 400 employers on the West Coast working with Carrum Health, a South San Francisco start-up that negotiates bundled prices and chooses surgeons based on data on complications and readmissions.

“Not all surgeons are equal. We don’t want to give Scripps a blank check. That defeats the whole purpose,” said Sachin Jain, Carrum’s chief executive.

Santa Barbara officials try to persuade workers and their family members to participate in its program by waiving copays and deductibles. The county pays about $2,700 in travel costs and still comes out way ahead.

“If that doesn’t speak to the inefficiencies in our health care system, I don’t know what does,” Pyper said. “It’s almost like buying a Toyota Corolla for $50,000 and then going to San Diego to buy the same Corolla for $16,000. How long would the more expensive Toyota dealership last?”

Even as more employers and insurers embrace bundled payments, the Trump administration is applying the brakes. In August, Medicare officials proposed canceling mandatory bundled payments for certain surgeries and scaling back the program for knee and hip replacements. Health and Human Services Secretary Tom Price, when he was still a member of Congress, accused Medicare of overstepping federal authority and interfering in the doctor-patient relationship. Hospital trade groups have voiced similar objections.

That leaves some health-policy experts dismayed.

“These bundled payments put pressure on medical providers … and the savings are astonishing,” said Bob Kocher, a former health official in the Obama administration and now a partner in the venture capital firm Venrock.

Santa Barbara County officials said they had no choice after seeing their medical costs soar by 15 percent in each of the past two years. Like many local governments, it has an older workforce prone to chronic illness, blocked arteries and bum knees.

But health costs run higher than the state average in this scenic coastal county of about 450,000 people, according to data from Oakland-based Integrated Healthcare Association. By one measure, the average health insurance premium in the individual market runs $660 a month in Santa Barbara, 27 percent higher than in Los Angeles.

Still, Maya Barraza, the county’s manager for employee benefits and rewards, knew the program would be a hard sell to workers. “You don’t want to be away from your family and what’s familiar,” she said.

Cottage Health, the county’s largest health system, says it wants to keep patients in town for treatment and follow-up care.

Established in 1891, it’s grown from a single hospital to more than 500 beds across three hospitals, and annual revenue hit $746 million last year.

Maya Barraza, Santa Barbara County’s manager for employee benefits and rewards, said she knew it would be a hard sell persuading workers to head elsewhere for surgeries. “You don’t want to be away from your family and what’s familiar,” she said. (Heidi de Marco/KHN)
Since 1891, locals have been coming to Santa Barbara Cottage Health for their medical needs. It’s grown to more than 500 beds across three hospitals, and annual revenue hit $746 million last year. (Heidi de Marco/KHN)

Valet attendants greet visitors at two entrances outside the group’s white, Spanish-style hospital in the city of Santa Barbara. In the main lobby, the names of wealthy donors are splashed across one wall, including billionaire investor and Donald Trump confidant Thomas Barrack.

“We are continually looking at reducing costs and improving quality,” said Cottage Health spokeswoman Maria Zate. “Cottage Health has some of the top surgeons in California.”

Sixty miles north in Santa Maria, the state’s largest hospital chain, Dignity Health, offers another option: Marian Regional Medical Center.

Both Cottage and Dignity hospitals in Santa Barbara County have quality scores of fair to excellent for joint replacements, spinal procedures and coronary bypass surgeries, according to three years of Medicare data analyzed by research firm Mpirica Health.

Dignity Health didn’t respond to requests for comment.

Carrum tries to help employers like Santa Barbara County find more affordable options. It has struck bundled price deals for various procedures with Scripps hospitals in the San Diego area, Stanford Health Care in the Bay Area and Swedish Medical Center in Seattle, part of the Providence Health chain.

Several other companies, such as Health Design Plus, are also assisting employers, insurers and patients with the logistics of surgery shopping. Boeing and other large employers are the most aggressive at pursuing bundled pricing and sending workers across the country for care.

Since 2014, more than 2,000 joint replacement and spinal surgeries have been performed for fixed prices through the Pacific Business Group on Health’s “centers of excellence” program, which includes employers such as JetBlue and Lowe’s. It added gastric bypass and other bariatric surgeries last year, and the employer group is working on bundled prices for cancer treatment.

Some companies have gone so far as to send patients overseas for cheaper care, but most employers favor a more regional approach, experts say. Workers still rely on local physicians for follow-up care.

Municipalities, school districts and other public employers have been slower to adopt some of these strategies, perhaps to avoid the political risk of antagonizing local providers, some researchers suggest.

For some hospitals, there are advantages in offering deep discounts: They get patients they otherwise would never see and are paid in full right after the patient is discharged, avoiding the onerous billing and collections process.

They also have the financial capacity to offer such sharply reduced prices.

Michael Bark, assistant vice president of payer relations at Scripps Health, said most hospitals significantly mark up their commercial rates for orthopedic procedures and cardiac surgeries to compensate for lower government reimbursements.

Robinson-Stone, a Santa Barbara County retiree, sits on her front step at her home in Lompoc, Calif. Her former employer sent her 250 miles away for knee replacement surgery at a hospital near San Diego and saved $30,000. (Heidi de Marco/California Healthline)

“There are immense profit margins built into those cases,” Bark said.

Robinson-Stone, a former county sheriff’s deputy and a computer support specialist, was initially wary of traveling for her surgery. But the 62-year-old Lompoc resident had ongoing pain that kept her from biking, walking her dogs and tending to her fruit trees. Medication and cortisone shots didn’t work, and she had no ties to local surgeons. So she signed up online and was given a choice of six orthopedic surgeons at Scripps Green Hospital in La Jolla.

In June 2016, she and her husband, Frank Stone, checked in at the Estancia La Jolla Hotel and Spa.

Robinson-Stone met the surgeon on a Wednesday, had the operation the next day and returned to her hotel room by Saturday. She continued physical therapy at the hotel and returned to the hospital a few days later to have the staples removed.

She was back on her bike within two months and eventually lost about 20 pounds.

“I just celebrated one year from surgery,” she said, “and I’m a happy camper.”

Heidi DeMarco contributed to this story.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Cost and Quality

Tags: Payment Bundling

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Trump Administration Whacks Millions From Budget Used To Push Obamacare

President Donald Trump has insisted for months that “Obamacare is already dead.”

His administration matched its harsh words with damaging action on Thursday — slashing millions of dollars from the government’s budget to promote the health law’s annual open enrollment season beginning in two months.

The move is likely to translate into reduced marketing and fewer navigators — trained representatives deployed by nonprofit groups that receive federal grants to help people understand health insurance options and purchase a plan. The effect could cause more confusion for consumers in an abbreviated enrollment period that is 45 days shorter than last year — running from Nov. 1 to Dec. 15.

Grants to the nonprofits that supply navigators will fall by 40 percent to $36.8 million this year and advertising will drop by 90 percent to $10 million, the Centers for Medicare & Medicaid Services said. The money will be spent in 38 states that use the government’s healthcare.gov exchange.

Administration officials said that five years into the Affordable Care Act, most people know they need to sign up and what their options are, and that there is no evidence that more advertising leads to higher enrollment. Last year’s $100 million advertising budget was double that of 2015’s.

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The administration’s announcement was denounced by prominent Democrats, former Obama administration officials and navigator organizations.

“The Trump administration is deliberately trying to sabotage our health care system,” said Senate Minority Leader Chuck Schumer (D-N.Y.).

“I can’t think what the justification is for doing this” because experience has shown people need help getting through the enrollment process, said Jodi Ray, who leads the University of South Florida’s navigator program. It has won the largest navigator award in the country for the past several years, about $5.9 million.

Ray doesn’t know what USF will get this year. Grant amounts to navigators have not been announced yet.

“It’s going to be a really big challenge and doing a lot of extra work with fewer people on the ground and doing the work in half the time,” she said.

Shelli Quenga, director of programs for the Palmetto Project in Charleston and Columbia, S.C., fears her group will have to reduce its workforce and events. Palmetto received $1 million last year.

“We will face massive cuts to our budget,” Quenga said. “I am very worried for the fate of South Carolinians who need access to impartial and unbiased information.”

Funding for 98 navigator organizations will be tied to how each performed last year relative to the enrollment goals they set for themselves. Those that didn’t meet their goals — 78 percent did not, according to CMS — will get less money this year. If an organization hit only 30 percent of its goal last year, it will receive 30 percent of last year’s funding.

That formula has some flaws, said Lori Lodes, who directed CMS’ outreach efforts in 2014 and 2015 under the Obama administration.

For one, navigators don’t get credit for every enrollment they help produce. Sometimes, consumers consult navigators about their choices and then complete their enrollment in private at home, said Lodes, who now directs the Families USA campaign called Protect Our Care.

Another problem with the formula, she said, is that it fails to recognize the large amounts of time that navigators sometimes invest in helping people who are not native English speakers or have disabilities and need more help finding suitable health plans. That could contribute to groups signing up fewer people than anticipated.

“The people that really need help come from more vulnerable populations,” Lodes said. “More vulnerable populations are not going to get the care they need.”

In a background briefing for reporters, Health and Human Services Department officials said too much money was spent in past years with too little to show for it. They cited a navigator group in one state last year that enrolled only one person in an insurance plan but received $200,000, which they said could have paid insurance premiums for 31 people in that state for the entire year.

They noted that the advertising budget doubled last year, but despite the increase, enrollment fell by 42 percent, or about 500,000 people.

But Joel Ario, a former HHS official in the Obama administration who oversaw the federal and state insurance exchanges, challenged their judgment.

The decrease resulted from the Trump administration’s decision to end advertising as 2017’s open enrollment period entered its final weeks in January, he said.

“It’s disingenuous to say that ads didn’t tie to enrollment,” Ario said.

States that run their own marketplaces are not included in the navigation program. But some of them are continuing to put resources into enrollment. California’s 2017-18 marketing budget stands in stark contrast to the federal government’s. The state is poised to spend $111.5 million advertising Obamacare, more than 10 times what CMS plans to spend in 38 states.

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

Tags: CMS, HHS, Obamacare Plans, Open Enrollment, Trump Administration

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Anthem cuts back Obamacare coverage in Missouri to 68 counties

NEW YORK (Reuters) – U.S. health insurer Anthem Inc said on Friday that it will no longer offer Obamacare plans in 17 counties in Missouri but will remain in the bulk of the state, covering 68 counties that would not otherwise have Obamacare coverage for their residents.

Health insurers are facing an upheaval in their businesses amid growing uncertainty about healthcare legislation under President Donald Trump, who seeks to follow through on his promise to dismantle former President Barack Obama’s signature healthcare law, formally known as the Affordable Care Act.

Insurers such as UnitedHealth Group Inc, Aetna Inc and Humana Inc have exited most of the states where they sold Obamacare plans, leaving hundreds of U.S. counties at risk of losing access to private health coverage in 2018.

But other insurers, including Centene Corp, have filled those gaps, expanding into counties that had lost their coverage options.

Every U.S. county is currently projected to have at least one insurer offering Obamacare individual coverage next year. Still, 1,476 counties could have only one insurer in 2018.

Reporting by Michael Erman; Editing by Steve Orlofsky

Our Standards:The Thomson Reuters Trust Principles.

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