CVS bid for Aetna: A $66 billion bet on cutting drug costs

NEW YORK (Reuters) – The proposed merger between U.S. pharmacy operator CVS Health Corp and No. 3 health insurer Aetna Inc represents a $66 billion bet that insurers can drive down high U.S. drug prices by cutting out the middleman.

FILE PHOTO: The CVS logo is seen at one of their stores in Manhattan, New York, U.S., August 1, 2016. REUTERS/Andrew Kelly/File Photo

The move is the most expensive effort to date that would enable a national health insurer to take back full control of prescription medicines for their customers by negotiating prices with pharmaceutical manufacturers and setting customer out-of-pocket costs for each drug.

CVS, one of the largest U.S. pharmacy benefits managers, has offered to buy No. 3 health insurer Aetna for more than $200 per share, sources said on Thursday. It could take at least several weeks for any deal to materialize.

If the deal happens, it would likely pressure rival insurers, drugmakers, pharmaceutical benefits managers, and retail pharmacies to also consider mergers or switching partners to try to keep up with the potential healthcare cost savings or increase in profit margins.

“It’s an alternate model at this point. It’s not clear that it’s definitely a better one,” BMO Capital Markets analyst Matt Borsch said. “More consolidation could lead to pressure on some of the brand-name drug prices and a better counterweight to the big pharma companies.”

For years, insurers paid drug benefits managers like CVS and Express Scripts Holdings Co to negotiate down drug prices, with both parties taking a share of any discount by the time a medicine was paid for by consumers.

But outrage over the high costs of drugs has grown as consumers have picked up a larger portion of the tab for drug costs and it is threatening profit margins all along the drug supply chain, from manufacturers to distributors, insurers and pharmacies.

UnitedHealth Group Inc and Humana Inc currently have in-house pharmacy benefits businesses, and say that it has helped them keep medical costs down.

Anthem Inc recently decided to go down that same path. It cut ties with Express Scripts during a $3 billion legal fight, and said it would use CVS to build its own pharmacy benefits business in the next few years. That tie-up could now be at risk if CVS reaches a deal to buy Aetna, Leerink analyst Ana Gupta said.

    CVS also provides management services for Aetna rival Cigna Corp. If CVS buys Aetna, that could revive Cigna’s interest in buying Humana, analyst Christine Arnold of investment bank Cowen & Co said in a research note.

Aetna earlier this year closed the door on a deal with rival insurer Humana Inc after antitrust regulators said that combination and a rival deal between Anthem Inc and Cigna Corp were anti-competitive.

The pharmacy chain Walgreens Boots Alliance could need to match its business model closer to CVS to attempt to stay competitive, Arnold said in a note, and may look at buying Express Scripts.

Jefferies analyst Brian Tanquilut said that Express Scripts could also be a target for Amazon Inc which is reported to be looking to get into the pharmacy business.

    SWINGING PENDULUM

Over the past decade, health insurers have diverged on the value of the pharmacy benefits business.

Anthem sold its pharmacy benefit manager to Express Scripts and outsourced almost all of the business in 2010.

UnitedHealth took the opposite approach when it decided in 2011 to bring its pharmacy benefits management in house, then bought an even bigger standalone benefits manager, Catamaran, in 2015.

    Humana operates its own pharmacy benefit manager and Cigna and Aetna have hybrid approaches where they manage some parts in house and outsource others.  

    Until recently, insurers sought to expand their profit margins by reducing their spending on hospital services, using their size to negotiate down what they pay to healthcare providers.

But with those profits in hand, and with drug prices representing a bigger proportion of overall healthcare spending, they see new opportunity in targeting the pharmacy benefits, Leerink’s Gupta said.

    Another potential lure of a deal for Aetna would be to capitalize on the growing number of simple health services offered in a CVS store, from flu shots to blood pressure checks. Reimbursing such patient care outside of a doctor’s office or hospital could cut healthcare costs, Gupta said.

Reporting by Caroline Humer and Carl O’Donnell; editing by Michele Gershberg and Meredith Mazzilli

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Rural Areas — Already Short On Health Resources — Face Enrollment Hitches

ATLANTA — Ms. Stella’s, a home-cooking restaurant in Milledgeville, Ga., serves roast beef, grilled pork chops, chicken wings and oxtails with 24 sides from which to choose. Last spring, owners Jeri and Lucious Trawick opened a second restaurant in Eatonton, about 20 miles away, and Jeri decided to leave her full-time job to help shepherd the expansion.

But she needed to update the couple’s health insurance and went shopping on the Affordable Care Act’s online marketplace. Trawick, 43, who considers herself nearly as skilled with a computer as she is with a skillet, found the Obamacare website daunting.

“It was not exactly user-friendly,” she said. Trawick needs specific medications to control her hypertension, and the section on drug coverage left her “confused.”

She turned to Insure Georgia, a program funded in large part by federal money to help consumers enroll in Obamacare. A trained navigator showed her how to compare policies on the website, look at drug formularies and examine differences in prices and provider networks.

“I could have done it without her, maybe, but it would have taken me forever,” Trawick said.

This fall, it will be different.

Open enrollment for ACA plans, which begins Nov. 1, has been shortened to 45 days. At the same time, funding for navigator programs and other support for consumers has been cut dramatically in Georgia — by 86 percent — and across the country.

The number of navigators for Insure Georgia, the nonprofit agency that has received the bulk of federal funding for enrollment efforts in past years, will drop to 21 from 42 last year, said Fred Ammons, chief executive officer of Community Health Works, the parent organization of Insure Georgia.

There is no advertising budget to even inform consumers that open enrollment begins. Ammons said he is concerned that with all the past year’s rhetoric among Republicans in Washington about repealing and replacing Obamacare, some people may not even understand that the program is still available.

That could be a problem in Georgia, which, after seeing increased enrollment in the first three years of the marketplaces, experienced a 16 percent drop in sign-ups for 2017 coverage. In some rural counties the decline was as much as 36 percent. Georgia ranks third in uninsured residents, behind only Texas and Florida.

Lucious and Jeri Trawick, who have two restaurants in rural Georgia, turned to a navigator to help them decipher their health insurance choices and are nervous about less help being available when they sign up for 2018 coverage. (Family photo)

‘Isn’t Obamacare Dead?’

ACA supporters are concerned that residents in the rural portions of Georgia — which make up about 17 percent of the population — could be most at risk. In recent decades, those rural areas have fallen behind other parts of the state in income, educational achievement and in access to health care.

With enrollment assistance resources so strapped, it will be hard to reach out to rural consumers.

“We had a booth at the PRIDE festival in Atlanta last Sunday, and someone said, ‘Why are y’all even here? Isn’t Obamacare dead?’” Ammons said. “And if they think that in Atlanta, you can only imagine what they think in south Georgia.”

Health economist William Custer, who teaches at Georgia State University in Atlanta, echoed those fears about increases in the number of uninsured in rural Georgia.

The effects of less insurance will be felt hard in those areas, he explained. Nearly half of the state’s counties, most of them in rural areas, do not have an OB-GYN. Seven hospitals in rural Georgia have closed within the past four years. Several have closed their labor and delivery units. If people in rural Georgia lose insurance rather than gain it, efforts made in recent years by state leaders to stanch financial bleeding at rural hospitals could be jeopardized, Custer said.

“This is really the big worry. The problem in Georgia is that we have very different geographics, very different demographics and very different health care. These changes this year really seem to be pushing us even more to two Georgias,” Custer said.

‘Let Obamacare Fail’

Much of the cutbacks and confusion, health care advocates said, follows President Donald Trump’s disparagement of the law. He campaigned on a promise to “repeal and replace the disaster that is Obamacare” and announced in July that he would “let Obamacare fail.” Even though Congress could not pass a replacement bill, the Trump administration’s changes in timing and funding for enrollment will have an effect, the advocates charge.

“The most damaging has been the rhetoric and confusion,” said Laura Colbert, executive director of Georgians for a Healthy Future, an advocacy group. “Overall, this could be a bellwether for future years.”

Enrollment Resources

And while the need for insurance is high in the state, Georgia lawmakers have been resistant to the federal health law. Georgia, like 18 other Republican-leaning states, refused to expand Medicaid, as the law allowed. The Legislature also prohibited the state from employing navigators to help enroll consumers.

Ammons, who is from rural Georgia, said he lies awake at night wondering how to reach people who need health insurance.

“I don’t know what I can do to help these uninsured people,” he said, adding that “for a brief moment, I thought ‘We can’t even do this.’”

That was the night he learned, in an email, that Insure Georgia’s funding had been cut from $2.3 million to $328,000.

Ammons said he realized that he would have to lay off full-time employees. He said he also figured out that he would have to cut back on navigators that Insure Georgia typically hired short term for open enrollment.

Next, he cut every non-personnel line item he could, which meant terminating leases and closing offices. The group found donated space in Vidalia, in central Georgia, and in Brunswick, a port city near Savannah. But that leaves the southwestern portion of the state, an especially poor area of Georgia, without a nearby office.

Ammons said that other nonprofit groups have donated money that will allow Insure Georgia representatives to travel to 500 community enrollment events across the state. While Insure Georgia held more than 1,500 community events last year in all of Georgia’s 159 counties, his goal is more modest this year.

“We want to at least be in every county with a Walmart,” he said.

Jeri Trawick said she is worried for herself and for thousands of other Georgians.

To help with enrollment efforts, the Trawicks on Nov. 6 will be serving something else along with their homemade food at Ms. Stella’s in Eatonton.

“We’re going to have an open enrollment event, with a navigator here, from 10 until 6,” she said. “And I’ll be the first one in line.”

Categories: Insurance, States, The Health Law

Tags: Disparities, Federal Exchange, Georgia, Open Enrollment

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Seeking A Peaceful Death Amid The Flames

SONOMA, Calif. — Even when fire threatened her home in downtown Sonoma, the elderly woman inside who was suffering from late-stage cancer refused to leave.

She had returned home to die in peace, after all. Smoke was everywhere. Her caretaker begged her to heed the mandatory evacuation order.

Another woman on the outskirts of town, who was also home receiving hospice care, said all the young people telling her to get out were just “making hay” over nothing.

“They didn’t want to leave because they wanted to die in their home,” said Karna Dawson, a social worker with Hospice by the Bay. “They didn’t want to leave because they didn’t realize the severity of the problem. They didn’t want to leave because they were stubborn.”

While the worst wildfires in state history were ravaging California’s Wine Country earlier this month, Hospice by the Bay and other hospice providers had to do something that seemingly contradicted their mission: They had to persuade dozens of their terminally ill clients to evacuate the homes they had hoped would serve as quiet, familiar havens in their final days.

“Some people were feeling like if they were going to die, they wanted to die in their house, and [were] not really thinking that through very clearly,” Dawson said. “We’re not talking about dying of your cancer. We’re talking about dying in a fire. And those are two very different deaths.”

When the fires broke out on Oct. 8, nurses and staff with Hospice by the Bay were providing home care, pain management and spiritual counseling to 108 patients in Napa and Sonoma counties. Nearly half of those patients had to be evacuated.

Under federal rules, hospice agencies that receive payment from Medicare, the publicly funded health insurance program for older Americans, are required to have a disaster plan in place, including how to get bed-bound patients out of their homes.

Robin Finkelstein, who runs Heartland Hospice Care in Santa Rosa and San Rafael, had to evacuate her own home in Santa Rosa on the day the fires first began but came to work every day that week to make sure her patients were settled, and in many cases, resettled multiple times. About 40 percent of her 150 patients were moved.

Patients and their family members were not available to comment for this story.

“There were mandatory evacuations that changed each and every day,” Finkelstein said. “We’ve had patients who evacuated and went back home, then were evacuated again.”

Karna Dawson helped lead the effort to make sure patients getting care from Hospice by the Bay were safely evacuated during the North Bay wildfires. (April Dembosky/KQED)

Dawson, of Hospice by the Bay, was implementing the disaster plan by 4 a.m. Oct. 9, as fires exploded across the area. She sat huddled over her laptop at her home in Petaluma, wearing her grey pajamas and tattered pink bathrobe. She was talking on two phones at once, trying to locate all of her agency’s hospice patients and ordering ambulances for them when necessary.

In some cases, once the ambulances retrieved patients, they just drove away from the fires to get to safety, Dawson said. The hospice staff had to figure out where they ended up.

“It was just a moving target of where people were going and where they were landing,” said Wendy Ranzau, Hospice by the Bay’s chief operating officer.

For many patients, the first stop was one of more than 20 Red Cross evacuation shelters in Sonoma and Napa counties. This required hospice staff to adjust their goals, while still trying to fulfill their mission to provide patients an opportunity to die with dignity.

“Our priority was to make sure that we did not have a patient die in an evacuation center,” Ranzau said. “So even if they can’t die at home, they’re going to die someplace other than a cot in an auditorium.”

Within two days, Hospice by the Bay had safely relocated all of its patients, even ones who had temporarily landed in shelters. Some patients went to live with relatives across the state, from Citrus Heights near Sacramento to Santa Barbara down south.

Some were resettled in assisted living facilities or nursing homes, with Hospice by the Bay dipping into its reserves to pay the fees — costs the Medicare program does not require hospice agencies to cover under their disaster plans.

A couple of patients actually found the shelters surprisingly comfortable.

“There was one gentleman who didn’t want to leave the shelter. He had lived alone and he was loving the attention. He thought it was great,” Dawson said. “It took us 24 hours and the medics saying, ‘You can’t really stay here.’”

Several of the hospice’s patients died in a strange place away from home during the first week of the fire. By the second week, about 70 percent of patients returned home.

Several Heartland Hospice patients also passed away in unfamiliar settings. Finkelstein was able to return to her home — the fire had come within 50 yards of her property.

Ranzau predicts some patients will never return because their homes burned down, there’s still no power or they’re too medically fragile to survive another move. One patient lost 5 pounds in the week after the fire started, she said.

“When you think about hospice, our median length of stay is about three weeks,” Ranzau said. “A week in the life of a hospice patient, unfortunately, is a third of their time on hospice. So it just doesn’t make sense. You know, is a trauma of transferring again too much for them?”

That means some of these patients won’t have the death they planned, making them tragic players in the overall trend in dying: 70 percent of Californians say they want to die at home, but only 32 percent do.

Now the Sonoma woman with cancer, whose dying wish was to spend her final days in her own house, will die in a nursing home.

“She’s OK. She’s OK,” Dawson said uncertainly, when asked about her status a week after the fires began. “She’s adjusting.”

Finkelstein said her patients are traumatized.

“They have real losses that they’re dealing with and changes,” she said.

“Psychologically, there’s a high level of distress. And not just patients. It’s their families, and all of our employees.”

For most hospice patients, there just isn’t enough time to adapt to all the changes.

“I, or you, can have six months or a year to process this and think it through,” Dawson said. “We can have another fall that’s pretty and recover. Where they might not, and likely won’t.”

Categories: Public Health

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Merck Keytruda sales soar, but European application pulled

(Reuters) – Merck & Co (MRK.N) on Friday said quarterly sales of its Keytruda cancer immunotherapy exceeded $1 billion for the first time, but it withdrew an application for European use of the drug in lung cancer, raising questions about future sales.

The logo of Merck is pictured in this illustration photograph in Cardiff, California April 26, 2016. REUTERS/Mike Blake/Illustration/File Photo

Merck’s shares, which fell 6 percent to close at $58.24, were down another 3 percent at $56.68 after hours.

Despite a near tripling in Keytruda sales to $1.05 billion, Merck said that the cost of a June cyber attack that temporarily crippled manufacturing coupled with lower sales of off-patent products caused its third-quarter revenue to fall 2 percent to $10.33 billion.

The drugmaker said nearly one in three new lung cancer patients in the United States were starting with Keytruda and that the launch in bladder cancer was going well. Lung cancer is by far the most lucrative oncology market.

Despite approvals for numerous cancer types, “Keytruda is almost completely reliant on the performance in first-line lung cancer,” said Leerink Partners analyst Seamus Fernandez.

Late Friday Merck said it had withdrawn a European application for use of Keytruda in combination with chemotherapy as an initial treatment for nonsquamous non-small cell lung cancer (NSCLC), the most common form of the disease.

European approval had been expected next year, according to Sanford Bernstein analyst Tim Anderson.

The U.S. Food and Drug Administration granted accelerated approval to that combination May, making Keytruda the first, and so far only, immunotherapy approved for first-line lung cancer.

Merck earlier on Friday said a decision to make overall survival a main goal for a large, pivotal lung cancer trial of Keytruda plus chemotherapy would delay those results until February 2019.

Merck spokeswoman Pam Eisele said no decisions have been made about when the European application would be resubmitted, but there would be opportunities for the company to conduct interim analyses of trial data.

Merck said quarterly sales were cut by about $240 million as it had to borrow from the U.S. Centers for Disease Control and Prevention’s stockpile doses of its Gardasil vaccine to prevent cancer caused by the human papillomavirus.

Revenue fell by about $135 million from lost sales and there was another $175 million in costs related to the NotPetya cyber attack. The company expects a similar impact in the fourth quarter.

Merck’s Zostavax shingles prevention vaccine is also about to face potentially withering competition from GlaxoSmithKline’s (GSK.L) just-approved Shingrix, which appears to maintain efficacy far longer. Zostavax sales rose 23 percent to $234 million.

Merck cautioned that its Januvia diabetes drug would face continued pricing pressure. It along with the related Janumet saw sales fall 2 percent to $1.52 billion.

The company’s recently off-patent cholesterol medicines Zetia and Vytorin saw sales cut in half at $462 million.

“They need to identify other growth drivers for the business,” said Fernandez, noting other areas under pressure, such at intense competition for the hepatitis C franchise.

Chief Executive Ken Frazier said business development was an important priority, but that he would prefer bolt-on deals to enhance innovation rather than a major acquisition.

Merck’s animal health business reached $1 billion in quarterly sales for the first time.

“We see animal health as a pillar of growth for the company,” Frazier said.

Merck now expects full-year adjusted earnings of $3.91 to $3.97 per share, above Wall Street estimates of $3.87, according to Thomson Reuters data. It previously forecast earnings of $3.76 to $3.88.

Due to a $2.35 billion charge related to its collaboration with AstraZeneca Plc (AZN.L), Merck posted a third-quarter net loss of $56 million.

Excluding items, the company earned $1.11 per share, beating analysts’ average estimates by 8 cents, with help from cost controls.

Reporting by Bill Berkrot in New York and Manas Mishra in Bengaluru; additional reporting by Deena Beasley; Editing by Phil Berlowitz and Diane Craft

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Cyber attack hits Merck results, Keytruda notches new milestone

(Reuters) – Merck & Co (MRK.N) on Friday said quarterly sales of its Keytruda cancer immunotherapy exceeded $1 billion for the first time, but the cost of a cyber attack that temporarily crippled manufacturing and declines in off-patent products caused overall revenue to fall.

The logo of Merck is pictured in this illustration photograph in Cardiff, California April 26, 2016. REUTERS/Mike Blake/Illustration/File Photo

Merck’s shares fell 4.3 percent to $59.27.

For the first time, the company quantified the cost to its operations of the June NotPetya cyber attack.

It said sales were reduced by about $240 million as the company had to borrow Gardasil from the U.S. Centers for Disease Control and Prevention’s pediatric vaccine stockpile to meet demand. Gardasil is Merck’s vaccine to prevent cancer caused by the human papillomavirus.

In addition, revenue fell by about $135 million from lost sales in certain markets and there was another $175 million in costs related to the cyber attack. The company expects a similar impact in the fourth quarter.

Keytruda, by far Merck’s most important growth driver, saw sales almost triple from a year ago to $1.05 billion.

Merck said nearly one in three new lung cancer patients in the United States were starting with Keytruda and that the launch in bladder cancer was going well. Lung cancer is by far the most lucrative oncology market.

Despite approvals for numerous cancer types, “Keytruda is almost completely reliant on the performance in first-line lung cancer,” said Leerink Partners analyst Seamus Fernandez.

“They need to identify other growth drivers for the business,” said Fernandez, noting other areas under pressure, such at intense competition for the hepatitis C franchise.

Its Zostavax shingles prevention vaccine is also about to face potentially withering competition from GlaxoSmithKline’s (GSK.L) just-approved Shingrix, which appears to maintain efficacy far longer. Zostavax sales rose 23 percent to $234 million.

Merck cautioned that its Januvia diabetes drug would face continued pricing pressure. It along with the related Janumet saw sales fall 2 percent to $1.52 billion.

The company’s recently off-patent cholesterol medicines Zetia and Vytorin saw sales cut in half at $462 million.

Chief Executive Ken Frazier said business development was an important priority, but that he would prefer bolt-on deals to enhance innovation rather than a major acquisition.

Merck’s animal health business reached $1 billion in quarterly sales for the first time.

Eli Lilly and Co (LLY.N) said this week it was looking at a sale or spinoff of its Elanco animal health business. Merck has no such intentions.

“We see animal health as a pillar of growth for the company,” Frazier said.

Merck now expects full-year adjusted earnings of $3.91 to $3.97 per share, above Wall Street estimates of $3.87, according to Thomson Reuters data. It previously forecast earnings of $3.76 to $3.88.

Revenue for the quarter fell 2 percent to $10.33 billion, short of analysts’ expectations of $10.54 billion.

Net loss attributable to the drugmaker was $56 million, or 2 cents per share, in the third quarter, compared with a year-ago profit of $2.18 billion, or 78 cents per share.

The net loss was due to a $2.35 billion charge related to its collaboration with AstraZeneca Plc (AZN.L) for cancer drug Lynpraza.

Excluding items, the company earned $1.11 per share, beating analysts’ average estimates by 8 cents, with help from cost controls.

Merck said it expects research and development costs to rise in 2018.

(This version of the story recasts, adds analyst and company comment, cyber attack cost)

Reporting by Bill Berkrot in New York and Manas Mishra in Bengaluru; Editing by Martina D’Couto and Phil Berlowitz

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In pro-Trump Ohio county, opioid announcement disappoints

COLUMBUS, Ohio (Reuters) – Doug Corcoran is in the trenches every day in the fight against the opioid crisis in the rural Ohio county he helps oversee.

Ross County Commissioner Doug Corcoran poses in Chillicothe, Ohio, U.S., September 12, 2017. REUTERS/Tim Reid

So President Donald Trump’s failure this week to formally declare the overdose epidemic a “national emergency” – words that would have freed up more federal funds to tackle the crisis – was disappointing for him.

“I have been hopeful for the last several years that the federal government would step up and help us with this crisis, and they haven’t. They’ve really dropped the ball on this and it’s sad,” said Corcoran, a county commissioner in Ross County, home to 77,000 people an hour south of Columbus, Ohio.

The county’s child services budget nearly doubled in the past five years to almost $2.4 million from $1.3 million, because of the number of children needing care due to addicted parents. For a county with a general fund of $23 million, that is a stress on the finances.

Corcoran struggles constantly to make funds available from the county budget for the likes of drug treatment centers, the county jail and anti-drug education programs.

The disappointment about Trump’s announcement is more bitter in Ross County given that more than 60 percent of the county voted for the Republican at last year’s presidential election against Democrat Hillary Clinton.

ACROSS THE COUNTRY

Corcoran, who attended a youth education event about opioids on Friday in the city of Chillicothe, is not alone as the crisis strains local budgets across the country.

Brian Namey, a spokesman for the National Association of Counties, which represents 3,069 county and local governments, said Trump’s declaration on Thursday that the opioid crisis is a “public health emergency” rather than a national emergency lasts only 90 days and frees up no additional federal funds.

“We strongly urge the administration to release additional money to confront this emergency,” Namey said.

The opioid epidemic played a role in more than 33,000 deaths in 2015, according to the U.S. Centers for Disease Control and Prevention. The death rate has kept rising, both in cities and in many rural areas across the country, estimates show.

Opioids, primarily prescription painkillers, in addition to heroin and fentanyl – a pain medicine 50 to 100 times more powerful than morphine – are fueling the drug overdoses. More than 100 Americans die daily from related overdoses, according to the CDC.

Republican lawmakers called the president’s declaration an important step in combating the crisis. Some critics, including Democratic lawmakers, said it was meaningless without additional funding.

The National Association of County and City Health Officials (NACCHO), representing nearly 3,000 local health departments, also expressed disappointment that Trump did not go further and call the crisis a national emergency.

“The declaration of an opioid public health emergency and not a state of national emergency does not go far enough,” said NACCHO’s Laura Hanen, the association’s interim executive director. “We strongly urge the Administration to act further and release additional monies to bring this emergency to an end.”

Matt Osterberg is a county commissioner in rural Pike County, Pennsylvania. He said the county jail has roughly 120 inmates, the majority of whom are incarcerated for a drug-related crime.

The county of 55,000 has an overall annual budget of $42 million. It spends $3.5 million annually treating drug addicts inside the jail, but often when inmates are released they start taking drugs again and end up back behind bars.

Additional federal funds would be vital to help finance treatment centers for inmates once they are released, something the county cannot afford.

“If people got proper intensive treatment after they get out of jail, that would be my dream,” Osterberg said. 

Additional reporting by Paula Seligson in New York; Editing by Alistair Bell

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America’s Dementia Caregivers Cite Stresses, Rewards

Quick Guide to Dementia

News Picture: America's Dementia Caregivers Cite Stresses, RewardsBy Amy Norton
HealthDay Reporter

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WEDNESDAY, Oct. 25, 2017 (HealthDay News) — It’s tough, often thankless work done by millions of Americans every day. And people who tend to a loved one with dementia say they’re often overburdened, but the task has its rewards, too.

Those are just some of the findings from a new University of Michigan survey, the National Poll on Healthy Aging, which tallied the experiences of dementia caregivers.

About 5.5 million Americans are currently living with Alzheimer’s disease, according to the Alzheimer’s Association. It estimates that the bulk of their care — 83 percent — falls on unpaid family members. Alzheimer’s is the most common form of dementia.

It’s no secret that family caregivers face heavy demands. However, the new survey turned up some surprises, said Erica Solway, of the University of Michigan’s Institute for Healthcare Policy and Innovation.

A striking finding, she said, was that 45 percent of caregivers described their experience as “very rewarding,” while just 19 percent called it “very stressful.”

That illuminates the fact that there are positive aspects to dementia caregiving, Solway said, but she stressed that it should not overshadow the burdens families face.

Of the survey respondents, 78 percent said caregiving was at least “somewhat” stressful, and more than a fourth said they’d neglected their own health.

Dr. Gisele Wolf-Klein, director of geriatric education for Northwell Health in Great Neck, N.Y., was not surprised by that finding, saying she’s witnessed how caregivers put their own health care on the back burner.

“They don’t go for routine health screenings because they think they don’t have time,” Wolf-Klein said. “But something as simple as getting your flu shot is important for both you and your loved one — to help make sure neither of you gets sick.”

Beyond health care, caregivers often say they have little personal time at all. Of those Solway’s team surveyed, two-thirds said their responsibilities interfered with their work, everyday tasks or general ability to take care of themselves.

It’s crucial, Wolf-Klein said, that family caregivers have time for themselves — even if that means an afternoon to “just do nothing.”

She recommended that caregivers ask a trusted relative or friend to take over for the day, or a few hours — and do so “without guilt.”

If there’s no one who can step in, Wolf-Klein said, “respite” care might be an option. Some assisted-living facilities, for example, offer short-term care when a family member needs to travel or simply needs a break.

Those breaks are critical, agreed Ruth Drew, who directs information and support services for the Alzheimer’s Association.

“No one can do this on their own,” she said. “It’s not a sign of weakness to ask for help. It’s actually a sign of strength.”

Besides turning to family and friends, Drew said, caregivers can look to resources in their community and online. Those range from support groups and classes on caregiving to adult day centers — where people with dementia can go for supervised activities, giving their family members time off.

But in the survey, only 27 percent of caregivers said they’d used such resources.

Families often are unaware that help is out there, Drew said, and by the time caregivers need those resources, they might be so overwhelmed by their responsibilities that they feel they don’t have the time — or energy — to make it happen.

She suggested that families start planning for those needs soon after a loved one is diagnosed with dementia — before the caregiving becomes too intense.

Money, of course, can be another barrier. Medicare does not pay for adult day care, and offers only limited coverage for in-home health care. Some families, though, may be eligible for benefits through the U.S. Department of Veterans Affairs or state assistance programs, for instance, Drew said.

Also, the Alzheimer’s Association has a 24-hour “helpline” and information on a range of resources for caregivers on its website, she said.

“That’s a good starting point,” Solway agreed. Families can also try their local agency on aging, she said.

“We’re putting a lot of responsibility on the shoulders of family caregivers,” Solway said. “Supporting them is critical.”

The survey included 148 caregivers, ages 50 to 80. Most — 62 percent — were women, and 60 percent were caring for a parent. The others were caring for a spouse, another relative or a friend.

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‘No One Is Coming’: Hospice Patients Abandoned At Death’s Door

“I miss being whole,” says Patricia Martin of her husband, Bob. A family practice physician, Dr. Robert Martin died of prostate cancer in 2014 in the family’s Wasilla, Alaska, home. (Heidi de Marco/KHN)

WASILLA, Alaska — As her husband lay moaning in pain from the cancer riddling his body, Patricia Martin searched frantically through his medical bag, looking for a syringe.

She had already called the hospice twice, demanding liquid methadone to ease the agony of Dr. Robert Martin, 66. A family practice physician known to everyone as “Dr. Bob,” he had served this small, remote community for more than 30 years.

But the doctor in charge at Mat-Su Regional Home Health & Hospice wasn’t responding. Staff said he was on vacation, then that he was asleep. Martin had waited four days to get pain pills delivered, but her husband could no longer swallow them. Now, they said, she should just crush the drugs herself, mix them with water and squirt the mixture into his mouth. That’s why she needed the syringe.

This KHN story also ran in Time.com. It can be republished for free (details). logo Time

“I thought if I had hospice, I would get the support I needed. They basically said they would provide 24/7 support,” she said, shaking her head in disbelief, three years later. “It was a nightmare.”

The Martins had entrusted the ailing doctor’s final days to one of the nation’s 4,000-plus hospice agencies, which pledge to be on call around-the-clock to tend to a dying person’s physical, emotional and spiritual needs.

Yet the hospice care that people expect — and sign up for — sometimes disappears when they need it most. Families across the country, from Alaska to Appalachia, have called for help in times of crisis and been met with delays, no-shows and unanswered calls, a Kaiser Health News investigation shows.

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A KHN analysis of 20,000 government inspection records reveals that missed visits and neglect are common for patients dying at home. Families or caregivers, shocked and angered by substandard care, have filed over 3,200 complaints with state officials in the past five years.

Those complaints led government inspectors to uncover problems in 759 hospices, with more than half cited for missing visits or other services they had promised to provide at the end of life, KHN found.

The horrifying reports, which do not include victims’ names, describe a 31-year-old California woman whose boyfriend tried for 10 hours to reach hospice as she gurgled and turned blue, and a panicked caregiver in New York calling repeatedly for middle-of-the-night assistance from confused hospice workers unaware of who was on duty. In Michigan, a dementia patient moaned and thrashed at home in a broken hospital bed, enduring long waits for pain relief in the last 11 days of life, and prompting the patient’s caregiver to call nurses and ask, “What am I gonna do? No one is coming to help me. I was promised help at the end.”

Only in rare cases were hospices punished for providing poor care, the investigation showed.

Using death records and public records searches, KHN identified some victims of the worst abuse detailed in the complaints and interviewed surviving family members.

I thought if I had hospice, I would get the support I needed. They basically said they would provide 24/7 support . . . It was a nightmare.

Patricia Martin of Wasilla, Alaska, widow of hospice patient Dr. Bob Martin

Contacted by KHN, Patricia Martin tearfully said she’d given up hope that anyone would take seriously her complaints about her husband’s care. She had enrolled him in hospice when the metastatic prostate cancer reached his brain, expecting the same kind of compassionate, timely attention he had given his own patients.

But Bob Martin had the misfortune to require care during a long holiday weekend, when hospices are often too short-staffed to fulfill written commitments to families. It took six days and three more calls before he received the liquid methadone he needed. Hospice denied his wife’s requests for a catheter, and she and her son had to cut away his urine-soaked clothing and bedding, trying not to cause him additional pain. The supervising hospice doctor never responded. A nurse who was supposed to visit didn’t show up, saying she was called for jury duty.

Bob Martin died just after midnight on Jan. 4, 2014. Six weeks later, his wife filed a complaint against Mat-Su Regional with the Alaska Department of Health and Social Services. An investigation concluded that the hospice failed to properly coordinate services, jeopardizing his end-of-life care. Hospice officials declined interview requests.

“It was just sheer chaos,” Patricia Martin said. “It makes me wonder about other people in this situation. What happens to them?”

Patricia Martin looks through old photographs of her husband on April 14. Bob Martin, a family practice physician, died in 2014. (Heidi de Marco/KHN)

Ross Martin, Patricia Martin and Emily Martin with the family dog, Mabel, at their home in Wasilla, Alaska, in April. (Heidi de Marco/KHN)

Hospice’s Holistic Promise

Hospice is available through Medicare to critically ill patients expected to die within six months who agree to forgo further curative treatment. The care is focused on comfort instead of aggressive medical interventions that can lead to unpleasant, drawn-out hospital deaths.

It’s a booming industry that served about 1.4 million Medicare patients in the U.S. in 2015, including over a third of Americans who died that year, according to latest industry and government figures.

Although many people think of hospice as a site where people go to die, nearly half of hospice patients receive care at home, according to industry figures.

The mission of hospice is to offer peaceful, holistic care and to leave patients and their loved ones in control at the end of life. Agencies receive nearly $16 billion a year in federal Medicare dollars to send nurses, social workers and aides to care for patients wherever they live. While the vast majority of hospice care is covered by Medicare, some is paid for by private insurance, Medicaid and the U.S. Department of Veterans Affairs.

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To get paid a daily fee by Medicare, hospice agencies face many requirements. They must lay out a plan of care for each patient, ensuring they’ll treat all symptoms of the person’s terminal illness. And they’re required to be on call 24/7 to keep patients comfortable, but because each patient is different, there’s no mandate spelling out how often staff must show up at the home, except for a bimonthly supervisory visit. Hospices must stipulate in each patient’s care plan what services will be provided, when and by whom, and update that plan every 15 days. Hospices are licensed by state health agencies and subject to oversight by federal Medicare officials and private accreditation groups.

At its best, hospice provides a well-coordinated interdisciplinary team that eases patients’ pain and worry, tending to the whole family’s concerns. For the 86 percent of Americans who say they want to die at home, hospice makes that increasingly possible.

But when it fails, federal records and interviews show it leaves patients and families horrified to find themselves facing death alone, abandoned even as agencies continue to collect taxpayer money for their care.

In St. Stephen, Minn., Leo Fuerstenberg, 63, a retired Veterans Affairs counselor, died panicked and gasping for air on Feb. 22, 2016, with no pain medication, according to his wife. Laure Fuerstenberg, 58, said a shipment sent from Heartland Home Health Care and Hospice included an oxygen tank, a box of eye drops and nose drops, but no painkillers.

Leo Fuerstenberg of St. Stephen, Minn., shown here in 2013, died in home hospice care in February 2016 at age 63. His wife, Laure, said hospice staff failed to respond to her calls for help as he struggled to breathe. (Courtesy of Laure Fuerstenberg)

“They were prescription drugs, but it didn’t say what they were or how to give them,” she recalled. “I just panicked. I called the hospice, and I said, ‘We’re in trouble. I need help right away.’ I waited and waited. They never called back.”

For more than two hours, she tried desperately to comfort her husband, who had an aggressive form of amyloidosis, a rare disease that affects the organs. But he died in her arms in bed, trapping her under the weight of his body until she managed to call neighbors for help.

“That last part of it was really horrible,” she said. “The one thing I promised him is that he wouldn’t be in pain, he wouldn’t suffer.”

Later, state investigators determined that Heartland’s on-duty hospice nurse had muted her cellphone, missing 16 calls for help. Hospice officials did not respond to repeated interview requests.

“They never followed their protocol, and I’ve never had anybody from there say ‘We failed, we were wrong,’” said Fuerstenberg, a school counselor who said she relives her husband’s death daily. “If that had been me on my job, I’d be fired.”

Her account was among more than 1,000 citizen complaints that led investigators to uncover wrongdoing from January 2012 to February 2017, federal records show. But experts who study hospice say many more families may be too traumatized to take further action.

The complaints offer only a glimpse of a larger problem, warned Dr. Joan Teno, a researcher at University of Washington in Seattle who has studied hospice quality for 20 years. “These are people who got upset enough to complain.”

Officials with the National Hospice and Palliative Care Organization (NHPCO), an industry trade group, said that such accounts are inexcusable — but rare.

“I would venture to say whatever measure you want to use, there are an exponential number of positive stories about hospice that would overwhelm the negative,” said Jonathan Keyserling, NHPCO’s senior vice president of health policy.

When you serve over a million people and families a year, “you’re going to have instances where care could be improved,” he added.

But even one case is too many and hospices should be held accountable for such lapses, said Amy Tucci, president and chief executive of the Hospice Foundation of America, a nonprofit focused on education about death, dying and grief.

“It’s like medical malpractice. It’s relatively rare, but when it happens, it tarnishes the entire field,” she said.

Have you or your loved one received hospice care?

Dearth Of Hard Data

How often hospices fail to respond to families or patients is an understudied problem, experts say, in part because it’s hard to monitor. But a recent national survey of families of hospice patients suggests the problem is widespread: 1 in 5 respondents said their hospice agency did not always show up when they needed help, according to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey, designed by the Centers for Medicare & Medicaid Services.

“That’s a failing grade,” Teno said. “We need to do better.”

Hospice care in the U.S. got its start in the 1970s, driven by religious and nonprofit groups aimed at providing humane care at the end of life. Today, however, many providers are part of for-profit companies and large, publicly traded firms. It’s a lucrative business: For-profit hospices saw nearly 15 percent profit margins on Medicare payments in 2014, according to the Medicare Payment Advisory Commission.

Most families are happy with hospice, according to the CAHPS survey. In data collected from 2015 to 2016 from 2,128 hospices, 80 percent of respondents rated hospice a 9 or 10 out of 10.

Kaiser Family Foundation polling conducted for this story found that out of 142 people with hospice experience, 9 percent were “dissatisfied” and 89 percent “satisfied” with hospice. (Kaiser Health News is an editorially independent program of the foundation.)

Indeed, many people give hospice glowing reviews. Lynn Parés, for instance, gushed about her experience from 2013 to 2014 with Family Hospice of Boulder, Colo. When Parés’ 87-year-old mother cut her leg, staff came daily to treat the wound. A nurse visited every day in the dying woman’s last week of life. The hospice also provided family counseling, spiritual guidance and volunteers who surrounded her mother’s bedside, singing old-time songs.

“They were in constant contact with us,” Parés said of the hospice. “It’s amazing to me how much heart there is involved in hospice care.” After her mother died, Parés and her siblings donated part of their inheritance to the hospice. “I can never say enough good about them.”

Following industry trends, the small, family-owned Boulder company subsequently got acquired by a large regional chain, New Century Hospice, in 2015. As the industry grows — hospice enrollment has more than doubled since 2000 — some companies are not following through on their promises to patients.

For instance, data show many hospices fail to provide extra care in times of crisis. To get Medicare payments, hospices are required to offer four levels of care: routine care, which is by far the most common; respite care, to give family caregivers a break for short time periods; and two levels of so-called crisis care, continuous care and general inpatient care, when patients suffer acutely. But 21 percent of hospices, which together served over 84,000 patients, failed to provide either form of crisis care in 2015, according to CMS.

While there’s no guarantee that a given patient will need crisis care, not offering any such care for an entire year raises a concern about “whether they’re providing adequate symptom control,” Teno said.

“I’d be very surprised if there wasn’t a significant proportion of those people” — at least 5 percent — “who really needed that service,” she said.

Other research has found troubling variation in how often hospice staff visit when death is imminent. A patient’s final two days of life, when symptoms escalate, can be a scary time for families, who often need professional help, Teno said. She and her co-authors found that 281 hospice programs, or 8.1 percent of the hospices studied, didn’t provide a single skilled visit — from a nurse, doctor, social worker or therapist — to any patients who were receiving routine home care, the most common level of care, in the last two days of life in 2014.

Regardless of how often they visit, hospices collect the same flat daily rate from Medicare for each patient receiving routine care: $191 for the first 60 days, then $150 thereafter, with geographic adjustments as well as extra payments in a patient’s last week of life.

I called the hospice, and I said, ‘We’re in trouble. I need help right away.’ I waited and waited. They never called back.

Laure Fuerstenberg, of St. Steven, Minn., widow of hospice patient Leo Fuerstenberg

Overall, 12.3 percent of patients on routine home care received no skilled visits in the last two days of life, the study found. Patients who died on a Sunday had the worst luck: They were more than three times less likely to have a skilled visit than those who died on a Tuesday. Teno said that gives her a strong suspicion that missed visits stem from chronic understaffing, since hospices have fewer staff on weekends.

In Minnesota, Fuerstenberg’s pleas for help went unanswered on a Sunday evening; her husband died just after midnight on Monday. She was appalled when she received a bill for care the agency said occurred on that day.

“When they got paid for nothing, it was like a slap in the face,” said Fuerstenberg, who filed a complaint with Minnesota health officials last year. She heard nothing about the case from hospice officials and didn’t learn it had been investigated until she was contacted by Kaiser Health News.

Left In The Lurch

In St. Paul, Va., a small town in the Appalachian mountains, Virginia Varney enlisted Medical Services of America Home Health and Hospice, a national chain, to care for her son, James Ingle, 42, who was dying of metastatic skin cancer. On his final day, Christmas Day 2012, he was agitated, vomiting blood, and his pain was out of control. Varney called at least four times to get through to hospice. Hours later, she said, the hospice sent an inexperienced licensed practical nurse who looked “really scared” and called a registered nurse for backup. The RN never came. Ingle died that night.

James Ingle, shown in an undated family photo, died of cancer on Christmas Day 2012. The day he died, he was vomiting and his pain was out of control. His family made several frantic calls to hospice, but couldn’t get a registered nurse to visit the house to help. (Courtesy of Virginia Varney)

Varney said she felt numb, angry and “very disappointed” in the hospice care: “It’s like they just didn’t do anything. And I know they were getting money for it.”

“They told me 24 hours a day, seven days a week, holidays and all,” Varney said. “I didn’t find that to be true.”

An investigation by Virginia state inspectors, which corroborated Varney’s story, revealed hospice staff changed the records from that night after the fact. The registered nurse was fired that February. The hospice declined to comment for this story.

Just how often are hospice patients left in the lurch? Inspection reports, performed by states and collected by CMS, don’t give a clear answer, in part because hospices are reviewed so infrequently.

Unlike nursing homes, hospices don’t face inspection every year to maintain certification. Based on available funding, CMS has instead set fluctuating annual targets for state hospice inspections. In 2014, CMS tightened the rules, requiring states to increase the frequency to once every three years by 2018.

Often, promising to do better is the only requirement hospices face, even when regulators uncover problems. The Office of the Inspector General at the federal Department of Health and Human Services has called for stricter oversight and monitoring of hospice for a decade, said Nancy Harrison, a New York-based deputy regional inspector general. One problem, she said, is there is no punishment short of termination — barring the hospice from receiving payment from Medicare or Medicare — which is disruptive for dying patients who lose service.

CMS records show termination is rare: Through routine inspections as well as those prompted by complaints, CMS identified deficiencies in more than half of 4,453 hospices from Jan. 1, 2012, to Feb. 1, 2017. During that same time period, only 17 hospices were terminated, according to CMS.

In Alaska, officials at Mat-Su Regional Home Health & Hospice, which cared for Bob Martin, cited patient privacy rules in declining to comment about his case. But “[we] strengthened our policy and procedures” as a result of the investigation, administrator Bernie Jarriel Jr. said in an email. “Members of our caregiving team have been re-educated on these practices.”

In Minnesota, officials with the local Heartland Home Health and Hospice agency referred questions to its corporate owner, HCR ManorCare of Toledo, Ohio. Officials there did not respond to multiple requests for comment about Leo Fuerstenberg’s care. CMS documents indicate the nurse who missed 16 messages “was re-educated on responsibilities of being on call.”

They told me 24 hours a day, seven days a week, holidays and all. I didn’t find that to be true.

Virginia Varney of St. Paul, Va., mother of hospice patient James Ingle

‘Misplaced Expectations’

Hospice industry officials note that resolving hospice complaints can be difficult during the fraught days at the end of life.

“Hospice is like any other health care provider in that there may be misplaced expectations,” said the NHPCO’s Keyserling.

Hospice providers must ensure that communications are clear and understood and patients and families must voice their concerns, he added. When that doesn’t happen, problems can follow.

Jim Mills, 56, a retired Navy submariner from West Liberty, Ky., is still angry about the care his wife, Leeanne Mills, 54, received in the summer of 2016 at Mountain Community Hospice, then run by Hospice of the Bluegrass in nearby Lexington. She was diagnosed in 2011 with ocular melanoma and spent five years in treatment for the rare eye cancer. When all options were exhausted, the couple recalled the excellent hospice care given to Mills’ father and brother-in-law.

“My wife and I saw that, so we said ‘OK,’” Mills recalled. “My wife wanted to die in the home that she and I lived in.”

But the experience was devastating, he said. Instead of round-the-clock care for his wife, he said the hospice left him alone to grapple with her excruciating pain. He detailed dozens of alleged problems with her care, ranging from a hospice nurse who didn’t respond for five hours to a middle-of-the-night call for pain medications to suspicions that use of a drug pump hastened her death.

“I’m in panic mode,” Mills recalled. “I don’t know what to do. I’m no doctor. I’m no nurse.”

Kentucky state health officials who investigated Mills’ complaint in October 2016 found “no deficient practice,” records show. Mountain Community Hospice, run by the Kentucky agency now known as Bluegrass Care Navigators, also disputed Mills’ version of events. Lawyers representing the agency said in a letter that care his wife received was appropriate and suggested that the trauma of loss may have colored his perceptions.

Jim and Leeanne Mills of West Liberty, Ky., celebrate at the 2014 wedding of their daughter. Leeanne Mills died in hospice care in August 2016 after aggressive treatment for ocular melanoma, a type of eye cancer. (Courtesy of Jim Mills)

“MCH treated your wife and family with dignity and compassion throughout her hospice stay and was in no way negligent, abusive or harmful to her or your family,” the letter said. “Unfortunately, emotional pain and anguish for dying patients and their loved ones are unavoidable in such tragic circumstances despite high quality and supportive hospice care.”

Liz Fowler, the hospice president and chief executive, said in an email to KHN, “We are concerned when a family member has a negative perception of our care. We wish we could improve that perception.”

But Mills said nothing will shake his belief that his wife was treated badly in her final days.

“There should be some clarity when a family is facing this, in whatever state it happens to be, they should know their rights, they should know what to expect,” he said. “I want my wife’s death and suffering to not have been in vain.”

Help For Families

In a 2016 study, the OIG’s Harrison and colleagues called for state surveyors to better scrutinize the plans of care hospices outline for their patients. And they recommended that CMS create a range of different levels of punishment for hospice infractions, such as requiring in-service training, denying payments, civil fines and imposing temporary management.

CMS has no statutory authority to impose those alternative sanctions, said spokesman Jibril Boykin. But it did increase transparency in August by launching a consumer-focused website called Hospice Compare that now includes hospices’ self-reported performance on quality measures and, next year, will include family ratings of hospices. Until that happens, there’s little information available for families trying to pick a hospice that will show up when it counts. Tucci, of the Hospice Foundation of America, suggests that families of ill or frail relatives consider hospice options before a crisis occurs. The agency recommends 16 questions families should ask before choosing a hospice.

Back in Alaska, Patricia Martin said she’s still waiting for officials with Mat-Su Regional Home Health & Hospice to answer questions about her husband’s poor care. She urges other families enrolling patients in hospice to be vigilant.

“It is my hope that no other family or patient will ever have to go through the nightmare that we did,” she said. “If they promise you they’re going to do something, they should do it.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation and its coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Health Industry, Medicare

Tags: End Of Life, Home Health Care, Hospice

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Trump declares opioid epidemic a national public health emergency

WASHINGTON (Reuters) – Calling it a “national shame” and “human tragedy,” President Donald Trump on Thursday announced steps to fight the opioid crisis in the United States by declaring it a national public health emergency and cracking down on the flow of the drug fentanyl.

U.S. President Donald Trump displays a presidential public health emergency declaration on the nation’s opioid crisis in the East Room of the White House in Washington. REUTERS/Carlos Barria

“We are going to overcome addiction in America,” Trump said at the White House.

He said the federal government would work to develop non-addictive painkillers and pledged to consider bringing lawsuits against “bad actors” in the opioid epidemic.

Reporting by Jeff Mason and Makini Brice; Editing by Cynthia Osterman

Our Standards:The Thomson Reuters Trust Principles.

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