Readers And Tweeters Bare Their Teeth On Dental Disparities (And Other Fine Points)

Letters to the Editor is a periodic Kaiser Health News feature. KHN welcomes all comments and will publish a selection. We edit for length and clarity and require full names.


Foaming At The Mouth Over Dental Insurance?

In response to the revelation that a 61-year-old academic had to rely on handouts from his mom to cough up over $50,000 for dental work (“When Is Insurance Not Really Insurance? When You Need Pricey Dental Care,” May 21), Trista McGlamery of Atlanta tweets that an ounce of prevention is worth a ton.

I blew through my coverage this year having 11 cavities filled and scaling done, so I will agree dental insurance isn’t sufficient. Another aspect of this is the gap in quality rural dental care. How many people are facing enormous bills now thanks to substandard care earlier? https://t.co/ZrxdmR3o6n

— Trista McGlamery (@tristamac) May 21, 2018

— Trista McGlamery, Atlanta


Jillian Tullis of San Diego seconds that emotion.

Great article about #dentistry. ‘Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.’ #healthcare https://t.co/pvLXpRdbjC

— Jillian Tullis (@ProfJillian) May 21, 2018

— Jillian Tullis, San Diego


A professor of economics at Elon University, Steve DeLoach, questions the logic:

It really defies logic. Why do we treat the inside of your mouth different that any other part of your body? Lots of economic problems here since an unhealthy mouth directly affects the health of the rest of your body (which is covered by typical insurance). https://t.co/RHCjABv2lj

— Steve DeLoach (@steve_deloach) May 28, 2018

— Steve DeLoach, Elon, N.C.


Taking the long view is historian Debby Levine of Providence, R.I.

Worth thinking about historical reasons that American mouths and teeth have their own insurance system separate from the rest of the body: https://t.co/Wx37BudOC1

— D Lev (@debbylevine) May 21, 2018

— Debby Levine, Providence, R.I.


Rachel Perrone of Washington, D.C., tells how she took it in the teeth for her son.

I brought my son in for a tooth that was coming in wonky and *hurting* him. But because that was considered orthodonture, not a penny of it was covered. I’ll be paying on it forever. https://t.co/ZJ0KzvHpRB

— Rachel Perrone (@RachelPerrone) May 21, 2018

— Rachel Perrone, Washington, D.C.


Representing Pharmacists

I’m disappointed that your image of a pharmacist is a white male (“Looking For Lower Medicare Drug Costs? Ask Your Pharmacist For The Cash Price,” May 30). In 2015, according to the Bureau of Labor Statistics, 57 percent of pharmacists were women, nearly 9 percent were black or African-American, 15 percent Asian and roughly 5 percent Hispanic. Please consider reflecting the diversity of people in this occupation.

— Regina Flynn, Strafford, N.H.


Pardon Our ‘Spanish’

In the story “California Lawmakers Seek Reparations For People Sterilized By The State” (April 25), Samantha Young’s use of the adjective “Spanish” to describe the predominantly Mexican Hispanic/Latino community in Hayward, Calif., should be reconsidered. I know this is a complicated descriptive-language issue, but the female population targeted for sterilization was heavily Mexican, and Rosie was of Mexican heritage in a community with little representation from Spain. I’d be inclined not to use the word “Spanish” to generalize about this community.

— Dave Hallock, Edmonds, Wash.


Why Punish The Ill?

Many of these incarcerated individuals who are receiving psychotropic medications have needed them for years but were unable to obtain them for any number of reasons (“Use Of Psychiatric Drugs Soars In California Jails,” May 8). It’s a shame that the only way they can get what their bodies require is to be imprisoned. In fact, the prisons are not just filled with criminals. In most states, inmate populations are made up largely of those with “medical needs” not “criminal rehabilitation needs.” A case of “the wrong doctors treating the wrong diseases.”

— Joe Blough, Rock Hill, Mo.

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Cost and Quality Insurance Public Health

Dental Health Disparities Letter To The Editor

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Another antibiotic crisis: fragile supply leads to shortages

LONDON (Reuters) – Shortages of some life-saving antibiotics are putting growing numbers of patients at risk and fuelling the evolution of “superbugs” that do not respond to modern medicines, according to a new report on Thursday.

FILE PHOTO: A technician stocks the shelves of a pharmacy in Kentucky, February 2018. REUTERS/Bryan Woolston/File Photo

The non-profit Access to Medicine Foundation (AMF) said there was an emerging crisis in the global anti-infectives market as fragile drug supply chains – reliant on just a few big suppliers – come close to collapse.

The result is shortages of products like piperacillin-tazobactam, an antibiotic combination used intravenously in intensive care, which has been in tight supply since a 2016 explosion at a Chinese pharmaceutical ingredients factory.

Another antibiotic, benzathine penicillin G (BPG), faces shortages in at least 39 countries, including Germany and Brazil.

BPG is a key drug for preventing transmission of syphilis from mother to child and the shortage frustrated Brazil’s efforts to bring a disease outbreak under control between 2012 and 2015. BPG is also used to fight rheumatic heart disease.

In absence of the right drugs, patients may take less effective or poor quality medicines that increase the risk of antimicrobial resistance developing.

“Things are getting worse because the market is not fixing the problem, despite the expansion in the need for such specialist antibiotics,” said AMF Executive Director Jayasree Iyer.

Global demand for antibiotics has grown by two-thirds since 2000, driven by population growth and the need for medicines to fight infectious diseases in low- and middle-income countries.

Most antibiotics are cheap, off-patent generic medicines, which is good for affordability. But that also means they have very low profit margins – particularly compared to modern drugs for diseases like cancer – offering manufacturers little incentive to invest in new production facilities.

The rise in shortages has gone hand in hand with a wave of consolidation among the companies making generic drugs – which range from global pharmaceutical giants to smaller firms in countries such as India – reducing the number of suppliers making individual product lines.

Sporadic drug shortages are not unique to antibiotics. Recently, for example, there has been a worldwide shortage of Mylan’s (MYL.O) market-leading EpiPen emergency allergy device.

But antibiotic shortages can have especially dire consequences, since doctors have to resort to sub-optimal treatments that are less efficient at killing specific pathogens, leading to the rise of resistant bacteria or so-called superbugs.

An estimated 70 percent of bacteria are already resistant to at least one antibiotic that is commonly used to treat them, making the evolution of such superbugs one of the biggest threats facing medicine today.

Reporting by Ben Hirschler; Editing by Mark Potter

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Utah sues opioid maker Purdue Pharma after settlement talks stall

(Reuters) – Utah’s attorney general on Thursday sued OxyContin maker Purdue Pharma LP to hold it responsible for its role in the opioid epidemic after he said talks to reach a settlement between various states and the drugmaker stopped being productive.

FILE PHOTO: A pharmacist holds prescription painkiller OxyContin, 40mg pills, made by Purdue Pharma L.D. at a local pharmacy, in Provo, Utah, U.S. on April 25, 2017. REUTERS/George Frey/File Photo

The lawsuit alleges that Purdue engaged in a marketing campaign that concealed the risks of treating chronic pain with addictive opioids.

The suit filed by Utah Attorney General Sean Reyes in the 7th Judicial District Court in Carbon County, added to a growing list of lawsuits by states and local governments accusing the Stamford, Connecticut-based company of deceptively marketing opioid painkillers.

Reyes had been part of a group of 41 state attorneys general who were working together to investigate opioid manufacturers and distributors and to negotiate settlements with the companies.

But Reyes, during a news conference in Salt Lake City, said that after months of negotiation with Purdue, he and other state attorneys general leading the effort concluded settlement talks with the company were “no longer effective.”

“There was some progress, and it was looking potentially hopeful that we would could come to a possible global settlement,” he said. “Unfortunately, with Purdue, things didn’t continue to move, so that’s why we decided to file now.”

The announcement came after six other states participating in the multistate opioid investigation decided to sue Purdue on May 15. In total, it faces lawsuits by 23 states and the territory of Puerto Rico.

Purdue Pharma in a statement said it was disappointed that Reyes had decided to sue “after months of good faith negotiations working toward a meaningful resolution to help the state of Utah address the opioid crisis.”

“We vigorously deny these allegations and look forward to the opportunity to present our defense,” Purdue said.

Opioids were involved in more than 42,000 overdose deaths in 2016, according to the U.S. Centers for Disease Control and Prevention.

Purdue and other drugmakers have been battling hundreds of lawsuits nationally claiming they downplayed the risks of addiction and engaged in misleading marketing that overstated the benefits of opioids for treating chronic pain.

At least 718 lawsuits, largely by local governments, are consolidated in Cleveland, Ohio, before U.S. District Judge Dan Polster, who has been pushing the parties to reach a settlement.

Purdue and three executives previously pleaded guilty in 2007 to federal charges related to the misbranding of OxyContin, and agreed to pay a total of $634.5 million to resolve the U.S. Justice Department’s probe.

Reporting by Nate Raymond in Boston; Editing by Bill Berkrot

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‘Markers’ of Alzheimer’s Don’t Doom You to Dementia

News Picture: 'Markers' of Alzheimer's Don't Doom You to DementiaBy Dennis Thompson
HealthDay Reporter

Latest Alzheimers News

TUESDAY, May 29, 2018 (HealthDay News) — Even if you discover that you have the first biological signs of Alzheimer’s, you are not doomed to develop the crippling dementia, a new study suggests.

“Just because you have amyloid [proteins] in the brain doesn’t mean you’re going to get dementia tomorrow. It doesn’t mean you’re going to get dementia in five years,” said lead researcher Ron Brookmeyer. He’s a professor of biostatistics with UCLA’s Fielding School of Public Health.

“It could be many years, and it could be longer than your natural life expectancy,” Brookmeyer added.

For example, high levels of abnormal amyloid proteins in your brain or shrinkage of your brain each confer only a minimal risk of future dementia, a new statistical risk model indicates.

Further, a person’s dementia risk is even lower if the amyloid or shrinkage is detected at a more advanced age, the study authors noted.

On the other hand, a person’s risk does rise if early biological signs of Alzheimer’s start stacking up, the investigators found.

For instance, a 60-year-old man with high levels of amyloid protein has just a 23 percent chance of developing dementia in his lifetime, while a 60-year-old woman has a 31 percent risk, the researchers said.

Shrinking of specific brain regions confer similarly low lifetime dementia risks at age 60; about 23 percent for men and 30 percent for women.

But if men or women have both high amyloid levels and brain shrinkage at age 60, their dementia risk increases to 34 percent and 42 percent, respectively, according to the report.

People face the most risk if they have high amyloid levels, brain shrinkage and early signs of mild cognitive impairment, the researchers explained. This impairment usually crops up as memory loss.

With all three signs present, 60-year-old men and women have a 93 percent and 96 percent risk of developing Alzheimer’s, respectively.

Age and life expectancy also play a strong role in Alzheimer’s dementia risk, Brookmeyer said.

Dementia risk decreases with age because it’s less likely a person will develop Alzheimer’s during their lifetime, he explained. But life expectancy also plays a part.

“Females will generally have higher risks, because females have a longer life expectancy. With a longer life expectancy, there’s more time for the preclinical disease to progress,” Brookmeyer said.

For this study, the researchers analyzed data on just over 2,000 people who participated in two long-term studies on Alzheimer’s disease. These studies included scans for amyloid, brain shrinkage and cognitive impairment, all of which can be observed before a person falls victim to dementia.

This study could be considered good news for the 46.7 million Americans who carry some early signals of Alzheimer’s disease, Brookmeyer said.

“It may actually provide some reassurance to people that despite testing positive on some screening tests, their chances of developing Alzheimer’s dementia may remain low,” Brookmeyer said.

However, he noted that the model needs to be further refined to include other factors — such as genetics — that affect dementia risk.

James Hendrix, director of global science initiatives for the Alzheimer’s Association, agreed that it’s too early to take much hope from this study.

“I think we probably do ourselves a little bit of a disservice if we focus so much on the overall conclusion that Alzheimer’s risk is less than we thought, because I don’t think we know that for sure,” Hendrix said. “We need to dig into the numbers a little bit more and understand what is happening in the continuum of Alzheimer’s disease as it progresses.”

Hendrix is particularly concerned that these findings might prompt complacency in people, making them “think this is a solved problem.”

As a result, people might slack on advocacy, volunteer efforts in their community, or volunteering for clinical trials that are critical to understand Alzheimer’s, he said.

“The problem isn’t diminished,” Hendrix said. “It’s still there, and we need people to remain engaged.”

The findings were published online May 22 in Alzheimer’s & Dementia.

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SOURCES: Ron Brookmeyer, Ph.D., professor, biostatistics, University of California, Los Angeles, Fielding School of Public Health, Los Angeles; James Hendrix, Ph.D., director, global science initiatives, Alzheimer’s Association; May 22, 2018, Alzheimer’s & Dementia, online


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Quality Payment Program Exceeds Year 1 Participation Goal

May 31
by Centers for Medicare & Medicaid Services

By: Administrator, Seema Verma, Centers for Medicare & Medicaid Services

Quality Payment Program Exceeds Year 1 Participation Goal 

I’m pleased to announce that 91 percent of all clinicians eligible for the Merit-based Incentive Payment System (MIPS) participated in the first year of the Quality Payment Program (QPP) – exceeding our goal of 90 percent participation. Remarkably, the submission rates for Accountable Care Organizations and clinicians in rural practices were at 98 percent and 94 percent, respectively. What makes these numbers most exciting is the concerted efforts by clinicians, professional associations, and many others to ensure high quality care and improved outcomes for patients.

Meeting the Challenges Ahead

Even with this high rate of participation, we are committed to removing more of the regulatory burdens that get in the way of doctors and other clinicians spending time with their patients. After only eight months, we’ve made significant progress through our Patients over Paperwork initiative: streamlining our regulations, increasing efficiencies, and improving care for patients. At the same time, we continue to put patients first by protecting the safety of our beneficiaries and strengthening the quality of healthcare they receive.

For example, we reviewed many of the MIPS requirements and developed policies for 2018 that continue to reduce burden, add flexibility, and help clinicians spend less time on unnecessary requirements and more time with patients.

In particular we have:

  • Reduced the number of clinicians that are required to participate giving them more time with their patients, not computers.
  • Added new bonus points for clinicians who are in small practices, treat complex patients, or use 2015 Edition Certified Electronic Health Record Technology (CEHRT) exclusively as a means of promoting the interoperability of health information.
  • Increased the opportunity for clinicians to earn a positive payment adjustment.
  • Continued offering free technical assistance to clinicians in the program.

Under the Bipartisan Budget Act of 2018 we have additional authority to continue our gradual implementation of certain requirements for three more years to further reduce burden in areas of MIPS.

We’re also eager to improve the clinician and patient experience through our Meaningful Measures initiative so that clinicians can spend more time providing care to their patients and improving the quality of care their patients receive. Within MIPS, we are adopting measures that improve patient outcomes and promote high-quality care, instead of focusing on processes.

Working with the Healthcare Community

We want to express our gratitude to all of the clinicians who collaborated with us as part of the voluntary Clinician Champions Program and the Clinician Voices initiative. We also want to thank all of you who participated in our various listening sessions and user groups throughout the year. Your input and feedback opened a dialogue, highlighted opportunities for improvement, and helped us identify ways to continue to reduce burden within the Quality Payment Program.

We deeply appreciate the contributions professional associations, consumer advocates and other important stakeholders have made to help engage their members and prepare them for success. We also want to acknowledge the networks supporting the free technical assistance available to clinicians, specifically the Small, Underserved, and Rural Support initiative, Quality Innovation Networks, and the Transforming Clinical Practice Initiative, who worked tirelessly to help clinicians familiarize themselves with the program so they can successfully participate. Together with our stakeholders and technical assistance networks, we hosted over 6,000 Quality Payment Program events last year. We used these events to describe requirements, offer tips, listen to you, and act on your feedback.

And, we’re proud to announce that our free technical assistance received a 99.8 percent customer satisfaction rating by over 200,000 clinicians and practice managers. The technical assistance networks also responded to 98.7 percent of initial referrals for additional support from the Quality Payment Program Service Center and Centers for Medicare & Medicaid Services (CMS) Regional Offices within 1-business day. We believe that there is an obligation to respond quickly, so clinicians can spend less time trying to figure out the program and more time with their patients.

Additionally, our Quality Payment Program Service Center complemented the technical assistance effort by fielding more than 130,000 inquiries and delivering world class customer support.

Better yet, all of the free and customized support from the technical assistance networks and the Quality Payment Program is still available to clinicians in the 2018 performance year!

Moving Forward Together

While we’re proud of what has been accomplished, there is more work to be done. CMS remains committed to listening to the healthcare community and exploring ways to reduce clinician burden, strengthen quality, introduce new payment models, develop meaningful measures including for patient safety, and promote interoperability. We look forward to continuing to hearing from you to make sure that we focus on patients, not paperwork.

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Choose health, not tobacco

Are you or a loved one hooked on tobacco? Make May 31—named by the World Health Organization as World “No Tobacco” Day—your starting point to kick the habit.

Tobacco use is the second leading cause of death worldwide, responsible for 1 in every 10 adult deaths. Join the millions who’ve found a good reason to give it up. If you’re ready to quit smoking, Medicare can help.

Medicare Part B covers up to 8 face-to-face counseling sessions in a 12-month period when you get them from a qualified doctor or other qualified health care provider. You pay nothing for these sessions if your doctor or other health care provider accepts assignment.

Visit the Centers for Disease Control and the National Cancer Institute to learn more about how you can quit smoking. You can also watch our video to learn more about how Medicare can help you kick the smoking habit.

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FDA approves first oral medication for adults with moderately to severely active ulcerative colitis

May 30, 2018

The U.S. Food and Drug Administration today expanded the approval of Xeljanz (tofacitinib) to include adults with moderately to severely active ulcerative colitis. Xeljanz is the first oral medication approved for chronic use in this indication. Other FDA-approved treatments for the chronic treatment of moderately to severely active ulcerative colitis must be administered through an intravenous infusion or subcutaneous injection.

“New treatments are needed for patients with moderately to severely active ulcerative colitis,” said Julie Beitz, M.D., director of the Office of Drug Evaluation III in FDA’s Center for Drug Evaluation and Research. “Today’s approval provides an alternative therapy for a debilitating disease with limited treatment options.”

Ulcerative colitis is a chronic, inflammatory bowel disease affecting the colon. Patients experience recurrent flares of abdominal pain and bloody diarrhea. Other symptoms include fatigue, weight loss and fever. More than 900,000 patients are affected in the U.S., many of them experiencing moderately to severely active ulcerative colitis, and there is currently no cure.

The efficacy of Xeljanz for the treatment of moderately to severely active ulcerative colitis was demonstrated in three controlled clinical trials. This included two 8-week placebo-controlled trials that demonstrated that 10 mg of Xeljanz given twice daily induces remission in 17 to 18 percent of patients by week eight. In a placebo-controlled trial among patients who achieved a clinical response by week eight, Xeljanz, at a 5 mg or 10 mg dose given twice daily, was effective in inducing remission by week 52 in 34 percent and 41 percent of patients, respectively. Among patients who achieved remission after 8 weeks of treatment, 35 percent and 47 percent achieved sustained corticosteroid-free remission when treated with 5 mg and 10 mg, respectively.

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The safety of chronic use of Xeljanz for ulcerative colitis was studied in the 52-week placebo- controlled trial. Additional supportive safety information was collected from patients who received treatment in an open-label long-term study.

The most common adverse events associated with Xeljanz treatment for ulcerative colitis were diarrhea, elevated cholesterol levels, headache, herpes zoster (shingles), increased blood creatine phosphokinase, nasopharyngitis (common cold), rash and upper respiratory tract infection.

Less common serious adverse events included malignancy and serious infections such as opportunistic infections. Xeljanz has a boxed warning for serious infections and malignancy. Patients treated with Xeljanz are at increased risk for developing serious infections that may lead to hospitalization or death. Lymphoma and other malignancies have been observed in patients treated with Xeljanz.

Use of Xeljanz in combination with biological therapies for ulcerative colitis or with potent immunosuppressants, such as azathioprine and cyclosporine, is not recommended.

Xeljanz, made by Pfizer Labs, was previously approved in 2012 for rheumatoid arthritis and in 2017 for psoriatic arthritis.

Source:

https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm609225.htm

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Scientists engineer bi-specific antibodies that attract immune killers directly to cancer cells

May 30, 2018

Our immune system’s arsenal of defenses usually protects us from cancer. But sometimes, cancer cells overwhelm or evade this elaborate defense system.

In the lab of biochemist and immunologist Christoph Rader, PhD, associate professor at The Scripps Research Institute in Florida, scientists have engineered a new type of anti-cancer antibody, one intended to enhance nature’s cancer-fighting strategies by attracting killer T cells directly to cancer cells covered with a distinctive protein.

Dubbed “T-cell engaging bi-specific antibodies,” these cancer combatants attack malignant cells but leave healthy cells untouched. That’s thanks to their selective targeting system, which zeroes in on a protein found on the surface of several types of cancer cells called ROR1, and also thanks to their talent for binding with T cells, the big guns of the immune system.

“Once the T cells are recruited and activated, they release cytotoxic molecules that penetrate the target cells and kill them,” Rader says. “Natural antibodies can’t do this. You have to engineer them in a bi-specific fashion to do this.”

The scientists’ work is described in the article, “Potent and Selective Antitumor Activity of a T-Cell Engaging Bispecific Antibody Targeting a Membrane-Proximal Epitope of ROR1,” appearing online May 29 in the journal Proceedings of the National Academy of Sciences.

Rader is particularly interested in applying his bi-specific antibodies to a type of breast cancer with fewer treatment options, HER2-negative breast cancer.

“If you look at ROR1 expression in breast cancer, you see that the patients who are HER2 negative are often ROR1 positive,” Rader says. “These breast cancer patients might benefit.”

Antibodies are proteins made by white blood cells to attack specific targets like viruses, bacteria and cancers. A bi-specific antibody is a Y-shaped immune factor engineered to both bind with a specific disease target, and also to attract killer T cells, a type of white blood cell that destroys infected or dangerous cells.

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ROR1 is an excellent target for a smart cancer-fighting system, Rader says, because it is seen only in mature cells that are malignant. Rader first discovered ROR1’s activity in leukemia a decade ago while working at the National Cancer Institute.

“ROR1 is expressed during embryogenesis, and then it is tightly down-regulated after birth. It later reappears in both blood cancers and solid malignancies,” Rader says.

It has been found on malignant cells including lung, breast, ovarian and blood-based cancers, Rader says.

“One of the most unique aspects of this bi-specific antibody is that it can work in so many different cancer indications,” Rader says.

He credits first author Junpeng Qi, PhD, a postdoctoral associate at Scripps Research in Florida, with engineering a group of bi-specific antibodies that stay active in animal models for about five days-;a feat compared with current approaches. The U.S. Food and Drug Administration has approved just one bi-specific antibody against cancer so far, against B-cell acute lymphoblastic leukemia. It stays active for a couple of hours, Rader says.

“Junpeng used a component of natural antibodies for this bi-specific antibody that gives it not only a larger size, but also the ability to be recycled and stay in the blood longer,” Rader says. “They are not there eternally, though. You get rid of them eventually, which is important for avoiding systemic toxicity.”​

Source:

https://www.scripps.edu/news/press/2018/20180530-cancer-antibody-florida.html

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‘They Deserve It’: In Foster Homes, Veterans Are Cared For Like Family

Ralph Stepney’s home on a quiet street in north Baltimore has a welcoming front porch and large rooms, with plenty of space for his comfortable recliner and vast collection of action movies. The house is owned by Joann West, a licensed caregiver who shares it with Stepney and his fellow Vietnam War veteran Frank Hundt.

“There is no place that I’d rather be. … I love the quiet of living here, the help we get. I thank the Lord every year that I am here,” Stepney, 73, said.

It’s a far cry from a decade ago, when Stepney was homeless and “didn’t care about anything.” His diabetes went unchecked and he had suffered a stroke — a medical event that landed him at the Baltimore Veterans Affairs Medical Center.

After having part of his foot amputated, Stepney moved into long-term nursing home care at a VA medical facility, where he thought he’d remain — until he became a candidate for a small VA effort that puts aging veterans in private homes: the Medical Foster Home program.

Ralph Stepney, a Vietnam War veteran who was homeless a decade ago, watches TV in his room earlier this month. Stepney moved into caregiver Joann West’s home in Baltimore in 2016 through the Veterans Affairs’ Medical Foster Home program. (LYNNE SHALLCROSS/KHN)

“There is no place that I’d rather be. … I thank the Lord every year that I am here,” Stepney says. (LYNNE SHALLCROSS/KHN)

The $20.7 million-per-year program provides housing and care for more than 1,000 veterans in 42 states and Puerto Rico, serving as an alternative to nursing home care for those who cannot live safely on their own. Veterans pay their caregivers $1,500 to $3,000 a month, depending on location, saving the government about $10,000 a month in nursing home care. It has been difficult to scale up, though, because the VA accepts only foster homes that meet strict qualifications.

For the veterans, it’s a chance to live in a home setting with caregivers who treat them like family. For the Department of Veterans Affairs, the program provides an option for meeting its legal obligation to care for ailing, aging patients at significantly reduced costs, since the veterans pay room and board directly to their caregivers.

Cost-effectiveness is but one of the program’s benefits. Stepney and Hundt, 67, are in good hands with West, who previously ran a home health care services company. And they’re in good company, watching television together in the main living room, going to elder care twice a week and sitting on West’s porch chatting with neighbors.

Ralph Stepney (left) and Frank Hundt sit on the front porch of the Baltimore home they share with caregiver Joann West on May 18, 2018.(Lynne Shallcross/KHN)

West, who considers caring for older adults “her calling,” also savors the companionship and finds satisfaction in giving back to those who spent their young lives in military service to the U.S.

“I took care of my mother when she got cancer and I found that I really had a passion for it. I took classes and ran an in-home nursing care business for years. But my dream was always to get my own place and do what I am doing now,” West said. “God worked it out.”

The Medical Foster Home program has slightly more than 700 licensed caregivers who live full time with no more than three veterans and provide round-the-clock supervision and care, according to the VA. Akin to a community residential care facility, each foster home must be state-licensed as an assisted living facility and submit to frequent inspections by the VA as well as state inspectors, nutritionists, pharmacists and nurses.

Unlike typical community care facilities, foster home caregivers are required to live on-site and tend to the needs of their patients themselves 24/7 — or supply relief staff.

“It’s a lot of work, but I have support,” West says. “I try to make all my personal appointments on days when Mr. Ralph and Mr. Frank are out, but if I can’t, someone comes in to be here when I’m gone.”

VA medical foster home providers also must pass a federal background check, complete 80 hours of training before they can accept patients, plus 20 hours of additional training each year, and allow the VA to make announced and unannounced home visits. They cannot work outside the home and must maintain certification in first aid, CPR and medicine administration.

But one prerequisite cannot be taught — the ability to make a veteran feel at home. West has grown children serving in the military and takes pride in contributing to the well-being of veterans.

“It’s a lot of joy taking care of them,” she said of Stepney and Hundt. “They deserve it.”

Caregiver Joann West sits in the living room of her Baltimore home, which she shares with veterans Frank Hundt (left) and Ralph Stepney. The Veterans Affairs’ Medical Foster Home program’s motto is “Where Heroes Meet Angels.” (LYNNE SHALLCROSS/KHN)

Ralph Stepney holds photos from a cruise he took to Bermuda with West and Hundt. Stepney put the photos into a keepsake album that he keeps at their home. (LYNNE SHALLCROSS/KHN)

To be considered for the program, veterans must be enrolled in VA health care; have a serious, chronic disabling medical condition that requires a nursing home level of care; and need care coordination and access to VA services. It can take up to a month to place a veteran in a home once they are found eligible, according to the VA.

The veterans also must be able to cover their costs. Because medical foster homes are not considered institutional care, the VA is not allowed to pay for it directly. The average monthly fee, according to the VA, is $2,300, which most veterans cover with their VA compensation, Social Security and savings, said Nicole Trimble, Medical Foster Home coordinator at the Perry Point VA Medical Center in Maryland.

Pilot Program Takes Off

Since 1999, the Department of Veterans Affairs has been required to provide nursing home services to veterans who qualify for VA health care and have a service-connected disability rating of 70 percent or higher, or are considered unemployable and have a disability rating of 60 percent or higher.

The VA provides this care through short- or long-term nursing home facilities, respite care, community living centers on VA hospital grounds, private assisted living facilities and state veterans homes.

Shortly after, the VA Medical Center in Little Rock, Ark., launched an alternative — a pilot program that placed veterans in individual homes, at an average cost to the VA of roughly $60 a day, including administration and health care expenses, compared with upward of $500 a day for nursing home care.

And because veterans who are enrolled in the Medical Foster Care program must use the VA’s Home-Based Primary Care program, which provides an interdisciplinary team of health professionals for in-home medical treatment, the program saves the VA even more. One study showed that the home-based care has yielded a 59 percent drop in VA hospital inpatient days and a 31 percent reduction in admissions among those who participate.

More than 120 VA medical centers now oversee a Medical Foster Home program in their regions, and the VA has actively promoted the program within its health system.

It also has attracted bipartisan congressional support. In 2013, Sen. Bernie Sanders (I-Vt.) introduced a bill to allow the VA to pay for medical foster homes directly.

In 2015, former House Veterans Affairs Committee chairman Rep. Jeff Miller (R-Fla.) introduced similar legislation that would have allowed the VA to pay for up to 900 veterans under the program.

And in May, Rep. Clay Higgins (R-La.) raised the issue again, sponsoring a bill similar to Miller’s. “Allowing veterans to exercise greater flexibility over their benefits ensures that their individual needs are best met,” Higgins said in support of the program.

Frank Hundt watches TV in his bedroom at caregiver Joann West’s home in Baltimore on May 18, 2018.(Lynne Shallcross/KHN)

A Guardian ‘Angel’

Foster care has been a blessing for the family of Hundt, who suffered a stroke shortly after his wife died and was unable to care for himself. Hundt’s daughter, Kimberly Malczewski, lives nearby and often stops in to visit her dad, sometimes with her 2-year-old son.

“I’m not sure where my father would be if he didn’t have this,” she said. “With my life situation — my husband and I both work full time, we have no extra room in our house, and we have a small child — I can’t take care of him the way Miss Joann does.”

Trimble, whose program started in 2012 and has five homes, said she hopes to expand by two to three homes a year. The VA will remain meticulous about selecting homes.

“There is a strict inspection and vetting process to be a medical foster home,” Trimble said. “We only will accept the best.”

It also takes a special person to be an “angel,” as the caregivers are referred to in the program’s motto, ”Where Heroes Meet Angels.”

Stepney and Hundt agree West has earned her wings. On a recent cruise to Bermuda, she brought Stepney and Hundt along.

For Hundt, it was the first time he’d been on a boat. And Stepney said it was nothing like the transport ships he and his fellow troops used in the late 1960s: “Well, I’ve gotten to travel, but it was mainly two years in Vietnam, and there weren’t any women around.”

When asked why she brought the pair along, West said caregiving is “a ministry, something you really have to like to do.”

“And you know how the saying goes,” she said. “When you like what you do, you never work a day in your life.”


KHN’s coverage of aging and long-term care issues is supported in part by The SCAN Foundation.

Related Topics

Aging Public Health

Caregiving Maryland Veterans’ Health

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Trump says drug companies to announce ‘massive’ price cuts soon

WASHINGTON (Reuters) – President Donald Trump on Wednesday said he expects major drug companies to slash prices on their products in two weeks, but did not provide details on which companies would do so or the means by which they would provide such reductions.

U.S. President Donald Trump arrives prior to signing the “Right to Try Act,” which gives terminally ill patients the right to use experimental medications not yet been approved by the Food and Drug Administration (FDA), at the White House in Washington, U.S., May 30, 2018. REUTERS/Leah Millis

“You’re going to have some big news. I think we’re going to have some of the big drug companies in two weeks said they’re going to announce, because of what we did, they’re going to announce voluntary massive drops in prices,” Trump said at a signing ceremony for a new law making it easier for seriously ill people to try experimental treatments.

A Health and Human Services Department (HHS) spokeswoman said the agency had nothing else to share on Trump’s comments because it didn’t want to get ahead of any announcements.

Earlier this month, Trump unveiled the administration’s plan to lower prescription drug prices, largely through regulatory authority, calling it “the most sweeping action in history” to reduce the cost of medicines for consumers.

But healthcare stocks rose as it became clear his administration avoided aggressive direct measures to cut prices.

HHS has yet to issue any new regulations or pilot programs to lower drug prices based on the new plan.

The NYSE Arca Pharmaceutical Index .DRG, comprised of major drugmakers, fell about a quarter of a percent just after Trump’s comments on Wednesday. But it steadily recovered and was up 1.7 percent, close to the high for the day and up more than the broader S&P 500 Index.

It is exceedingly rare for drug companies to lower prices prior to facing competition from cheap generics.

Amid increased public and Congressional criticism over high drug prices, some companies pledged to voluntarily limit annual price increases to less than 10 percent. Previously, many drugmakers typically raised prices on prescription medicines twice a year, adding up to well over 10 percent.

As public pressure mounted, drug companies have blamed middlemen, including pharmacy benefit managers (PBMs) and health insurers, for not passing discounts and rebates they demand off high list prices to consumers.

PBMs and insurers have said they are part of the solution for lowering costs and blame pricing on drugmakers.

Trump campaigned on lowering drug prices and has said that pharmaceutical companies were “getting away with murder,” but has since backed off that rhetoric.

PhRMA and BIO, the major lobby groups for the pharmaceutical and biotechnology industries, did not immediately respond to requests for comment on Trump’s statement.

Reporting by Yasmeen Abutaleb and Steve Holland; Editing by Chizu Nomiyama and Bill Berkrot

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