California Attorney General And Santa Clara County Face Off Over Sale Of Two Hospitals

When U.S. Sen. Kamala Harris approved the sale of six nonprofit California hospitals in 2015 as the state attorney general, she imposed strict conditions on the new corporate owners, requiring them to continue to provide critical health services to area residents.

Now her successor, fellow Democrat Xavier Becerra, is asserting his authority in court to enforce those conditions on Santa Clara County, which wants to buy two of the hospitals out of bankruptcy. County officials warn that the attorney general’s stance could force the closure of the hospitals, limiting health care access for hundreds of thousands of people.

A court hearing is set for Wednesday.

At the heart of the power struggle is whether Santa Clara County, which has made a $235 million bid to acquire the financially troubled Verity Health System hospitals, must abide by a 2015 agreement between the attorney general’s office and the new corporate owner.

“To some extent the attorney general doesn’t want to give up this authority,” said Susan Channick, a law professor emerita at California Western School of Law, San Diego. “The idea of the attorney general’s office is to make these hospitals provide health services.”

The attorney general is the state watchdog who oversees sales of nonprofit hospitals. In this role, legal experts say, the attorney general can take steps to ensure that key services, such as emergency room care, and surgical and reproductive health services aren’t dropped because they don’t make money for new owners.

That’s what happened when Harris, who last week announced her candidacy for president in 2020, intervened in the purchase of two Verity hospitals — O’Connor Hospital in San Jose and St. Louise Regional Hospital in Gilroy — along with four other nonprofit hospitals in San Mateo and Los Angeles counties. As part of the deal with Harris, Verity would keep a number of services running for five to 10 years, including intensive care and obstetric services in Gilroy and 24-hour medical services in San Jose.

Now Verity has filed for bankruptcy and its hospitals are for sale.

Santa Clara County was the only bidder for the two hospitals within its borders, and in December a federal bankruptcy judge in Los Angeles ruled that the county didn’t have to meet any of the attorney general’s requirements, saying that Becerra had stated in court documents that he didn’t object to the sale and had waived the conditions during his failed negotiations with the county.

Becerra vehemently disagrees with the judge’s assessment and denies that he waived the conditions, arguing that the new owner must comply with the conditions even though it’s a government entity.

He filed an appeal and a motion to temporarily block the sale, hoping to give both sides more time to negotiate. A hearing on his motion is scheduled for Wednesday. If Becerra loses, the sale would likely proceed.

“We’re going to do everything we must to make sure that the people who live and depend on those health facilities know that their health services will be protected,” Becerra told California Healthline.

Local elected officials say Becerra isn’t acknowledging that the hospitals would likely close without them, and that a purchase by the county government — whose mission is to provide safety-net health services — is a far cry from a corporate takeover.

“There’s a difference between a corporate acquisition and a rescue operation,” said County Board of Supervisors President Joe Simitian, a former state senator. “The attorney general’s office has been clear about its need to assert jurisdiction, but let’s focus on the patients.”

“It shouldn’t be about power and politics,” Simitian added. “It should be about the residents of Santa Clara County who may not have a hospital if this deal crumbles.”

Although Santa Clara County makes up part of the wealthy Silicon Valley, more than 403,000 of its residents are eligible for Medi-Cal, the state health insurance program for low-income people. County officials say the purchase of the two hospitals — especially St. Louise in rural Gilroy — will expand the county’s safety-net health care system and relieve pressure on its overcrowded public hospital, Santa Clara Valley Medical Center.

The KPC Group, which owns hospitals, clinics, commercial real estate and agricultural research centers around the world, has bid $610 million to purchase the four Verity hospitals in San Mateo and Los Angeles counties, but the sale has yet to be approved by a court.

The dispute between Becerra and Santa Clara County is troubling to area residents, who showed up to support local officials at a news conference last week to denounce the attorney general’s attempt to block the sale. If the 93-bed St. Louise Regional Hospital closes, the nearest major hospital would be at least 20 miles away.

“South County really needs a major hospital. We are a community of farmworkers, of low-income people,” said Gilroy resident Sally Armendariz, 76.

While Becerra wants to ensure certain health services remain, county officials argue the requirements are too prescriptive. For example, they don’t want to agree to provide a specific number of beds for intensive care and obstetrics, they say, because they need flexibility to organize public health services across the region.

Santa Clara County Counsel James Williams described Becerra’s legal action as “really dangerous,” because it threatens not only the sale of the hospitals — but their existence. The county’s purchase agreement with Verity expires Feb. 28, and if the deal isn’t concluded by then, it’s voided, county officials said.

It’s not clear whether county officials are posturing to get out of the conditions that Harris imposed, or expressing a legitimate concern that the hospitals would indeed close, said Thomas Greaney, professor of law at UC Hastings College of the Law-San Francisco.

“There’s clearly a factual question here. Is it really true?” Greaney asked. “Is it really an endgame that they are presenting?”

Over time, attorneys general around the county have become more vigilant about sales of nonprofit hospitals that have been supported by the public for years with tax exemptions and other benefits, Greaney said.

“There are important concerns they are protecting,” he said. “It is the kind of thing I think should be subject to negotiation and settlement.”

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Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles

After seven years of a vigorous fight, Jim Hart worried he was running out of options.

Diagnosed with prostate cancer at age 60, Hart had undergone virtually every treatment — surgery, radiation and hormones — to eradicate it. But a blood test showed that his level of prostate-specific antigen, which should have been undetectable, kept rising ominously. And doctors couldn’t determine where the residual cancer was lurking.

“I didn’t like the sound of that,” said Hart, a retired international oil specialist for the federal government. “I wanted it gone,” he added, especially after learning that he had inherited the BRCA2 gene, making him vulnerable to other cancers.

So when Andrew Joel, Hart’s longtime urologist at Virginia Hospital Center in Arlington, mentioned the hospital’s membership in the Mayo Clinic Care Network and suggested consulting specialists at the Rochester, Minn., hospital for a second opinion, Hart enthusiastically agreed.

A Mayo immunologist told Joel about a new PET scan, not then available in the Washington area, that can detect tiny cancer hot spots. Hart flew to Mayo for the scan, which found cancer cells in one lymph node in his pelvis. He underwent chemotherapy at Virginia Hospital Center and five weeks of radiation at the Mayo Clinic. Since September 2016, there has been no detectable cancer.

“This collaboration was sort of a magic process,” Hart said. “I feel very fortunate.”

‘Benefit By Association’

Hart’s experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.

For prospective patients, it can be hard to assess what these relationships actually mean — and whether they matter.

Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.

“Brand names don’t always signify the highest quality of care,” she said. “And hospitals are really complicated places.”

Affiliation agreements are “essentially benefit by association,” said Gerard Anderson, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. “In some cases it’s purely branding and in other cases it’s a deep association.”

A key question is “how often does the community hospital interact with the flagship hospital? If it’s once a week, that’s one thing. If it’s almost never, that’s another,” Anderson said.

Feeling ‘Plugged In’

To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors.

In return, large hospitals receive new sources of patients for clinical trials and for the highly specialized services that distinguish these “destination medicine” sites. Affiliations also boost their name recognition — all without having to establish a physical presence.

In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children’s Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s Hospital in 2016.

New York’s Memorial Sloan Kettering Cancer Center has embraced a hybrid strategy. It operates a ring of facilities surrounding Manhattan and has forged alliances with three partners in Connecticut, Pennsylvania and Florida.

“Every one of these models is different,” said Ben Umansky, managing director for research at the Advisory Board, a Washington-based consulting firm.

Local hospitals, he said, particularly those operating “in the shadows of giants,” may be better able to retain patients “by getting a name brand on their door. … There is a sense that they are plugged in.” (Virginia Hospital Center, for example, competes with Hopkins, MedStar Washington Hospital Center, which has an alliance with the Cleveland Clinic, and the Northern Virginia-based Inova system.)

Doctors can obtain speedy second opinions for their patients and streamline visits for those with complex or unusual medical needs, processes that can be daunting and difficult without connections.

Dr. Michael Kupferman, senior vice president of the MD Anderson Cancer Network, said it seeks to “elevate the quality of cancer care” by forming partnerships with “high-quality [hospitals] to keep patients at home and provide the imprimatur of MD Anderson.”

Virginia Hospital Center’s association with Mayo is “not just a branding affiliation, it’s a deep clinical affiliation,” said Dr. Jeffrey DiLisi, senior vice president and chief medical officer at the Arlington facility.

Despite extensive marketing, many patients seem unaware of the linkage. “We still think a lot about ‘How do we communicate this?’” DiLisi said.

Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years.

Acceptance is preceded by site visits and vetting of the community hospitals’ staff and operations. Strict guidelines control use of the flagship name.

“It is not the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”

Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.

For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.

“In theory, it can be very helpful,” Binder said of such alliances. “The problem is that theory and reality don’t always come together in health care.”

Case in point: Hopkins’ All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.

“For me and my family, I always look at the data,” Binder said. “Nothing else matters if you’re not taken care of in a hospital, or you have the best surgeon in the world and die from an infection.”

Cancer During Pregnancy

Bryan Mills, chief executive of Community Health Network, was unhappy with his oncology service. Specialists at the Indianapolis-area hospitals he headed were competing against each other and patients were being ill-served. So Mills cold-called MD Anderson and, in 2012, Community joined its network.

“We needed something we could rally around,” Mills said.

“This is really not about a competitive advantage to me, but about providing optimal care,” said Mills, whose network competes with three other systems including one run by the University of Indiana, which operates a National Cancer Institute-designated center.

“One hundred percent of the work we do is audited by MD Anderson,” Mills said. “We can get second opinions almost instantly.”

Mills said he believes that the affiliation, which is prominently displayed on Community’s website, has attracted patients. In 2012, he said, Community treated about 2,000 cancer patients. In 2018, the number was 5,000.

Among them is Kamaljit “Kelly” Kaur. Shortly before Christmas 2015 the Greenwood, Ind., licensed practical nurse was diagnosed with inflammatory breast cancer, a rare and aggressive form of the disease usually discovered at an advanced stage. At the time, Kaur was 35 and five months pregnant with her third child.

Kaur said that her Indiana doctors conferred with MD Anderson oncologists and used “their guidelines to treat me. I felt comforted by that, like it was the right choice for me.” Her biggest concern, she said, was the health of her baby.

During the final months of her pregnancy, Kaur received weekly chemotherapy. Her son was born healthy and at full term in February 2016. She then underwent a bilateral mastectomy, followed by more chemo and radiation. Kaur said she has been cancer-free since January 2017, when she finished treatment. The collaboration, she said, “helped me get through this.”

Kaur’s Indiana oncologist, Dr. Anuj Agarwala, said he thought the MD Anderson involvement was helpful, because it reassured Kaur and him by concurring with his recommendations. He said he presented his treatment plan to specialists in Houston and “they didn’t change anything.”

Overall, he said, “it really doesn’t affect what I do very much. We are following national guidelines and not giving off-the-wall treatment.”

Initially, Agarwala said, some Community oncologists bristled at having their charts audited by Houston specialists, a resistance he said has diminished.

The affiliation has strengthened safety measures involving the administration of chemotherapy and has made the informed consent process more rigorous, Agarwala said, to the benefit of patients. “Overall it has been a valuable relationship.”

“The population I work with don’t have the resources to get care outside of their hometown,” he added, “and feel more confident with the input of a world-class institution.”

So did Dr. James Ouellette, a cancer surgeon with Premier Health in Dayton, Ohio, which joined the MD Anderson network in 2016.

In November 2018, Ouellette removed a huge and rare malignant tumor from Joanne Dotson’s abdomen during a four-hour surgery. The solitary fibrous tumor was in a dicey location: It had grown so large it was displacing Dotson’s liver and compressing her vena cava, a major vein that carries blood to the heart.

Dotson, 70, said she had never heard of MD Anderson until her doctors mentioned it.

The affiliation, she said, did not affect her choice of hospital or surgeon, in whom she had confidence.

“I wasn’t even worried,” she said. “His hands are God’s hands,” she said, referring to Ouellette.

Her surgeon felt differently.

“While I was very glad Mrs. Dotson wasn’t worried, I was, with a big surgery like that,” Ouellette said. Before the operation, Ouellette said he conferred with an MD Anderson surgeon, radiation oncologist and medical oncologist about how best to treat the grapefruit-size growth. As a result of those discussions, Ouellette said, he altered the initial treatment plan.

Getting A Vibe

Virginia Hospital Center officials say that only a handful of the approximately 170 patients, the vast majority with cancer diagnoses, who annually receive second opinions from Mayo wind up getting treatment there. Most of those who do, DiLisi said, received care unavailable at his hospital.

“The patients [that affiliates] send us are more complex patients,” said Mayo’s Hayes. “We have a broad and deep bench of specialists.”

Even so, it’s often doctors who suggest a second opinion, not patients who request one. Joel said he mentions the option to those urology patients from whom he gets “a vibe” that they might be interested.

DiLisi said that the affiliation can save patients time and money.

“We get them as good a second opinion as they would get at Hopkins,” DiLisi said, without incurring the costs and additional testing involved. “And they don’t have to drive to Baltimore.”

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U.S. lawmaker Yarmuth says Democrats to begin Medicare for All hearings

WASHINGTON (Reuters) – Democrats in control of the U.S. House of Representatives will begin holding hearings on expanding Medicare this spring and will aim to pass a bill by the end of next year, a senior Democratic lawmaker said on Tuesday.

Chairman of the House Budget Committee John Yarmuth (D-KY) speaks during an interview with Reuters in Washington, U.S., January 29, 2019. REUTERS/Joshua Roberts

John Yarmuth, chairman of the House Budget Committee, said in an interview with Reuters that the most feasible option might be passing legislation that offers Medicare, which currently starts at 65 years of age, to all those above 50 or 55.

“I would say a majority (of Democrats) wants to do something, some kind of Medicare expansion,” Yarmuth said. “I’ve had a number of major corporate CEOs say to me we need to go to Medicare for All.”

Yarmuth, who campaigned in midterm elections in 2018 on expanding Medicare, said he is waiting on an assessment from the Congressional Budget Office that will help lawmakers understand what variables they need to consider in expanding Medicare to more or all of the U.S. population.

Medicare is the government health insurance program for the elderly and disabled, and it currently covers about 60 million Americans.

The idea of “Medicare for All,” which for many references a single-payer system that would largely replace private insurance, has gained traction among Democrats and is poised to play a central role in the 2020 presidential election.

A single-payer system is variously understood as one in which the government pays for healthcare for more people, or one where the government owns health services providers and manages all aspects of care, such as in the United Kingdom.

A Reuters/IPSOS poll in August found that 70 percent of Americans support some sort of single-payer system.

A major Medicare expansion is unlikely to pass the Republican-controlled Senate, however.


Several Democrats have introduced bills in the House and the Senate that would expand Medicare, but the definition of Medicare for All remains unclear.

“I personally would be very concerned about a massive immediate transition from our current system to everybody in Medicare,” Yarmuth said. “That would be so disruptive.”

U.S. Democratic Senator Kamala Harris, a top 2020 Democratic presidential contender, said on Monday she supported the idea of Medicare for All and ending private insurance.

Many Democratic presidential candidates so far are campaigning on a version of Medicare for All.

Yarmuth said the aim of the hearings is to more clearly define the proposal ahead of the 2020 election and develop a framework for legislation.

He said Democrats hope to avoid the mistake Republicans made in trying to repeal and replace Obamacare, which they failed to do after campaigning on it for eight years because they could not agree on how to overturn the law.

Obamacare, formally known as the Affordable Care Act, was former President Barack Obama’s signature domestic achievement that expanded health insurance to some 20 million Americans.

The American Hospital Association opposes Medicare for All, and America’s Health Insurance Plans (AHIP), the health insurance industry’s biggest trade group, has said a single payer system cannot work.

Private health insurers, including United Health, Anthem and Aetna, now owned by CVS Health Corp, could lose business under such a system.

Members of the Trump administration have given speeches criticizing a Medicare for All proposal, including Health and Human Services Secretary Alex Azar.

“The main thrust of Medicare for All is giving you a new government plan and taking away your other choices,” Azar said in a speech in September.

Reporting By Yasmeen Abutaleb and Susan Cornwell; Additional reporting by Jilian Mincer in New York; Editing by Andrea Ricci

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U.S. senator asks J&J for documents on talc, baby powder safety

FILE PHOTO: A Johnson & Johnson building is shown in Irvine, California, U.S., January 24, 2017. REUTERS/Mike Blake/File Photo

(Reuters) – U.S. Democratic Senator Patty Murray sent a letter to Johnson & Johnson on Tuesday seeking information related to allegations in a Reuters Special Report that the healthcare company knew about the presence of asbestos in its talc-based baby powder.

The letter addressed to J&J Chief Executive Alex Gorsky asks for documents and information related to testing of its talc products for the presence of carcinogens and “how it presented that information to regulators and consumers.”

Reuters on Dec. 14 published a Special Report detailing that the company knew that the talc in its raw and finished powders sometimes tested positive for cancer-causing asbestos from the 1970s into the early 2000s – test results the company did not disclose to regulators or consumers.

While exposure to asbestos has been linked to mesothelioma, J&J has repeatedly said that its talc products are safe, and that decades of studies have shown them to be asbestos-free and that they do not cause cancer.

J&J spokesman Ernie Knewitz, in an emailed statement, acknowledged receiving the letter and said the company looks forward to sharing its response with the senator.

“As we have consistently stated, we firmly stand behind the safety and purity of our talc, which has been confirmed by thousands of independent tests by regulators worldwide, including the U.S. FDA and many of the world’s leading independent laboratories,” the company statement said.

Murray, the top Democrat on the Republican-controlled Senate Committee on Health, Education, Labor and Pensions, referred to the Reuters report in her letter. It began, “I am troubled by recent reports of an alleged decades-long effort by Johnson & Johnson to potentially mislead regulators and consumers about the safety of one of its products, which may have resulted in long-term harm for men, women, and children who used Johnson & Johnson baby powder.”

J&J is facing more than 11,000 lawsuits alleging that use of its talc products, including baby powder, caused cancer.

Murray asked for documents to support the company’s claim that its current talc products do not contain any level of asbestos, documents on the testing of its talc products and communications with the Food and Drug Administration about the safety of its baby powder dating from 1966 to present.

Reporting by Julie Steenhuysen; Editing by Bill Berkrot

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Hope You’re Sitting Down: Hospital Charges $4,700 For A Fainting Spell

Listen to NPR’s All Things Considered tonight for our audio report on Bill of the Month. It’s scheduled to air at approximately 5:20 p.m. on your local public radio station.

Matt Gleason had skipped getting a flu shot for more than a decade.

But after suffering a nasty bout of the virus last winter, he decided to get vaccinated at his Charlotte, N.C., workplace in October. “It was super easy and free,” said Gleason, 39, a sales operations analyst.

That is, until Gleason fainted five minutes after getting the shot. Though he came to quickly and had a history of fainting, his colleague called 911. And when the paramedics sat him up, he began vomiting. That symptom worried him enough to agree to go to the hospital in an ambulance.

He spent the next eight hours at a nearby hospital — mostly in the emergency room waiting area. He had one consult with a doctor via teleconference as he was getting an electrocardiogram. He was feeling much better by the time he saw an in-person doctor, who ordered blood and urine tests and a chest-X-ray.

All the tests to rule out a heart attack or other serious condition were negative, and he was sent home at 10:30 p.m.

And then the bill came.

The Patient: Matt Gleason, who works for Flexential, an information technology firm in Charlotte. He is married with two children.

Total Bill: $4,692 for all the hospital care, including $2,961 for the ER admission fee, $400 for an EKG, $348 for a chest X-ray, $83 for a urinalysis and nearly $1,000 for various blood tests. Gleason’s insurer, Blue Cross and Blue Shield of North Carolina, negotiated discounts for the in-network hospital and reduced those costs to $3,711. Gleason is responsible for that entire amount because he had a $4,000 annual deductible. (The ambulance company and the ER doctor billed Gleason separately for their services, each about $1,300, but his out-of-pocket charge for each was $250 under his insurance.)

Matt Gleason questioned many of the charges he was billed after a trip to the ER and asked the health care provider for clarity. They sent him their chargemaster so he could investigate the charges himself.(Logan Cyrus for KHN)

Service Provider: Atrium Health Pineville (formerly called Carolinas HealthCare System-Pineville), a 235-bed nonprofit hospital in Charlotte and one of more than 40 hospitals owned by Atrium.

Medical Service: On Oct. 4, Gleason was taken by ambulance to Atrium Health Pineville emergency room to be evaluated after briefly passing out and vomiting following a flu shot. He was given several tests, mostly to check for a heart attack. 

What Gives: Fainting after getting the flu vaccine or other shots is a well-described phenomenon in the medical literature. But once 911 is summoned, you could be facing an ER work-up. And, in the U.S., that usually means big money.

The biggest part of Gleason’s bill — $2,961 — was the general ER fee. Atrium coded Gleason’s ER visit as a Level 5 — the second-highest and second-most expensive — on a 6-point scale. It is one step below the code for someone who has a gunshot wound or major injuries from a car accident. Gleason was told by the hospital that his admission was a Level 5 because he received at least three medical tests.

Gleason argued he should have paid a lower-level ER fee, considering his relatively mild symptoms and how he spent most of the eight hours in the ER waiting area.

The American Hospital Association, the American College of Emergency Physicians and other health groups devised criteria in 2000 to bring some uniformity to emergency room billing. The different levels reflect the varying amount of resources (equipment and supplies) the hospital uses for the particular ER level. Level 1 represents the lowest level of ER facility fees, while ER Level 6, or critical care, is the highest. Many hospitals have adopted the voluntary guidelines.

David McKenzie, reimbursement director at the American College of Emergency Physicians, said the guidelines were set up to help hospitals charge appropriately. Asked if hospitals have an incentive to perform extra tests to get patients to a higher-cost billing code, McKenzie said: “It’s not a perfect system. Hospitals have an incentive to do a CT exam, and taxi drivers have an incentive to take the long way home.”

The guidelines don’t determine the prices hospitals set for each ER level. Hospitals are free to set whatever prices they want as long as their system is consistent among patients, he said.

He said the multiple tests on Gleason suggest the hospital was worried he could be seriously ill. But he questioned why Gleason was told to stay in the ER waiting area for several hours if that was the case. It’s also not clear if Gleason’s history of fainting and overall good health were considered.

Blue Cross and Blue Shield of North Carolina said in a statement that the hospital “appears to have billed Gleason appropriately.” It noted the hospital reduced its costs by about $980 because of the insurer’s negotiated rates. But the insurer said it has no way to reduce the general ER admission fee.

“We work hard to negotiate discounts that reduce costs for our members, but costs are still far too high,” the insurer said. “This forces consumers to pay more out of pocket and drives up premiums.”

Gleason, in fighting his bill, actually got the hospital to send him its entire “chargemaster” price list for every code – a 250-page, double-sided document on paper. He was charged several hundred dollars more than the listed price for his Level 5 ER visit.

Gleason reviews the chargemaster he received from Atrium Health.(Logan Cyrus for KHN)

“In this specific example, the price of admission to the ER was more than $2,960. That was on top of more than $1,000 for the medical procedures actually performed. We won’t significantly bring down health care costs until we address the high prices like these,” BCBS-NC said in the statement.

John Hennessy, chief business development officer for WellRithms, a consulting firm that reviews bills for large employers, said the hospital charges are significantly higher than what Medicare pays in the Charlotte area, but those are the prices Gleason’s insurer has negotiated. “Seeing billed charges well in excess of what Medicare pays is nothing unusual,” Hennessy said.

He said the insurer likely agreed to the higher charges to make sure it had the large hospital system in its network. Atrium is the biggest health system in North Carolina.

He said the coding “makes sense” because it meets the guidelines — even if that meant a nearly $4,000 bill for Gleason.

“The hospital has every right to collect it, regardless if you or I think it’s a fair price,” he said.

Gleason says the $3,700 hospital bill won’t bankrupt his family, but “what it does is wipe out our savings.”(Logan Cyrus for KHN)

Resolution: After Gleason appealed, Atrium Health reviewed the bill but didn’t make any changes. “I understand you may be frustrated with the cost of your visit; however, based on these findings, we are not able to make any adjustments to your account,” Josh Crawford, nurse manager for the hospital’s emergency department, wrote to Gleason on Nov. 15.

Atrium Health, in a statement to KHN and NPR, defended its care and charges as “appropriate.”

“The symptoms Mr. Gleason presented with could have been any number of things — some of them fatal,” the hospital said.

“Atrium Health has set criteria which determines at what level an [emergency department] visit is charged. In Mr. Gleason’s case, there were several variables that made this a Level 5 visit, including arriving by ambulance and three or more different departmental diagnostic tests.”

Gleason said the $3,700 hospital bill won’t bankrupt his family. “What it does is wipe out our savings,” he added.

The Takeaway: Gleason, understandably, said he’s reluctant to get a flu shot in the future. But that’s not the best response. It’s important to know that fainting is a known reaction to shots and some people seem particularly prone. It’s best to sit or lie down when you get the vaccine, and wait five to 10 minutes before jumping up and returning to business.

Be aware: If you — or someone else — calls 911 for a health emergency, you are very likely to be taken to the hospital. You probably won’t have a choice of which one. And a hospital trip may not even be needed, so think before you call: “How do I feel?”

The medical professional who administered the shot might have suggested that calling 911 wasn’t a smart or needed response for a known side effect of a vaccine injection in a young person.

The emergency room is the most expensive place to seek care.

In hindsight, Gleason might have gone to an urgent care facility or called his primary care doctor, who could have evaluated him and run some tests at much lower prices, if needed.

But employers, hospitals and doctors regularly tell patients if they need immediate care to go to the ER, and hospitals often tout short waiting times in their ERs.

With high deductibles becoming more common, consumers need to be aware that a single trip to the hospital, especially an ER, could cost them thousands of dollars — even for symptoms that turn out to be nothing serious.

Alex Olgin of WFAE and Elisabeth Rosenthal of Kaiser Health News contributed to the audio version of this story.

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Depressed kids more likely to play choking game

(Reuters Health) – Children and adolescents who suffer from depression or behavior problems may be more likely to play potentially fatal “choking games” to achieve a euphoric high than young people who don’t have mental health issues, a French study suggests.

Roughly one in 10 teens and pre-teens have participated in this dangerous game at least once, researchers report in Pediatrics. The risk was more than doubled, however, for young people with symptoms of depression or conduct disorders.

This game is deadly and can attract suicidal children, said lead study author Gregory Michel, a psychology researcher at the University of Bordeaux in France.

“But this game can also attract young people who are depressed and who will use this game as a way to replace the depressive sensation with a strong sensation provoked by this game,” Michel said by email. “It is a question of hiding the feeling of depression.”

Choking game players typically use their hands, a belt or a tie to put pressure on the carotid artery in the neck, temporarily limiting the flow of oxygen and blood to the brain. The goal is to achieve a euphoric feeling when the flow of blood and oxygen rushes back to the brain.

It’s dangerous enough in groups, but when children play alone, without others present to interrupt the asphyxiation, they face an increased risk of loss of consciousness and inability to stop strangulation when a noose, belt or other ligature is being used.

Nearly all deaths from the game occur when youngsters play alone, and some previous research has linked depression to a higher risk of trying the game without other kids around to watch or help in an emergency.

For the current study, researchers examined survey data collected from 1,771 French middle school students in 2009 and 2013.

Students with depression were 2.2 times more likely to play the choking game than students without depression, the study found.

And, youth with conduct disorders, like a tendency to break rules or behave in antisocial ways, were 2.3 times more likely to participate in the game.

While previous studies have found the game is more widespread among teen boys than girls, the current analysis didn’t find any differences based on sex.

The study wasn’t designed to prove whether specific psychological or behavioral health problems might cause kids to play the choking game.

It’s also not clear from the survey whether participating in the game might have caused mental health problems to develop, the study authors note.

“Teens with depression are often bored and apathetic and some may be attracted to this thrill-seeking activity,” said Dr. Benjamin Shain, head of child and adolescent psychiatry at NorthShore University HealthSystem in Evanston, Illinois.

Some teens with depression might try the choking game as “a rehearsal for a suicide attempt,” Shain, who wasn’t involved in the study, said by email. Others might develop emotional problems as a result of brain damage caused by the choking game, Shain said.

“Presumably reduction of depressive symptoms from treatment may reduce participation in the choking game, but the current study does not address this issue,” Shain added.

The choking game has been also been linked to risky health behaviors like drinking and drug abuse, noted Sarah Knipper, an adolescent health researcher at the Oregon health Authority in Portland.

“It is not a surprise that teens who are struggling with their mental health may lack the tools and supports to make healthy decisions, or may look for ways of coping that feel good but don’t serve them well,” Knipper, who wasn’t involved in the study, said by email.

“I am not aware of any evaluation of specific medication or mental health treatment for reducing choking game participation,” Knipper added. “However, we know that access to a youth-friendly mental health system including counseling/psychotherapy and behavioral support is essential for young people with depression or poor mental health.”

SOURCE: Pediatrics, online January 28, 2019.

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Insys founder’s lawyer rejects charge he fed U.S. opioid epidemic

BOSTON (Reuters) – A lawyer for Insys Therapeutics Inc’s (INSY.O) one-time billionaire founder on Monday rejected claims that her client directed a scheme to bribe doctors to prescribe an addictive fentanyl spray and denied the product was related to the U.S. opioid crisis.

John Kapoor, the billionaire founder of Insys Therapeutics Inc, arrives at the federal courthouse for the first day of the trial accusing Insys executives of a wide-ranging scheme to bribe doctors to prescribe an addictive opioid medication, in Boston, Massachusetts, U.S., January 28, 2019. REUTERS/Brian Snyder

John Kapoor, the company’s former chairman, and four colleagues are the first painkiller manufacturer executives to face trial over conduct authorities say contributed to an opioid abuse epidemic that has killed tens of thousands of Americans.

Assistant U.S. Attorney David Lazarus told jurors that Insys paid doctors to participate in speaker programs ostensibly meant to educate medical professionals about its medication, Subsys, but that were actually poorly attended sham events.

But at the start of the 75-year-old’s trial in Boston federal court, defense lawyer Beth Wilkinson called those charges “patently false.”

Prosecutors have alleged that from 2012 to 2015, Kapoor and four co-defendants conspired to illegally pay doctors millions of dollars to prescribe Subsys, an under-the-tongue fentanyl spray approved only for managing severe pain in cancer patients.

Fentanyl is an opioid 100 times stronger than morphine.

Kapoor’s co-defendants include former Insys executives and managers Michael Gurry, Richard Simon, Sunrise Lee and Joseph Rowan.

Wilkinson acknowledged Insys paid doctors. But she said Kapoor’s goal was to legally compensate them for acting as speakers at educational events.

She called Kapoor, who served as Insys chief executive from 2015 to 2017, a visionary who developed Subsys after watching his wife suffer from breast cancer.

The product had no role in the drug crisis, Wilkinson argued, saying Subsys made up a tiny fraction of all prescription opioids.

“It is certainly not part of the opioid crisis,” she said in her opening statement.

A record 47,600 Americans died of opioid-related overdoses in 2017, according to the U.S. Centers for Disease Control and Prevention

Lazarus told jurors Kapoor’s scheme led doctors to write medically unnecessary prescriptions for Subsys to patients, many of whom did not have cancer.

“John Kapoor and his co-defendants paid doctors to abandon their medical duties,” he said.

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Lazarus said Kapoor also helped defraud insurers into paying for the expensive drug.

Two top former executives – Michael Babich, Insys’ CEO from 2011 to 2015, and Alec Burlakoff, its ex-vice president of sales – will to testify against Kapoor after pleading guilty, Lazarus told jurors.

Insys in August said it would pay at least $150 million to resolve a Justice Department probe related to its marketing of Subsys.

Reporting by Nate Raymond in Boston; Editing by Scott Malone and Bill Berkrot

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Israeli cabinet approves law to allow medical cannabis exports

JERUSALEM (Reuters) – Israel’s cabinet approved on Sunday a law to allow exports of medical cannabis in a move expected to boost state revenues and the agriculture sector, and which frustrates critics who fear it could lead to more recreational use of the drug.

An employee holds packages of cigarettes filled with medical cannabis at Pharmocann, an Israeli medical cannabis company in northern Israel January 24, 2019. REUTERS/Amir Cohen

The bill, backed last month by parliament, allows companies approved by the health regulator and police to export medical cannabis to countries that permit its use. Israeli media said exports could start in as little as nine months.

“I am glad this is finally happening. It opens a very big market in Israel. The technology is here in Israel and until now we simply had to give the technology to other countries. Therefore, I am glad we can reap the profits here in Israel,” said Justice Minister Ayelet Shaked.

Some lawmakers had tried to block the legislation, fearing more cultivation could push more drugs onto the streets at home.

Israeli companies – benefiting from a favorable climate and expertise in medical and agricultural technologies – are among the world’s biggest producers of medical cannabis.

The government estimates exports could raise tax revenue by 1 billion shekels ($273 million). At the same time, the bill imposes tough regulations on exporters and threatens jail terms and hefty fines for violations.

Shai Babad, director-general of the finance ministry, said Israeli technology in medical cannabis significantly improves the lives of millions of people who use it as a permanent remedy.

Babad said the new law would “lead to the development of the economy, agriculture, industry and medicine in Israel”.

Eight companies cultivate cannabis in Israel, many of which have opened farms abroad to get into the international market. Dozens of business owners have requested government authorization to export.

“The Israeli market has waited a long time to receive government authorization for export and Tefen is well positioned for any related developments,” said Yona Levy, chairman of Tefen, a maker of medical-grade cannabis.

Levy said that as part of its international initiatives, the firm has entered into a strategic cooperation that will assist it in penetrating the European market through Portugal.

After jumping on Thursday ahead of the vote, most shares of cannabis producers were down on Sunday in Tel Aviv.

Reporting by Steven Scheer; Additional reporting by Eli Berlzon; Editing by Mark Potter

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The digital drug: Internet addiction spawns U.S. treatment programs

CINCINNATI (Reuters) – When Danny Reagan was 13, he began exhibiting signs of what doctors usually associate with drug addiction. He became agitated, secretive and withdrew from friends. He had quit baseball and Boy Scouts, and he stopped doing homework and showering.

Danny Reagan, a former patient of the Lindner Center of Hope’s “Reboot” program, the first of its kind to admit only children who suffer from compulsion or obsession with their use of technology, sits in a common room at the center in Mason, Ohio, U.S., January 23, 2019. REUTERS/Maddie McGarvey

But he was not using drugs. He was hooked on YouTube and video games, to the point where he could do nothing else. As doctors would confirm, he was addicted to his electronics.

“After I got my console, I kind of fell in love with it,” Danny, now 16 and a junior in a Cincinnati high school, said. “I liked being able to kind of shut everything out and just relax.”

Danny was different from typical plugged-in American teenagers. Psychiatrists say internet addiction, characterized by a loss of control over internet use and disregard for the consequences of it, affects up to 8 percent of Americans and is becoming more common around the world.

“We’re all mildly addicted. I think that’s obvious to see in our behavior,” said psychiatrist Kimberly Young, who has led the field of research since founding the Center for Internet Addiction in 1995. “It becomes a public health concern obviously as health is influenced by the behavior.”

Psychiatrists such as Young who have studied compulsive internet behavior for decades are now seeing more cases, prompting a wave of new treatment programs to open across the United States. Mental health centers in Florida, New Hampshire, Pennsylvania and other states are adding inpatient internet addiction treatment to their line of services.

Some skeptics view internet addiction as a false condition, contrived by teenagers who refuse to put away their smartphones, and the Reagans say they have had trouble explaining it to extended family.

Anthony Bean, a psychologist and author of a clinician’s guide to video game therapy, said that excessive gaming and internet use might indicate other mental illnesses but should not be labeled independent disorders.

“It’s kind of like pathologizing a behavior without actually understanding what’s going on,” he said.


At first, Danny’s parents took him to doctors and made him sign contracts pledging to limit his internet use. Nothing worked, until they discovered a pioneering residential therapy center in Mason, Ohio, about 22 miles (35 km) south of Cincinnati.

The “Reboot” program at the Lindner Center for Hope offers inpatient treatment for 11 to 17-year-olds who, like Danny, have addictions including online gaming, gambling, social media, pornography and sexting, often to escape from symptoms of mental illnesses such as depression and anxiety.

Danny was diagnosed with Attention Deficit Hyperactivity Disorder at age 5 and Anxiety Disorder at 6, and doctors said he developed an internet addiction to cope with those disorders.

“Reboot” patients spend 28 days at a suburban facility equipped with 16 bedrooms, classrooms, a gym and a dining hall. They undergo diagnostic tests, psychotherapy, and learn to moderate their internet use.

Chris Tuell, clinical director of addiction services, started the program in December after seeing several cases, including Danny’s, where young people were using the internet to “self-medicate” instead of drugs and alcohol.

The internet, while not officially recognized as an addictive substance, similarly hijacks the brain’s reward system by triggering the release of pleasure-inducing chemicals and is accessible from an early age, Tuell said.

“The brain really doesn’t care what it is, whether I pour it down my throat or put it in my nose or see it with my eyes or do it with my hands,” Tuell said. “A lot of the same neurochemicals in the brain are occurring.”

Even so, recovering from internet addiction is different from other addictions because it is not about “getting sober,” Tuell said. The internet has become inevitable and essential in schools, at home and in the workplace.

“It’s always there,” Danny said, pulling out his smartphone. “I feel it in my pocket. But I’m better at ignoring it.”


Medical experts have begun taking internet addiction more seriously.

Neither the World Health Organization (WHO) nor the American Psychiatric Association recognize internet addiction as a disorder. Last year, however, the WHO recognized the more specific Gaming Disorder following years of research in China, South Korea and Taiwan, where doctors have called it a public health crisis.

Some online games and console manufacturers have advised gamers against playing to excess. YouTube has created a time monitoring tool to nudge viewers to take breaks from their screens as part of its parent company Google’s “digital wellbeing” initiative.

WHO spokesman Tarik Jasarevic said internet addiction is the subject of “intensive research” and consideration for future classification. The American Psychiatric Association has labeled gaming disorder a “condition for further study.”

“Whether it’s classified or not, people are presenting with these problems,” Tuell said.

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Tuell recalled one person whose addiction was so severe that the patient would defecate on himself rather than leave his electronics to use the bathroom.

Research on internet addiction may soon produce empirical results to meet medical classification standards, Tuell said, as psychologists have found evidence of a brain adaptation in teens who compulsively play games and use the internet.

“It’s not a choice, it’s an actual disorder and a disease,” said Danny. “People who joke about it not being serious enough to be super official, it hurts me personally.”

Reporting by Gabriella Borter; editing by Grant McCool

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