Bayer says October U.S. glyphosate trial delayed until February

FILE PHOTO: Logo and flags of Bayer AG are pictured outside a plant of the German pharmaceutical and chemical maker in Wuppertal, Germany August 9, 2019. REUTERS/Wolfgang Rattay/File Photo

FRANKFURT (Reuters) – A pending U.S. lawsuit over claims related to Bayer’s (BAYGn.DE) glyphosate-based herbicide Roundup has been delayed, the company said on Sunday, with a new court date set for February, 2020.

“The Oct. 15, 2019 trial date for Winston v. Monsanto in St. Louis City has been postponed,” Bayer said in a statement.

The lawsuit is the latest of several to be delayed as mediator Ken Feinberg tries to negotiate a settlement between the company and U.S. plaintiffs after a California jury in August last year found that Monsanto should have warned of alleged cancer risks.

“With the change in the trial schedule and no trial dates set through the rest of the year, the appeals of the three completed trials will be a significant focus of the litigation in the months ahead,” Bayer said.

Handelsblatt first reported the latest delay earlier on Sunday.

A court document from the Circuit Court of the City of St. Louis, dated October 4, said a new court date had been set for February 10.

The number of U.S. plaintiffs blaming Roundup and other glyphosate-based weed killers for cancer has been rising continuously to stand at 18,400 as of July 11, hitting Bayer’s share price.

Reporting by Tina Bellon; Editing by Kirsten Donovan

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Why Hospitals Are Getting Into The Housing Business

DENVER — One patient at Denver Health, the city’s largest safety net hospital, occupied a bed for more than four years — a hospital record of 1,558 days.

Another admitted for a hard-to-treat bacterial infection needed eight weeks of at-home IV antibiotics, but had no home.

A third, with dementia, came to the hospital after being released from the Denver County Jail. His family refused to take him back.

In the first half of this year alone, the hospital treated more than 100 long-term patients. All had a medical issue that led to their initial hospitalization. But none of the patients had a medical reason for remaining in the hospital for most of their stay.

Legally and morally, hospitals cannot discharge patients if they have no safe place to go. So patients who are homeless, frail or live alone, or have unstable housing, can occupy hospital beds for weeks or months — long after their acute medical problem is resolved. For hospitals, it means losing money because a patient lingering in a bed without medical problems doesn’t generate much, if any, income. Meanwhile, acutely ill patients may wait days in the ER to be moved to a floor because a hospital’s beds are full.

“Those people are, for lack of a better term, stranded in our hospital,” said Dr. Sarah Stella, a Denver Health physician.

To address the problem, hospitals from Baltimore to St. Louis to Sacramento, Calif., are exploring ways to help patients find a home. With recent federal policy changes that encourage hospitals to allocate charity dollars for housing, many hospitals realize it’s cheaper to provide a month of housing than to keep patients for a single night.

An architectural rendering of Denver Housing Authority’s renovation of the 10-story building once used as office space on Denver Health’s campus.(Courtesy of the Denver Housing Authority)

Hospital executives find the calculus works even if they have to build affordable housing units themselves. It’s why Denver Health is partnering with the Denver Housing Authority to repurpose a mothballed building on the hospital campus into affordable senior housing, including about 15 apartments designated to help homeless patients transition out of the hospital.

“This is an experiment of sorts,” said Peg Burnette, the hospital’s chief financial officer. “We might be able to help better their lives, as well as help the financials of the hospital and help free up capacity for the patients that need to come to see us for acute care.”

Spending To Save Money

Denver Health once used the shuttered 10-story building for office space but opted to sell it to the housing authority and grant a 99-year lease on the land for a minimal fee.

“It really lowers the construction costs for us,” said Ismael Guerrero, Denver Housing Authority’s executive director. “It was a great opportunity to build additional housing in a location that’s obviously close to the hospital, close to public transit, near the city center.”

Once the renovation is complete in late 2021, the housing group will hire a coordinator to assist tenants with housing-related issues, including helping those in the transitional units find permanent housing. The hospital will provide a case manager to help with their physical and behavioral health needs, preparing them for life on their own. Denver Health expects most patients will be able to move on from the transitional units within 90 days.

The hospital will pay for the housing portion itself. That will still be far cheaper than what the hospital currently spends.

It costs Denver Health $2,700 a night to keep someone in the hospital. Patients who are prime candidates for the transitional units stay on average 73 days, for a total cost to the hospital of nearly $200,000. The hospital estimates it would cost a fraction of that, about $10,000, to house a patient for a year instead.

“The hospital really is like the most expensive form of housing,” Stella said.

After its targeted late 2021 completion, the building will be used for affordable senior housing, including about 15 apartments designated to help homeless patients transition out of the hospital. (Courtesy of the Denver Housing Authority)

Growing Interest

A recent report from the Urban Institute found that while most hospital officials are well aware of how poor housing affects a patient’s recovery, they were stymied about how to address the issue.

“It’s on the radar of almost all hospitals,” said Kathryn Reynolds, who co-authored the report. “But it seemed like actually making investments in housing, providing some type of financing or an investment in land or something that has a good amount of value seems to be less widespread.”

The report found housing investment has been more likely among hospitals with their own health plans or other types of arrangements in which they were receiving a fixed amount of money to care for a group of patients. Getting patients into housing could lower their costs and increase their operating margins. Others, particularly religiously affiliated and children’s hospitals, sought housing solutions as part of their charitable mission.

Reynolds said the trend is due in part to the Affordable Care Act, which requires hospitals to perform a community needs assessment to help guide their charitable efforts. That prompted more hospitals to consider the social needs of their patients and pushed housing concerns up the list. Additionally, the Internal Revenue Service clarified in 2015 that hospitals could claim housing investments as charitable spending required under their tax-free status. And provisions included in the 2017 tax cut bill provided significant tax savings for investors in newly designated opportunity zones, increasing their interest in affordable housing projects.

Some hospitals, she said, may use their cash reserves to invest in housing projects that generate a lower return than other investment options because it furthers their mission, not just their profits.

In other cases, hospital systems play a facilitator role — using their access to cheap credit or serving as an anchor tenant in a larger development — to help get a project off the ground.

“Housing is not their business,” Guerrero said. “It’s not an easy space to get into if you don’t have the experience, if you don’t have a real estate development team in-house to understand how to put these deals together.”

Cutting Costs

In the southwestern corner of Colorado, Centura Health’s Mercy Regional Medical Center has partnered with Housing Solutions for the Southwest to prioritize housing vouchers for frequent users of the emergency room.

Under a program funded by the Catholic Health Initiatives, Mercy hired a social worker and a case manager to review records of frequent emergency room patients. They quickly realized how big an issue housing was for those patients. Many had diabetes and depended on insulin — which needs refrigeration. Kidney failure was one of the most costly diagnoses for the hospital.

Once patients received housing vouchers and found stable housing, though, costs began to drop.

“We now knew where they were. We knew that they had a safe place to live,” said Elsa Inman, program coordinator at Mercy Regional. “We knew they would be more effective in managing their chronic conditions.”

The patients with stable housing were more likely to make it to their primary care and specialist appointments, more likely to stay on top of medications and keep their chronic conditions in check.

The combination of intensive case management and patient engagement helped to halve ER visits for the first 146 patients in the program, saving nearly $495,000 in Medicaid spending in less than three years.

“Hospitals are businesses and nonprofits are businesses,” said Brigid Korce, program development director for Housing Solutions. “They are bottom-line, dollars-and-cents people.”

Inman acknowledged that the hospital might have missed out on some revenue by reducing ER use by these patients. Hospitals are still largely paid by the number of patients they treat and the number of services they provide.

But most of those patients were covered by Medicaid, so reimbursements were low anyway. And the move freed up more ER beds for patients with more critical needs.

“We want to be prepared for life-threatening conditions,” Inman said. “If you’ve got most of your beds taken up by someone who can be receiving patient care outside in the community, then that’s the right thing to do.”

That was less of an issue for the inpatients at Denver Health. Because hospitals are generally paid a fixed amount for a given diagnosis, the longer a patient stays in the hospital, the more money the hospital loses.

“They’ve basically exhausted their benefit under any plan because they don’t meet medical necessity anymore,” Burnette said. “If they had a home, they would go home. But they don’t, so they stay in the hospital.”

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Tenn. Block Grant Experiment Would Boost Federal Funding, State Medicaid Chief Says

Tennessee wants to be the first state to test a radical approach for federal financing of Medicaid, the federal-state health care program for low-income people.

The proposal, Tennessee Medicaid Director Gabe Roberts said, would increase the federal government’s contributions by millions of dollars and allow Tennessee to improve care for enrollees, perhaps offering additional services such as limited dental care for some people. But critics fear the plan will harm the poor.

Tennessee, controlled by a Republican governor and legislature, has not expanded its Medicaid program as allowed under the Affordable Care Act.

The federal government pays each state a percentage of the cost of caring for anyone eligible for Medicaid ― varying from 50% to 77%. And all who qualify get covered.

Tennessee has proposed altering its federal funding (66% of its total Medicaid budget) into an annual lump sum. (Drug expenses would be excluded from the new program.) The state said the change would give it more flexibility to run the program ― which serves 1.4 million people ― and would save money.

Conservatives have pursued Medicaid block grants for decades to give states more power over the program. But Democrats oppose such efforts, arguing block grants could result in less coverage and limit enrollment. They also stress that states, over time, could see significant drops in federal Medicaid funding because it would not be based specifically on the number of enrollees.

Tennessee’s plan, which was unveiled last month, would not change benefits or eligibility levels.

KHN senior correspondent Phil Galewitz sat down with Roberts last week to talk about the issue. His answers have been edited for clarity and length.

Q: Why are you seeking to turn Medicaid into a block grant now, especially as your state has been experiencing a budget surplus?

This isn’t a traditional block grant. We are calling it a modified approach. Tennessee Gov. Bill Lee has been a fan of the block grant idea for a while but also cares deeply about making sure that any approach isn’t going to reduce enrollment or services or people that we serve.

A state law passed this year instructing our administration to file a block grant waiver that would have a floor for federal dollars coming. So if enrollment fell, the money wouldn’t decrease. But if enrollment increased, the amount of federal payments would be indexed to account for that.

Gabe Roberts, Tennessee Medicaid director(Courtesy of Tennessee Medicaid)

Q: Can you discuss the shared-savings element that Tennessee is proposing?

Any savings from this program would be split in half with the federal government.

We have routinely underspent what the federal government projects for our costs by billions of dollars. So what this proposal does is to ask the Centers for Medicare & Medicaid Services (CMS) to reimagine the state-federal funding mechanism as a value-based one, so that states that operate well and serve their populations well ― but also contain costs ― are rewarded with additional federal dollars to invest in that population without the requirement to come up with a state match. Right now, we don’t keep any of the money we save.

Q: As one of the poorer states, are you willing to risk getting less money from the federal government for Medicaid?

We believe the way the waiver is designed mitigates any concerns around a traditional block grant program. We do not believe this will result in fewer federal dollars coming to the state. This is an opportunity to bring more federal dollars to spend to enhance services or perhaps to provide services to additional people we are not serving today.

Q: Some experts question the legality of the Trump administration approving a type of Medicaid block grant without congressional authority. Why do you believe this is legal?

There are a variety of ways we can reach a mutually agreeable solution with CMS on this that clearly comports to federal law.

Q: Why is turning Medicaid financing into a block grant a better idea for the poor than expanding Medicaid under the Affordable Care Act, which would provide coverage to nearly additional 300,000 residents? The federal government pays 90% of the cost of these new enrollees, bringing billions of additional federal funding into the state.

These are two different and not mutually exclusive goals. This is an approach that rewards Tennessee for a well-run program, providing high-quality care to members with high member satisfaction and underspending CMS projections. This allows us to get access to some of those federal savings. Medicaid expansion requires a significant amount of money that the state has to come up with on an ongoing basis. I don’t know that it’s fair to pit the two approaches against each other.

Correction: This story was updated on Oct. 3 at 11:20 a.m. ET to note that the Tennessee plan was unveiled last month and has not yet been submitted to the Centers for Medicare & Medicaid Services.

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Skin-Lightening Cream Put A Woman Into A Coma. It Could Happen Again.

[UPDATED on Oct. 1]

She had been buying face cream through a friend of a friend for 12 years. This time, it was Pond’s “Rejuveness,” a version of the company’s anti-wrinkle cream that is made and sold in Mexico.

But someone in the Mexican state of Jalisco laced the cream with a toxic skin-lightening compound, and it had a devastating effect on the 47-year-old Sacramento resident.

She showed up at the emergency room this summer slurring her speech, unable to walk or feel her hands and face, public health officials said. She now lies semi-comatose in a hospital.

Authorities aren’t releasing her name, but they say she is the first known victim of methylmercury poisoning from a cosmetic in the U.S.

Methylmercury is a heavy metal used in things like thermometers, batteries and mirrors, and long-term exposure can cause kidney damage, loss of peripheral vision and lack of coordination.

The chemical — along with a less potent, but still toxic, form of mercury known as calomel — is also a key ingredient in skin-lightening products. A bustling market for these products is driven by immigrants who buy them from their home countries.

The face cream that sickened the Sacramento woman was tampered with after manufacture, but some other skin-lightening products made overseas intentionally contain mercury as an active ingredient, said Bhavna Shamasunder, an associate professor at Occidental College in Los Angeles who studies skin-lightening cosmetics. While mercury removes skin pigmentation, Shamasunder said, the side effects are toxic.

Pond’s, owned by the international consumer products giant Unilever, said it doesn’t use mercury in its products. It encourages consumers to buy their products only from authorized retailers to avoid tampering. The company said it is working with authorities to investigate the Sacramento woman’s case.

In the past nine years, there have been more than 60 poisonings in California linked to “foreign brand, unlabeled, and/or homemade skin creams” that contained calomel, Sacramento County officials said.

While it is illegal to sell cosmetics in the U.S. with more than 1 part per million (ppm) of mercury — except eye products, which can have up to 65 — the Food and Drug Administration can’t keep up with the imports, whether they’re shipped, tucked into suitcases or purchased online.

Nor does it have the regulatory power to enforce recalls or require preapproval of cosmetic products and ingredients before they’re sold, Shamasunder said.

“The FDA has extremely poor oversight over our beauty products,” she said. “The burden of proof is on the consumer to get sick first.”

The FDA declined to comment on the record for this story.

Skin-lightening products are popular throughout the world, and the market is projected to grow to $31.2 billion by 2024, according to Global Industry Analysts, a publisher of market research.

Products made outside the U.S. aren’t subject to the same standards as American-made ones and may contain poisonous chemicals, like mercury, or have higher proportions of potentially dangerous ingredients, such as steroids.

Skin-lightening products are advertised for their ability to even out blemishes and skin tone, but some consumers feel pressure to use them on their whole face or body in cultures that tend to confer more money and social status on people with lighter skin.

Nearly 40% of women surveyed in Taiwan, Hong Kong, Malaysia, the Philippines and Korea said they used skin lighteners, while 77% of women in Nigeria and 25% in Mali said they did so, according to the World Health Organization.

In the U.S., potentially hazardous skin-lightening products can be purchased in some ethnic beauty stores, in ethnic supermarkets and at swap meets. They can even be found online at sites like Amazon and eBay.

It’s difficult to estimate how many people have been affected by mercury poisoning from cosmetics because screening for the heavy metal is not routine, said Tracey Woodruff, a professor of reproductive sciences at the University of California-San Francisco.

But the problem appears to be concentrated among certain ethnic groups. A recent Minnesota study measuring mercury in the urine of 396 pregnant women from 2015 to 2017 revealed that nine had elevated levels, mostly linked to skin-lightening product use among Hmong and Latina women. Ongoing testing is revealing even more cases, said Jessica Nelson, program director for the state’s biomonitoring project.

Often, poisoning victims get their spiked products from people they trust, Woodruff said.

Woodruff co-authored a report about a pregnant woman in San Francisco who had unusually high levels of mercury in her blood. The source was a jar of Pond’s face cream that had been adulterated in the Mexican state of Michoacán.

“A family member gave it to her, so it was a trusted source of information,” Woodruff said.

A 2013 study that sampled 367 skin-lightening products purchased in Chicago, Los Angeles, New York and Phoenix turned up at least a dozen products with exceptionally high levels of mercury, ranging from 1,729 ppm to 38,535 ppm.

In the Sacramento woman’s case, the contaminated face cream contained a methylmercury concentration of over 12,000 ppm. The level of methylmercury in her blood was 2,630 micrograms per liter, according to Sacramento County Public Health. Normal values are less than 5.

It’s unclear whether the FDA could have done anything to prevent her poisoning, said Melanie Benesh, legislative attorney for the Environmental Working Group, a nonprofit advocacy organization.

While the FDA has been able to intercept some high-mercury imports and turn them away, the agency lacks the authority to require companies to register their products and ingredients with the agency. That would make it easier to screen shipments that have a higher risk of being poisonous, Benesh said.

In a 2017 letter to Congress, the agency said it had six full-time inspectors to monitor 3 million cosmetics shipments annually.

“Right now, the FDA is really flying blind,” she said.

So it’s up to public health officials to catch poisoning cases as they happen and then trace their way back to the source.

In California, state public health officials are developing a campaign to educate shopkeepers and consumers. They also train volunteer community health workers like Sandra Garcia, 63, to meet with families to discuss the symptoms of mercury poisoning.

Garcia, who lives in Tulare County and picks and packs grapes for a living, estimates that she has purchased creams from 40 stores to send to public health officials for testing since March. And she has visited 60 homes to hand out brochures and help residents identify poisonous products.

“There are people that get angry and say that the cream is good and that nothing bad has happened to them,” she said. “But the majority of people are frightened and give me their creams.”

Leads on retailers that sell mercury-laced products may be handed over to law enforcement for potential follow-up, said California Department of Health spokesman Corey Egel.

Public health officials recommend consumers avoid buying cosmetics at swap meets and flea markets, and check that products are properly sealed and labeled.

At a discount store near MacArthur Park in Los Angeles, shop worker Lili Garcia dismissed the notion that consumers should avoid skin creams manufactured abroad.

She sells unopened jars of Pond’s Rejuveness cream from Mexico for $5 and $10, depending on the size, while Target lists American versions for $8 and $15, respectively.

Garcia, who uses the same cream herself, said she had heard about the Sacramento woman on the news and felt sorry for her. But she said it’s up to consumers to check that products are sealed; beyond that, there isn’t much else they can do.

“Well, the buyer buys the product, and they don’t know what’s inside,” she said.

[Update: This story was updated at 12:30 p.m. ET on Oct. 1 to clarify that the Food and Drug Administration declined to comment on the record for this story.]

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KHN Files Lawsuit To Force Feds To Disclose Medicare Advantage Audits

Kaiser Health News is suing the U.S. Centers for Medicare & Medicaid Services to release dozens of audits that the agency says reveal hundreds of millions of dollars in overcharges by Medicare Advantage health plans.

The suit, filed late Thursday in U.S. District Court in San Francisco under the Freedom of Information Act, seeks copies of 90 government audits of Medicare Advantage health plans conducted for 2011, 2012 and 2013 but never made public. CMS officials have said they expect to collect $650 million in overpayments from the audits. Although the agency has disclosed the names of the health plans under scrutiny, it has not released any other details.

“This action is about accountability for hundreds of millions of public dollars misspent,” said Elisabeth Rosenthal, KHN’s editor-in-chief. “The public deserves details about the overpayments, since many of these private companies are presumably still providing services to patients and we need to make sure it can’t happen again.”

Medicare Advantage, mostly run by private insurance companies, has enrolled more than 22 million seniors and people with disabilities, more than 1 in 3 people on Medicare.

On July 3, KHN reporters filed a FOIA requesting copies of the CMS audits, which are known as Risk Adjustment Data Validation, or RADV, and include the audit spreadsheets, payment error calculations and other records. CMS has yet to respond to that request, according to the suit.

“By this FOIA action, KHN seeks to shine a public light on CMS’s activities on behalf of millions of Americans and their families,” the suit states. The suit asks the court to find that CMS violated the FOIA law and order the agency to “immediately disclose the requested records.”

While Medicare publicly discloses audits of other medical businesses, Medicare Advantage insurers “are being treated differently,” according to the suit. “These audits are improperly being withheld by CMS, even though CMS estimates that these audits have identified some $650 million in improper charges,” the suit alleges.

While proving popular with seniors, the Medicare Advantage industry has long faced criticism that it overcharges the government by billions of dollars every year.

Medicare pays the health plans higher rates for sicker patients and less for those in good health. However, the RADV audits have shown that health plans often cannot document whether many patients actually had the medical conditions the government paid them to treat, generating overpayments. The secretive RADV audits are the primary means for CMS to hold the industry accountable and claw back overcharges for the U.S. Treasury.

In July, KHN reported that Medicare Advantage plans have overcharged the government by nearly $30 billion in the past three years alone, money federal officials have struggled to recoup.

This month, U.S. Sen. Sherrod Brown, an Ohio Democrat, and five other senators sent a letter to CMS Administrator Seema Verma asking her to investigate Medicare Advantage overbilling. “In many cases, CMS has known for years about the tendency for some MA plans to overbill the government yet, despite this, CMS has taken little to no action to course correct. It is critical that CMS act immediately to recoup these overpayments and prevent future overbilling by MA plans,” Brown wrote.

The insurance industry is fighting a proposal by CMS to expand the impact of RADV by extrapolating error rates found in a random sample of patients to the plan’s full membership — a technique expected to trigger many multimillion-dollar penalties.

America’s Health Insurance Plans, the industry’s trade association, said in an Aug. 28 statement that the CMS proposals “violate numerous statutory requirements and are fundamentally unfair and ill-conceived.”

Stepping up RADV penalties “could lead to higher costs, reduced benefits, and fewer MA plan options for seniors,” the group argued.

The FOIA lawsuit is the second by a media organization to compel CMS to disclose RADV audit findings. In 2014, the Center for Public Integrity sued CMS and won a court order forcing the release of RADV audits for the first time. The audits showed that 35 of 37 plans had been overpaid, in some cases by as much as $10,000 per patient in a year.

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The Delicate Issue Of Taking Away A Senior’s Smartphone

At first, Dr. Robert Zorowitz thought his 83-year-old mother was confused. She couldn’t remember passwords to accounts on her computer. She would call and say programs had stopped working.

But over time, Zorowitz realized his mother — a highly intelligent woman who was comfortable with technology ― was showing early signs of dementia.

Increasingly, families will encounter similar concerns as older adults become reliant on computers, cellphones and tablets: With cognitive impairment, these devices become difficult to use and, in some cases, problematic.

Computer skills may deteriorate even “before [older adults] misplace keys, forget names or display other more classic signs of early dementia,” Zorowitz wrote recently on a group email list for geriatricians. (He’s based in New York City and senior medical director for Optum Inc., a health services company.)

“Deciding whether to block their access to their bank accounts, stocks and other online resources may present the same ethical dilemmas as taking away their car keys.”

The emergence of this issue tracks the growing popularity of devices that let older adults communicate with friends and family via email, join interest groups on Facebook, visit virtually via Skype or FaceTime, and bank, shop, take courses or read publications online.

According to the Pew Research Center, 73% of adults 65 and older used the Internet in 2019, up from 43% in 2010. And 42% of older adults owned smartphones in 2017, the latest year for which data is available, up from 18% in 2013.

Already, some physicians are adapting to this new digital reality. At Johns Hopkins Medicine, Dr. Halima Amjad, an assistant professor of medicine, now asks older patients if they use a computer or smartphone and are having trouble such as forgetting passwords or getting locked out of accounts.

“If there’s a notable change in how someone is using technology,” she said, “we would proceed with a more in-depth cognitive evaluation.”

At Rush University’s Alzheimer’s Disease Center in Chicago, neurologist Dr. Neelum Aggarwal finds that older adults are bringing up problems with technology as a “non-threatening way to talk about trouble with thinking.”

“Instead of saying, ‘I have issues with my memory,’ people will say, ‘I just can’t figure out my smartphone’ or ‘I was trying to start that computer program and it took forever to get that done.’”

If the person previously used digital devices without difficulty, Aggarwal will try to identify the underlying problem. Does the older adult have problems with vision or coordination? Is she having trouble understanding language? Is memory becoming compromised? Is it hard for her to follow the steps needed to complete a transaction?

If using technology has become frustrating, Aggarwal recommends deleting apps on cellphones and programs on computers.

“The anxiety associated with ‘Oh, my God, I have to use this and I don’t know how’ totally sets people back and undoes any gains that technology might offer,” she said. “It’s similar to what I do with medications: I’ll help someone get rid of what’s not needed and keep only what’s really essential.”

Typically, she said, she recommends no more than five to 10 cellphone apps for patients in these circumstances.

When safety becomes an issue — say, for an older adult with dementia who’s being approached by scammers on email ― family members should first try counseling the person against giving out their Social Security or credit card information, said Cynthia Clyburn, a social worker in the neurology division at Penn Medicine in Philadelphia.

If that doesn’t work, try to spend time together at the computer so you can monitor what’s going on. “Make it a group activity,” Clyburn said. If possible, create shared passwords so you have shared access.

But beware of appropriating someone’s passwords and using them to check email or online bank or brokerage accounts. “Without consent, it’s a federal crime to use an individual’s password to access their accounts,” said Catherine Seal, an elder-law attorney at Kirtland & Seal in Colorado Springs, Colo. Ideally, consent should be granted in writing.

With his mother’s permission, one of Zorowitz’s brothers ― a physician in Baltimore — installed GoToMyPC, an application that allowed him to remotely manage her computer. He used it to reset passwords and manage items on her desktop and sometimes to order groceries online from Peapod.

Eventually, Selma Zorowitz lost interest in her computer as she slipped further into dementia and spent the end of her life in a nursing home. She died in 2014 at age 87.

Older adults with Alzheimer’s disease commonly turn away from digital devices as they forget how to use them, said Dr. Lon Schneider, a professor of psychiatry and neurology at the University of Southern California.

More difficult, often, are situations faced by people with frontotemporal dementia (FTD), which affects a person’s judgment, self-awareness and ability to assess risk.

Sally Balch Hurme’s 75-year-old husband, Arthur, has FTD, diagnosed in 2015. Every day, this elder-law attorney and author struggles to keep him safe in a digital world full of threats.

Hundreds of emails pour onto Arthur’s cellphone from telemarketers with hard-to-resist offers. His Facebook account is peopled with “friends” from foreign countries, all strangers. “He has no idea who they are. Some of them are wearing bandoliers of ammunition, holding their guns,” Hurme said. “It is horrific.”

Then, there’s Amazon, a never-ending source of shopping temptation. Recently, Arthur ordered four pocket translators, several watches and a large quantity of maple sugar candies for $1,000. Though returns are possible, Hurme doesn’t always know where Arthur has stored items he’s bought.

What steps has she taken to manage the situation? With Arthur’s permission, she unsubscribes him from accounts that send him emails and removes friends from his Facebook account. On his cellphone, she has installed a “parental control” app that blocks him from using it between midnight and 6 a.m. ― hours when he was most likely to engage in online activities. There’s also a “parental control” setting on the TV to prevent access to “adult” channels.

Instead of an open-ended credit card, Hurme gives Arthur a “stored value” card with a limited amount of money. She manages household finances, and he doesn’t have access to the couple’s online banking account. Credit bureaus have been told not to open any account in Arthur’s name.

If Hurme had her way, she said, she’d get rid of Arthur’s cellphone — his primary form of communication. (He has stopped using the computer.) But “I’m very sensitive to respecting his dignity and letting him be as independent and autonomous as possible,” she said. For all the dangers it presents, “his phone is his connection with the outside world, and I can’t take that away from him.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit to submit your requests or tips.

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Meet The Health Officials Who Alerted The World To The Alarming Vaping Illness

MILWAUKEE — Dr. Lynn D’Andrea knew something was amiss when three teenagers with similar mysterious, dangerous lung injuries came into the Children’s Hospital of Wisconsin one after another, gasping for air.

As the only pulmonologist on duty that Fourth of July holiday week, D’Andrea noticed those alarming cases followed on the heels of another teen who had a non-infectious condition with matching symptoms.

“‘We need to be thinking about something else,’” she told Dr. Michael Meyer, medical director of the Pediatric Intensive Care Unit, as he later recounted.

That “thinking about something else” led to the discovery of more than 530 probable vaping-related injury cases in 38 states, a U.S. territory and Canada. At least nine people have died. While the exact cause of the illness remains unclear, President Donald Trump is considering a ban on flavored e-cigarettes, and Walmart has taken them off its shelves altogether.

The epidemic has prompted outrage about federal oversight of vaping, but there is also a local public health success story to be told. Doctors and regional officials in Wisconsin, Illinois and elsewhere pieced together that this mysterious illness was much larger than it appeared. It’s a tale of teamwork, communication and long-serving public health officials tapping into their networks in an era of limited public health funding, diminished public health infrastructure and high turnover.

It’s surprising in some ways that Wisconsin became ground zero for uncovering the link. The state has ranked near the bottom nationwide for per-person spending on public health until a huge boost of $588 million more was greenlighted for the next two years. Wisconsin is also home to Juul vaping pod manufacturing sites, and one of its U.S. senators, Republican Ron Johnson, credits his win to vaping advocates.

And yet the state’s officials discovered the outbreak, which shows no signs of stopping.

“I don’t think anyone could have anticipated how wide-reaching this problem has become,” D’Andrea said in an email.

Discovering The Vaping Link 

Although isolated cases of vaping-related respiratory problems were spotted elsewhere, including as early as 2015 in West Virginia, a new wave of cases began popping up across the country starting in mid-April.

Otherwise healthy patients, many of them teenagers, complained of shortness of breath. unexplained weight loss, fatigue and gastrointestinal issues. They were often diagnosed with acute respiratory distress syndrome — essentially a lung injury from an unknown cause. The cases baffled health providers nationwide.

In North Carolina, clinicians puzzled over how healthy teenagers could suddenly be so ill that they needed ventilators for something that wasn’t infectious, said Zack Moore, the state’s epidemiology chief.

But in Wisconsin, doctors from Children’s Hospital used extensive patient histories to piece together the missing link among that cluster of four cases: vaping.

This is no easy feat when dealing with teenagers who may not want to admit to vaping in front of their parents — especially when it comes to vaping THC oil, the psychoactive chemical in marijuana. But for D’Andrea, a 25-year veteran who specializes in breathing issues among children and leads the hospital’s pulmonary team, the patients’ openness is part of what made the discovery possible.

“They were part of the ‘team’ who was trying to help us figure this out,” she said.

After discussing the cases with Meyer and other colleagues, D’Andrea called Dr. Michael Gutzeit, the hospital’s chief medical officer, on July 8. That phone call raised the warning from within Children’s Hospital to the local health department, then to the state health department and eventually to the Centers for Disease Control and Prevention in Atlanta — effectively putting this health crisis on the nation’s radar.

“It’s incredible that they saw this,” said Dr. Jeffrey Gotts, a pulmonologist at the University of California-San Francisco. “As front-line clinicians, there are very few things that we would report to public health authorities in the ICU. It’s not that unusual to have people show up with respiratory failure.”

From Local To State

Because the four patients with these symptoms at Children’s Hospital of Wisconsin were from Waukesha County just outside Milwaukee, infection specialists from the hospital gave the local health department a call.

Shortly thereafter, Waukesha’s public health officer, Ben Jones, reached out to the state’s respiratory disease epidemiologist, Thomas Haupt, whom he’d known for 15 years.

“They didn’t know how vaping would be involved” with these mysterious cases, said Haupt, a 34-year veteran of the Department of Health Services. “They called me right away.”

Haupt was immediately alarmed. He put down the phone and marched to the office of his boss, Chief Medical Officer Jonathan Meiman, on July 10, interrupting a meeting.

“We need to talk about this,” he recalled saying.

At that point, both the hospital and Haupt knew only that this was a local problem — and one that was getting worse. “It went from four cases to eight,” Haupt said. The team retroactively realized they had treated a patient admitted June 11 with similar symptoms, and had three more come in by July 19.

Haupt went to work notifying fellow public health officials across state lines in case this mysterious illness reached beyond Wisconsin, emailing two groups. Twelve years ago, he had set up a Midwest Influenza Coordinators Group, composed of officials from 11 states in the region to better manage flu season. He also helped lead the Council of State and Territorial Epidemiologists.

“Communication is always the biggest asset you’ve got as far as any disease investigation,” Haupt said.

It didn’t hurt that most of the people on these emails had run in the same public health circles for years. Several wrote back that they’d check things out with their poison control centers and public health departments.

In the meantime, the state health department and Children’s Hospital coordinated a press announcement and clinicians’ alert on July 25. Communication and trust was easy — Meiman and Gutzeit had worked together previously on Ebola preparedness efforts a few years earlier.

The news conference was livestreamed on Facebook. Following the briefing that day, another set of Wisconsin parents took a teenager with similar symptoms to the hospital.

The Case In Illinois

Within days, a clinician in Illinois who had seen the coverage called the Wisconsin state health department worried that a patient in Illinois might have the same condition. That’s when Meiman called his Illinois counterpart, Dr. Jennifer Layden, to let her know her state might have the mysterious illness, too.

“We started calling health departments and hospitals to see if others had this very vague description,” Layden said. “In a couple of days, just by those calls, we had two other patients.”

In San Francisco, Dr. Elizabeth Gibb saw a patient whose mom had seen the news out of Wisconsin and asked if it might be connected to her hospitalized teenager.

By Aug. 2, Illinois had put out a clinicians’ alert looking for more cases. Wisconsin was up to 11 cases.

As more cases appeared across the country, Wisconsin drafted a questionnaire for states to send out to clinicians, so they could all have a similar case definition and work off of similar data, Haupt said. At least 20 people in the Wisconsin state health department hustled on the response — on top of their regular workload.

The Epi-X Tipping Point

Following the news of a case across the border in Illinois — and one month since that first phone call from D’Andrea to Gutzeit — the Wisconsin health department decided to send out an Epi-X alert on Aug. 8. That’s an alert to all state health departments on the Epidemic Information Exchange network run by the CDC.

After the bulletin announcing Wisconsin had up to 25 suspected cases linked to vaping, calls poured in from New Jersey to North Carolina.

From there, it started to snowball.

The CDC announced on Aug. 17 that 94 possible cases existed, kicking off a media frenzy that culminated in national awareness of the dangers of vaping and cries for the head of the Food and Drug Administration to resign.

Within days, the CDC dispatched a team — two people to Illinois, two to Wisconsin — that helped comb through cases. Meiman and Layden continued to work together to further define the condition and coordinate information from other states.

As the caseload has quintupled, much still remains unknown about the illness. Many experts don’t believe this outbreak will end anytime soon. Still, Haupt said he’s incredibly proud of the work the officials in Wisconsin — from Children’s Hospital to the state health department — did spotting it. He believes their notification may have helped save lives.

“That’s the way public health is supposed to work,” he said. “And trust me, it doesn’t always work that way.”

California Healthline senior correspondent Anna Maria Barry-Jester contributed to this report.

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As Off-Label Use Spreads, Supplies Of Niche Drugs And Patients’ Patience Grow Short

[UPDATED at 3:15 p.m. ET]

Medical treatment has knocked down tumors in 6-year-old Easton Daniels’ brain, but the drug used also wiped out his immune system.

To bolster his immune function and help keep him healthy, he has visited a hospital for intravenous infusions of immune globulin about every month for the past year and a half.

But in early July, his family was stunned by a letter from Cincinnati Children’s Hospital: “All of Easton’s appointments canceled until further notice,” said his dad, Jeremy Daniels, who works in custodial services for a school.

Like Cincinnati Children’s, hospitals and clinics nationwide report a shortage of the medication, whose long manufacturing process starts with donated blood plasma. Often referred to as IVIG, intravenous immune globulin is used for a wide variety of medical conditions, beyond those for which it was first targeted — some treatments proven effective and some not. It is rich in antibodies, which are proteins that help fight off infection.

With IVIG in short supply, hospitals are left to make tough choices about who receives it, setting up a type of triage, like that faced by Easton’s family, who find themselves caught in a gray area over which conditions qualify.

“IVIG can be a useful treatment for evidence-based purposes, but it’s also often used as a last-chance, nothing-is-working Hail Mary kind of approach for myriad conditions even when there is not clear evidence that it helps the patient,” wrote Dr. Jerry Avorn, a professor of medicine at Harvard Medical School, in an email. He was speaking in general, not about any specific patient.

Nationwide, drug shortages of all kinds — from antibiotics to heart drugs to saline solution — are increasing and having a high impact on public health, the Food and Drug Administration said in a November public meeting. They often result from manufacturing problems — such as when a factory shuts down or too few suppliers exist to meet demand.

But the reasons for shortages of expensive infused drugs are particularly complicated, involving complex manufacturing processes, scientific uncertainty and financial motivations.

In the case of IVIG, the expensive treatment may be a victim of its own widening use.

Dating to the 1950s, immune globulin is often the only therapy for certain genetic, life-threatening conditions that disable the body’s infection-fighting function. Its intravenous form is FDA-licensed for six conditions, including primary immunodeficiencies; Kawasaki disease, which causes inflammation in the blood vessels; preventive care after bone marrow transplants; and a neurological condition called chronic inflammatory demyelinating polyneuropathy.

Easton Daniels(Courtesy of Jeremy Daniels)

Today, it is prescribed for patients whose immune systems have been compromised by viruses or treatments for cancer, so-called secondary immunodeficiency, although there may be other medicines for reinvigorating the immune system in those cases.

Prescribing a medicine for a purpose not approved by the FDA — known as off-label use — is legal and common. It sometimes leads to new and effective uses of a drug.

Some evidence shows that expanding the use of immune globulin to patients with a wider variety of illnesses, including types of cancers or recurrent infections, is helpful. But it is also being tried for conditions “where it is ineffectual and may actually increase the risks to patients,” the American Academy of Allergy, Asthma and Immunology warned in a March 2017 journal article that weighs the clinical rationale for various uses of the therapy.

In part as a result of this expanding off-label use, the industry’s trade group shows a 66% increase in distribution of the treatment from 2012 to 2018 across North America and Europe.

And Avorn said a portion of these uses may be encouraged by financial motivations. Cincinnati Children’s, for example, charges $6,800 to $10,000 for every 10-gram dose, according to the hospital’s list prices, which are generally higher than insurers pay. Adults often get more than 10 grams per infusion.

“And anytime an extremely costly infusion medicine is used in any setting, it’s worth looking at who benefits economically from its use, especially for conditions in which data on effectiveness is limited or absent,” Avorn said.

Nonetheless, increasing demand helped create the shortages, say pharmacists and others who study shortfalls. Immune globulin takes up to a year to produce, which includes plasma collection from healthy donors, processing, packaging and shipping — often at overseas manufacturing centers.

There are several manufacturers, with combined global sales of about $22.6 billion.

Aside from trying to boost plasma collection to deal with a shortfall, “the other piece is stewardship [of the supply], and that really is up to the hospitals, by and large,” said John Boyle, CEO of the Immune Deficiency Foundation, a group that advocates on behalf of people with genetic defects of the immune system. “Hospitals use an enormous portion of the plasma products out there.”

Many are scrambling to come up with ways to stretch their supplies.

Some, like Cincinnati Children’s, give top priority to patients with no other alternatives, often those with primary immune deficiencies, and those for whom not getting the treatment would be life-threatening.

Others, whose indications “were not as clear-cut or it was not necessarily dangerous to them to forgo it were placed on the bottom of the list,” said Dr. Derek Wheeler, chief of staff at Cincinnati Children’s.

Shortages are not affecting every hospital or clinic. That variation occurs because facilities have contracts with specific distributors or manufacturers, each of which can have a different supply line.

Dr. Cristina Porch-Curren, an immunologist in Camarillo, Calif., said her patients have not run into problems getting the treatment, although one had to change brands.

She is concerned about the increasing use of immune globulin for “off-label” conditions.

“Off-label doesn’t always mean bad. If you have someone who is really sick, with some terrible infection, on occasion that may be OK,” she said. But with limited supplies, she worries about growing interest by researchers and some physicians in using immune globulin for more widespread or ongoing conditions, such as dementia.

“That’s concerning, especially for patients with primary immune deficiencies [who have no other alternatives],” she said.

Back in Cincinnati, a temporary solution has been found for Easton.

FFF Enterprises offered to supply his family with a different type of immune globulin after Easton’s father reached out to the company, which is one of the largest distributors of the therapy. Instead of an intravenous dose, it has given Easton a subcutaneous form, injected as a shot at home. His doctor approved the switch, said Daniels, and the drug distributor said it would pick up the cost if his insurer, the state’s Medicaid program, balks.

[Correction: This story was updated at 3:15 p.m. ET to correct the name of the company supplying the Daniels family with an injectable form of immune globulin.]

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Hill Hodgepodge: Pelosi Draws From Democrats, GOP And Trump For Drug Plan

House Democratic leaders on Thursday unveiled an aggressive plan to lower drug prices through negotiations between federal health officials and the makers of some of the most expensive drugs.

Speaker Nancy Pelosi ushered the proposal through months of closed-door meetings primarily with other Democrats and experts on drug pricing.

But she and other Democratic leaders also incorporated ideas from legislation introduced in July by the top Republican and Democrat on the Senate Finance Committee and backed by President Donald Trump, including capping drug prices based on the rate of inflation — a measure that other Republicans said they would not support.

Democrats are also somewhat divided on this plan. Progressives in the House were quick to say the plan does not go far enough.

Even if the proposal never gets a vote, it offers congressional Democrats something they need with a little more than 13 months left before Election Day: a unifying message on an issue that most voters say is their biggest health care concern.

What’s all the fuss about? Let us walk you through it.

What’s In This Plan, Anyway?

The legislation, called the “Lower Drug Costs Now Act,” was formally introduced by Rep. Frank Pallone (D-N.J.), chairman of the House Energy and Commerce Committee, one of the panels with jurisdiction over the bill. The measure would restrict the ability of drugmakers to charge essentially whatever they want on brand-name drugs that have no competition on the market. Specifically, its changes would include:

  • A requirement that the secretary of Health and Human Services negotiate the prices of “as many as possible” of the 250 most expensive drugs marketed in the United States that lack at least one generic or biosimilar competitor. HHS would have to negotiate at least 25 drugs annually, addressing the concern that requiring more could overwhelm health officials.
  • Steep penalties for drugmakers who refuse to negotiate or comply with the outcome, equivalent to 65% of the drug’s annual gross sales, escalating up to 95% over time. There would also be penalties for overcharging, for example.
  • Limits on price increases for drugs covered under Medicare Part B (which includes treatments at doctors’ offices and dialysis centers) and Part D (referring to prescription drug plans). Those price increases would be restricted to the rate of inflation, including retroactively those that have risen since 2016. Drugmakers could either lower their price or pay the difference to the government as a rebate.
  • A $2,000 cap on the amount Medicare beneficiaries pay out-of-pocket for prescription drugs every year.

Outlining how the HHS secretary would determine which drugs to negotiate, the plan says HHS would identify the target drugs each year with the highest aggregate cost, meaning they would take into account the price and the volume of sales.

HHS would be required to negotiate the price of insulin, the proposal adds, singling out the lifesaving diabetes medication with sky-high costs that have spurred outrage at drugmakers this year.

The legislation would aid negotiations by creating a maximum price called the Average International Market price. Drawing on the idea of an international pricing index — which Trump has said he supports but which many Republicans dislike — the so-called AIM would be the average price of a drug in six countries (Australia, Canada, France, Germany, Japan and the United Kingdom) weighted on the basis of sales volume.

The goal of negotiations would be to establish “a maximum fair price,” which would be no more than 20% higher than the AIM, the plan says.

Who Would Benefit From This Plan, And How?

In short, all Americans would benefit from the pricing negotiations. The plan says the price would be available to all payers, not just the federal government, meaning drugmakers would have to offer the same deal to everyone.

The rest of the legislation offers benefits largely for Medicare beneficiaries, even suggesting that, if the drug savings were enough, it could mean expanded coverage, including adding services for vision, hearing and dental care.

It is legislation tailor-made for an election year. A Kaiser Family Foundation poll released last week showed 70% of the public said lowering prescription drug prices should be a major priority for lawmakers — more than any other health care issue. (Kaiser Health News is an editorially independent program of the foundation.)

It also helps that older Americans tend to be the most reliable voters, a trend that may explain why Medicare issues often come up around election season.

What Are The Critics Saying?

This legislation puts “politics over progress,” said a statement attributed to every Republican on the House Energy and Commerce Committee.

It is “more accurately a ‘dictate or destroy’ price control power that will halt valuable research into new lifesaving medicines and give foreign countries dangerous influence over America’s health care system,” said Rep. Kevin Brady of Texas, the top Republican on the House Ways and Means Committee, which also would oversee the proposal.

“We do not need to blow up the current system to make medicines more affordable,” said Stephen Ubl, head of PhRMA, the pharmaceutical industry’s trade group.

To sum it up, Republicans and the drug industry generally oppose efforts that would:

  • allow the government to negotiate drug prices.
  • tie drug prices to the lower prices paid overseas.
  • limit how fast drug companies can raise their prices.

They argue such measures interfere with the free market.

But Trump has broken with his party on some of these issues. The Office of Management and Budget is reportedly working on a proposal to create an international pricing index pilot project after Trump endorsed the idea. He has also expressed support in the past for empowering the government to negotiate drug prices.

Shortly before his inauguration, Trump commented that drug companies have been “getting away with murder” and vowed to change that, sparking occasional speculation about a Trump-Pelosi alliance on drug pricing. But with the 2020 presidential election season underway, it seems unlikely the pair would want to hand each other a policy victory.

In addition, progressive Democrats have expressed opposition to the plan, objecting to how little input they feel they were given in its consideration and its relatively modest scope by requiring that only 25 drugs be negotiated.

Will This Become Law?

Let’s zoom out for a moment. In July, the Senate Finance Committee members considered their leaders’ more modest drug-pricing proposal that would cap both the prices paid by Medicare to the rate of inflation and the out-of-pocket drug costs of seniors, as the Democratic leaders’ plan would.

The committee’s Republican chairman, Sen. Chuck Grassley of Iowa, a respected and powerful voice on the issue, had poured his efforts into the legislation, which incorporated policies Trump had supported.

Still, most of Grassley’s fellow Republicans warned him they would not support his measure if the full Senate voted on it.

While frustrated with his colleagues, Grassley noted during the hearing that he shared their opposition to two other ideas that would turn up in the eventual Pelosi plan: the international pricing index and HHS negotiations on drug prices.

“I don’t think that you’re going to get 60 votes in the United States Senate,” Grassley said of the idea of negotiations at the time.

The takeaway is that the odds aren’t in Democrats’ favor. There is strong, established Republican opposition to many of the ideas included in the Democrats’ plan, with plenty of drugmaker money flowing into congressional coffers to keep it that way.

What Happens Next?

The Energy and Commerce Committee has scheduled a hearing on the bill next week.

Democrats, who control the House, have said they are hoping for a vote in the next couple of months. But even if it passes the House, Senate Majority Leader Mitch McConnell, who controls what comes to the Senate floor, could pass on bringing it up for a vote at all.

Instead, the legislation may largely offer Democrats a potent talking point as Election Day 2020 approaches, giving them an ambitious proposal to point to as evidence that they are listening to voters’ concerns — just as congressional Democrats hammered Republicans for not protecting those with preexisting conditions during the 2018 midterms.

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Which Was Worse: The Bachelor Party Hangover Or The Hangover From The ER Bill?

DENVER — Two days before his wedding, Cameron Fischer had one heck of a bachelor party, hitting a few bars in the Old Town section of Fort Collins, Colo., with his friends into the wee hours. The next morning, the 30-year-old IT professional from nearby Loveland woke up with a killer hangover.

“I couldn’t keep anything down,” Fischer said. “I just felt miserable.”

He was in such bad shape that, with their wedding day fast approaching, Fischer’s fiancée urged him to leave their rehearsal dinner in Denver and head to an emergency room to be rehydrated.

That resulted in an even bigger headache: a medical bill that was initially $12,460, all told. That was more than twice the cost of their wedding.

Fischer’s case is a sobering illustration of America’s health care system. With few constraints on how emergency rooms set prices, hospital systems have jacked up rates and coded patient visits as being more complex than previously, which increases the payments they receive from insurance plans. The result: ER services have some of the fastest-growing prices in the health care system.

Many health economists think free-standing ER facilities, like the one Fischer visited — which are banned in many states but thriving in Colorado — are particularly culpable. While such ERs maintain they can’t survive on rates paid by Medicare and Medicaid, data suggests they are profit-seeking engines built primarily in high-income ZIP codes.

“It’s because they’ve figured out that they can get away with it,” said Vivian Ho, an economist with the Baker Institute at Rice University in Houston.

Fischer might have avoided the big bill had he sought treatment earlier in the day. But by 7 p.m. on a Saturday, urgent care facilities were closed. He checked Google Maps for the closest emergency room and — clutching a trash can — headed to HealthONE North Suburban Medical Center, a free-standing ER in the Denver suburb of Thornton.

The ER appeared to be devoid of patients, just a doctor and a couple of nurses on duty. Fischer told them what had happened, that he didn’t do drugs and doesn’t often drink.

“I knew exactly why I was there,” he said. “It wasn’t that I had some unknown reason for my symptoms.”

A nurse started an IV, gave Fischer two bags of saline and a dose of Zofran, an anti-nausea medication. She drew blood, although Fischer said he wasn’t told what tests would be run on the blood sample. He was out of the ER within 45 minutes, feeling much better.

Facility Fees As Price Of Entry

A few weeks after Fischer’s April wedding, he received the medical bill.

It included a $7,644 “facility fee” — an expense hospital systems charge to cover their overhead costs of keeping an ER open 24 hours a day and ready for any emergency.

Facility fees are set on a scale from 1 to 5, depending on how severe the patient’s condition appears during the initial triage. The ER rated Fischer’s visit as a 4, one of moderately high complexity in terms of care needs.

“There are no limitations on the facility fees that they can charge,” said Adam Fox, director of strategic engagement for the Colorado Consumer Health Initiative, a nonprofit consumer advocacy group. “The facility fee for over $7,000 is simply obscene.”

The Health Care Cost Institute, an independent, nonprofit health research firm, recently analyzed millions of insurance bills to get a better sense of the facility fees ERs were charging. It found the charges nearly doubled from 2009 to 2016, outpacing overall health spending four times over. In Colorado, the average facility fee charged for a Level 4 visit grew from $1,064 to $2,336.

Insurance plans generally don’t pay the full charge but pay a negotiated rate for in-network hospitals. The Center for Improving Value in Health Care, which maintains a database of insurance payments in Colorado, found that insurance plans paid an average of $1,754 for a Level 4 facility fee in 2018.

Still, those prices pale in comparison to the fee charged to Fischer. “That seems like an outlier on the high end,” said John Hargraves, a senior researcher at the institute who led the ER study. “That’s more than triple what it was in 2016.”

Other studies have found that ERs are increasingly coding visits at the higher 4 and 5 complexity levels than in past years. It’s not clear whether that reflects a deliberate attempt by hospital systems to increase payments or a shift in the type of patients who visit emergency rooms. It’s possible the growth in urgent care centers is siphoning off less complex cases.

The bill for Fischer’s emergency room visit was $12,460 — more than twice the cost of his wedding the next day.(Courtesy of Cameron Fischer)

Treatment Costs For A Hangover

Fischer’s bill included $500 for a complete blood count, a test the online price comparison tool Healthcare Bluebook says could be had for less than $20 in a doctor’s office. He was charged more than $1,300 for a complete metabolic panel, a routine test that generally costs about $31.

The two liters of saline, which the ER billed at $700, are available at Walmart for $10.99 a liter.

And spa-like hydration services in Denver market IV fluids for hangover relief consisting of the same combination of saline and nausea meds that Fischer received in the ER for just $168.

The ER also charged Fischer $970 for a drug test, something he said he never consented to undergo. Medicare typically pays health care providers about $114 for the same test.

“When you look at the bill, obviously the prices are astronomical,” Fischer said. “But it was also the work that was performed without my authorization. That was pretty frustrating.”

HealthONE officials said the prices at its ERs are higher than at urgent care clinics or other outpatient settings because the ERs are staffed by board-certified emergency physicians and cannot turn away any patients regardless of their ability to pay. So the patients who pay for care at their ERs subsidize those who show up and can’t pay.

“The move toward higher-deductible insurance plans has put a strain on many of our patients, but we understand their choice to pay a lower monthly premium, and we also understand their frustration with the larger out-of-pocket expenses they may experience as a result,” HealthONE North Suburban Medical Center spokeswoman Betty Rueda-Aguilar said, in a written statement to Kaiser Health News. She added that Fischer presented with symptoms of alcohol poisoning and had to be treated accordingly. The company declined an interview.

Emergency rooms tend to lose money on critically ill patients, as well as on Medicare, Medicaid and uninsured patients, said Dr. Jesse Pines, national director of clinical innovation for US Acute Care Solutions, which helps staff more than 200 hospitals and ERs. These facilities try to make up the difference with less sick, privately insured patients, like Fischer.

“To make the economics of an emergency department work, those patients have to subsidize the system to make the difference balance out,” Pines added.

But as more privately insured patients have high-deductible plans, he said, it’s been harder and harder for hospitals to collect on their bills from patients who don’t pay.

Free-Standing ERs

Free-standing ERs, such as North Suburban, may have found a way to skew their patient mix toward those who can pay. A report from the Colorado Health Institute found that free-standing ERs tend to set up shop in high-income neighborhoods. There, residents are more likely to have higher-paying commercial insurance, rather than Medicare or Medicaid, and are likelier than other patients to be able to pay for out-of-pocket costs their insurance doesn’t cover.

Colorado has more than 50 free-standing ERs, according to the report, trailing only Texas and Ohio. They are licensed as “community clinics and emergency centers,” a designation originally developed to help rural and underserved communities in Colorado that could not otherwise afford inpatient hospitals. But the report identified only eight free-standing emergency departments in rural Colorado — all in affluent ski resort towns.

For Fischer, the negotiated rates under his health plan knocked the $12,460 bill down to $4,694. The plan paid $2,102. That left Fischer with a bill of $2,593, an amount he said he cannot afford to pay.

“That’s quite the expensive bachelor party,” Fischer said.

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