Telehealth turned Jill Hill’s life around.

The 63-year-old lives on the edge of rural Grass Valley, an old mining town in the Sierra Nevada foothills of northern California. She was devastated after her husband Dennis passed away in the fall of 2014 after a long series of medical and financial setbacks.

“I was grief-stricken and my self-esteem was down,” Hill remembers. “I didn’t care about myself. I didn’t brush my hair. I was isolated. I just kind of locked myself in the bedroom.”

Hill says knew she needed therapy to deal with her deepening depression. But the main health center in her rural town had just two therapists. Hill was told she’d only be able to see a therapist once a month.

Then, Brandy Hartsgrove called to say Hill was eligible via MediCal (California’s version of Medicaid) for a program that could offer her 30-minute video counseling sessions twice a week. The sessions would be via a computer screen with a therapist who was hundreds of miles south, in San Diego.

Hartsgrove co-ordinates telehealth for the Chapa-de Indian Health Clinic, which is a 10-minute drive from Hills’s home. Hill would sit in a comfy chair facing a screen in a small private room, Hartsgrove explained, to see and talk with her counselor in an otherwise traditional therapy session.

Hill thought it sounded “a bit impersonal;” but was desperate for the counseling. She agreed to give it a try.

Hill is one of a growing number of Americans turning to telehealth appointments with medical providers in the wake of widespread hospital closings in remote communities, and a shortage of local primary care doctors, specialists and other providers.

Long-distance doctor-to-doctor consultations via video also fall under the “telehealth” or “telemedicine” rubric.

A recent NPR poll of rural Americans found that nearly a quarter have used some kind of telehealth service within the past few years; 14% say they received a diagnosis or treatment from a doctor or other health care professional using email, text messaging, live text chat, a mobile app, or a live video like FaceTime or Skype. And 15% say they have received a diagnosis or treatment from a doctor or other health professional over the phone.

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Those survey findings are part of the second of two recent polls on rural life and health conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

The Chapa-de clinic offers telehealth services not only for consultations in behavioral health and psychiatry, but also in cardiology, nephrology, dermatology, endocrinology, gastroenterology and more.

Hill feels fortunate; she knows most rural health facilities don’t include telehealth services, which means most patients living in remote areas would need their own broadband internet access at home to get therapy online.

And that’s out of reach for many, says Robert J. Blendon, co-director of NPR’s poll and professor of health policy and political analysis at the Harvard Chan School.

The poll found that one in five rural Americans say getting access to high-speed internet is a problem for their families.

Blendon says advances in online technology have brought a “revolution” in healthcare that has left many rural patients behind.

“They lose the ability to contact their physicians, fill prescriptions and get follow-up information without having to go see a health professional,” he says.

Critical care pediatrician James Marcin at UC Davis Children’s Hospital, directs the University of California, Davis, Center for Health and Technology and regularly consults via a telehealth monitor with primary care doctors in remote hospitals in rural areas.

“We’re able to put the telemedicine cart [virtually] at the patient’s bedside,” Marcin says, “and within minutes our physicians are able to see the child and talk with the family members and help assist in the care that way.”

If not for telehealth, Marcin says, the costs of getting what should be routine care “are significant barriers for those living in rural communities.”

“We have patients that drive to our Sacramento offices and they have to drive the night before,” he says, “and spend the night in a hotel because it’s a five-hour trip each way.” And there are additional costs for many patients, he says, such as childcare services, and missed days of work.

With telehealth, “a video is truly worth a thousand words,” he says; it can mean patients don’t have to make costly time-consuming trips to see a specialist.

Though Hill initially had reservations about meeting with a therapist online, she says she’s been amazed by how helpful the sessions have been.

“She gives me assignments and works me really hard,” Hill says, “and I have grown so much — especially just in the last few months.”

Her latest assignment in therapy: writing down positive characteristics of herself. Initially, she could only come up with three: loyalty, compassion and resilience. But the therapist questioned that, and encouraged Hill to consider that there might be more.

“She wanted 10,” says Hill, who proceeded to work through some other issues and talk more with therapist. “Now I’ve got like 15 at least,” Hill says, “and I keep adding to the list; once I started writing things down, I started really seeing that I have a lot of strengths I didn’t even know I had.”

Attorney Mei Kwong, executive director of the Center for Connected Health Policy in Sacramento, says telehealth services have the potential to remove many barriers to good health care in rural America.

But policies that regulate which telehealth services get paid for “lag way behind the technology,” Kwong says. Many policies are 10 to 15 years behind what the technology is able to do, she says.

For example, high-resolution photos can now be taken – and sent anywhere digitally — of skin conditions that many doctors say are better than “the naked eye looking at the condition,” she says. But the policies on the books of what Medicare, Medicaid and private insurers will pay for often means these services are not fully covered.

That’s unfortunate, Kwong says, especially for underserved communities where there is a shortage of specialists.

Changes are starting to be made in state, federal and private insurance policies, Kwong says. But it’s “slow going.”

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When Mary Kay Gilbert saw her doctor in May for a skin infection on her leg, she wasn’t surprised to receive a prescription for an antibiotic cream.

But Gilbert, 54, a nurse and health consultant, was shocked when her physician clicked on the desktop computer and told Gilbert the medicine would cost $30 on her Blue Cross and Blue Shield plan.

“I was like, ‘Wow — that’s pretty cool that you know that information,’ ” she recalled telling the doctor in Edina, Minn.

Allina Health, the large Minnesota-based hospital network Gilbert’s doctor belongs to, is one of a growing number of health systems and insurers providing real-time drug pricing information to physicians so they can help patients avoid “sticker shock” at the pharmacy.

The pricing tool, which is embedded in each participating physician’s electronic health records and prescribing system, shows how much patients can expect to pay out of pocket, based on their insurance and the pharmacy they choose.

It also allows the doctor to find a cheaper alternative, when possible, and start the process of getting authorization for a drug, if the insurer requires that.

The soaring cost of drugs has been front and center in the growing national debate about revamping U.S. health care.

Patients abandon hundreds of thousands of prescriptions each year at the pharmacy, often because of high prices. Studies show that can jeopardize their health and often lead to higher costs down the road.

Such a tool can help consumers — many of whom are also facing increasing copayments and higher deductibles — learn about cheaper options in the doctor’s office.

Still, doctors have been slow to adopt the technology, sometimes because of concerns about getting bogged down in long discussions about drug costs. Humana, for example, introduced its drug pricing tool to its network of doctors in 2015. Today, fewer than 10% are using it, according to Humana officials.

These sorts of pricing tools do have serious limitations. Because price negotiations among insurers, drugmakers and middlemen are often highly competitive and secretive, the tools often don’t have useful data for every patient.

For example, Allina’s works for only about half its patients. The company says that’s because not all pharmacy benefit managers share their data on health plan enrollee costs, and those that do often provide only a fraction of their information.

“It’s a chicken-and-egg thing where doctors don’t use it because they don’t have the data for all their patients, and health plans don’t promote it to physicians because doctors don’t have the technology in place,” says Anthony Schueth, a health information technology consultant in Jacksonville, Fla. “It can be a powerful tool when it works, but at the moment the drivers are not there across the board for widespread adoption.”

At a hearing last month, Sen. Martha McSally, R-Ariz, pressed a top Trump administration health official about why many patients lack access to information on prescription drug prices at their doctor’s office.

“This is America. Why can’t we have this tool available now?” she asked. “The data is out there; the information is out there. What is it going to take to make this happen?”

The technology got a boost last month when the Centers for Medicare & Medicaid Services mandated that all Medicare drug plans embed such a tool in their doctors’ electronic prescribing system starting in 2021.

The details of what consumers spend out of pocket for drugs is provided by pharmacy benefit managers, or PBMs. They are the middlemen who negotiate with drugmakers on the prices insurers will pay for the medications and which ones the insurers will cover. So a tool’s usefulness is undermined when key PBMs are not included in the listings.

For example, a drug pricing tool sold by Surescripts, which is owned partly by the PBMs CVS Caremark and Express Scripts, includes data from those companies, but not from OptumRx, a PBM owned by insurance titan UnitedHealth. And the OptumRx drug pricing tool includes Optum data but not that of Express Scripts and CVS.

Demetrios Kouzoukas, who heads the Medicare program for CMS, says he hopes the program’s new drug mandate will spark the industry to provide doctors and patients access to a standard pricing tool, regardless of their insurance.

“What we are hoping and expecting is that there will be a standard that’s developed by the industry … so that the tool is available in all the electronic health records, for all the doctors and all patients, and spreads even beyond Medicare,” he told McSally at the hearing.

But cooperation does not seem to be on the horizon, some health industry officials say.

“I don’t see any chance that there will be a centralized system that will connect all of the plans/PBMs with all of the EHR systems currently in use anytime soon,” says Thomas Borzilleri, CEO of InteliSys Health, a health technology company based in San Diego.

Still, the National Council for Prescription Drug Programs, a nonprofit group that helps set guidelines for the pharmacy industry, has been working on standards for a drug pricing tool. John Klimek, a senior vice president of the nonprofit, predicts that by next year doctors across the country will be able to use the same drug pricing tool to look up all their patients’ drug costs, regardless of the insurer.

Even without such a standard in place, doctors and hospitals have an incentive to use the tool that goes beyond saving their patients money: Such a tool can be good for a provider’s wallet, too.

For example, Allina, which owns or operates about a dozen hospitals and dozens of clinics in Minnesota and Wisconsin, gets a set fee from some insurers to care for all of a patient’s health needs. So the doctors and health system all benefit when they can reduce costs and improve patients’ adherence to taking their medication, says Dr. David Ingham, a family doctor also from Edina. He’s one of 600 primary care doctors at Allina using the tool.

“When we prescribe a more expensive medication, we share less revenue from the insurance contract,” he says.

For example, he notes that the tool helped him prescribe inhalers to asthma patients.

“I pulled up one medication I normally use, and it said it would be $240 out of pocket, but it suggested an alternative for $20 that was pharmacologically equivalent,” Ingham says. “I sheepishly asked the patient which we should choose.”

Dr. Norman Rosen, a family physician in Orange, Calif., who is employed by Providence St. Joseph Health System, is one of 800 doctors who are testing the Blue Shield of California drug pricing tool this year. Based on the first few months of use, the tool is expected to save patients more than $100,000 in out-of-pocket costs this year, according to the companies.

Without the tool, Rosen says, it would be impossible for him to quickly know what drugs are covered by which insurers and what the copays are. He says he already has saved some patients several thousand dollars a year by changing their blood pressure and diabetes medications.

“It doesn’t take a lot of time, and this can be an important intervention,” Rosen says.

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation and is not affiliated with Kaiser Permanente.

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This article was produced in partnership with MLK50, which is a member of the ProPublica Local Reporting Network.

Methodist Le Bonheur Healthcare, the largest hospital system in Memphis, Tenn., said it has suspended “court collection activities” over unpaid medical bills — just days after an investigation by MLK50 and ProPublica (which also appeared on NPR) detailed its relentless pursuit of debts held by poor people and even its own employees.

“We recognize that we serve a diverse community and we are always thinking about how we can do more and serve our community better,” Methodist said in a written statement. “Over the next 30 days we will be reviewing our policies and procedures to ensure we are doing everything possible to provide the communities we serve with the care and assistance they need. Also, we will immediately suspend any further court collection activities during this period.

“As a learning organization that is committed to continuous quality improvement, we want to be absolutely sure that our practices continue to support our mission and vision of improving every life we touch regardless of ability to pay.”

Methodist dropped more than two dozen cases that were set for initial hearings on Wednesday’s morning docket at Shelby County General Sessions Court.

“Currently, Methodist is in the process of reviewing its collection processes,” R. Alan Pritchard, one of Methodist’s attorneys, told General Sessions Court Judge Deborah M. Henderson.

“You are free to leave,” Henderson told one defendant, who looked puzzled, a purse on her shoulder and a folder full of papers in her hand.

Henderson called the names of other defendants whose cases were on the docket.

Again and again, Pritchard said: “Dropped, please, your honor.”

One of the defendants whose case was dropped is Adrien Johnson, who works for the city of Memphis. Methodist sued him this year for an unpaid hospital bill of more than $900.

Reached by phone, Johnson said he believes the hospital bill was for X-rays he had taken while he was covered by his wife’s insurance. Wednesday was his first court date, and after the hearing, he said he wasn’t clear what the status of his debt was.

“I don’t know what they’re doing,” he said. “I need to find out what’s going on.”

From 2014 through 2018, the hospital system affiliated with the United Methodist Church filed more than 8,300 lawsuits, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records. That’s more than all but one creditor during that five-year period.

One story by the news organizations chronicled the struggle of Carrie Barrett, who makes $9.05 an hour at Kroger, to pay her 2007 hospital bill for $12,019. The bill has ballooned to more than $33,000 due to interest and attorney’s fees.

Another story detailed how Methodist sues its own employees, some of whom make less than $13 an hour, for unpaid bills related to care delivered at its hospitals. Its health plan doesn’t allow workers to seek care at hospitals with more generous financial assistance policies.

Defendants talked about how the lawsuits upended their lives and left them in a position where they would never be able to pay off their debts, which grew from year to year as interest mounted.

With $2.1 billion in revenue and a health system that includes six hospitals, Methodist leads the market: In 2017, it had the most discharges per year and profits per patient, according to publicly available data analyzed by Definitive Healthcare, an analytics company.

Methodist says it has “a hospital in all four quadrants of the greater Memphis area, unparalleled by any other healthcare provider in our region,” plus more than 150 outpatient centers, clinics and physician practices. The system also said it provides community benefits of more than $226 million annually.

The number of lawsuits Methodist files isn’t out of proportion to its size, at least compared to competitor Baptist Memorial Health Care and Regional One Health, the county’s public hospital. But Methodist stands out in other respects.

Its financial assistance policy, unlike those of many of its peers around the country, all but ignores patients with any form of health insurance, no matter their out-of-pocket costs. If they are unable to afford their bills, patients then face what experts say is rare: A licensed collection agency owned by the hospital.

Also, after the hospital sues and wins a judgment, it repeatedly tries to garnish patients’ wages, which it does in a far higher share of cases than other nonprofit hospitals in Memphis. A court-ordered garnishment requires that the debtor’s employer send to the court 25% of a worker’s after-tax income, minus basic living expenses and a tiny deduction for children under age 15.

Methodist secured garnishment orders in 46% of cases filed from 2014 through 2018, compared with 36% at Regional One and 20% at Baptist, according to an analysis of court records by MLK50.

Methodist’s announcement was welcomed by some local lawmakers.

“Methodist has been such a great community partner throughout Shelby County that I’m glad to hear they’re reviewing their process over the next 30 days,” said Shelby County Commissioner Mickell Lowery, whose district includes Methodist University Hospital.

U.S. Rep. Steve Cohen, D-Tenn., said: “I was surprised to read about Methodist Le Bonheur’s billing practices, and I’m glad that the company is re-examining them. … I will continue to monitor this situation and look forward to the company’s assessment.”

But the Rev. Anthony Anderson, a United Methodist elder at Faith United Methodist in Memphis, was more reserved.

“I am still heartbroken, and I say that spiritually,” Anderson said. “It breaks my heart to know that a Methodist-related entity, a hospital, would have these types of practices.”

He welcomed the policy review, but only if it leads to the complete erasure of all outstanding patient debt.

“This debt needs to be wiped away,” Anderson said. “That will be the direction I will be pushing towards as a Methodist — that we don’t burden families with these type of financial penalties.”

New data obtained from Shelby County General Sessions Court shows that Methodist has filed more than 600 new lawsuits this year. Its most recent suits were filed on June 21, days before the MLK50-ProPublica stories were published. Its most recent garnishment order was filed on Tuesday.

Wendi C. Thomas is the editor of MLK50: Justice Through Journalism. Email her at wendicthomas@mlk50.com and follow her on Twitter at @wendicthomas.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

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While abortion bans in Republican-led states dominated headlines in recent weeks, a handful of other states have passed laws to expand abortion access. Maine joined those ranks in June with two new laws — one requires all insurance and Medicaid to cover the procedure and the other allows physician assistants and nurses with advanced training to perform it.

With these laws, Maine joins New York, Illinois, Rhode Island and Vermont as states that are trying to shore up the right to abortion in advance of an expected U.S. Supreme Court challenge. But what sets Maine apart from the other states is how recently Democrats have taken power.

“Elections matter,” says Nicole Clegg of Planned Parenthood of Northern New England. “In 2018, we saw the largest number of women get elected to our legislature. We saw an overwhelming majority of elected officials who support reproductive rights and access to reproductive health care.”

The dramatic political change also saw Maine elect its first female governor, Janet Mills, a Democrat who took over from Paul LePage, a Tea Party stalwart who served two terms. LePage had blocked Medicaid expansion in the state even after voters approved it in a referendum.

Clegg and other supporters of abortion rights have hailed the new abortion legislation as a big win.

“It will be the single most important event since Roe v. Wade in the state of Maine,” Clegg says.

Taken together, the intent of the two laws is to make it easier for women to afford and find abortion care in the rural state.

Nurse practitioners like Julie Jenkins, who works in a small coastal town, say that increasing the number of abortion providers will make it easier for patients who now have to travel long distances in Maine to get the procedure from a doctor.

“Five hours to get to a provider and back — that’s not unheard of,” Jenkins says.

Under the law set to go into effect in September, physician assistants and nurses with advanced training will be able to perform a surgical form of the procedure known as an aspiration abortion. These clinicians already are allowed to use the same technique in other circumstances, such as when a woman has a miscarriage.

Maine’s other new law will require all insurance plans — including Medicaid — to cover abortions and is supposed to be implemented early next year. Kate Brogan of Maine Family Planning says this legislation is a workaround for dealing with the U.S. law known as the Hyde Amendment, which prohibits federal funding for abortions except in extreme circumstances.

“That is a policy decision that we think coerces women into continuing pregnancies that they don’t want to continue,” Brogan says. “Because if you continue your pregnancy, Medicaid will cover it. But if you want to end your pregnancy, you have to come up with the money [to pay for an abortion].”

State dollars, not federal, will pay for the abortions performed through Maine’s Medicaid program (in general, Medicaid is funded by both state and federal tax dollars).

Though the bill passed in the Democratic-controlled Legislature, it faced staunch opposition from Republicans, including state Sen. Lisa Keim, during floor debates.

“Maine people should not be forced to have their hard-earned tax dollars [used] to take the life of a living pre-born child,” Keim says.

Instead, Keim argues, abortions for low-income women should be funded by supporters who wish to donate money. Otherwise, she said during the debate, the religious convictions of abortion opponents are at risk.

“Our decision today cannot be to strip the religious liberty of Maine people through taxation,” Keim says.

Rep. Beth O’Connor, a Republican who says she personally opposes abortion but believes women should have a choice, says she had safety concerns about letting clinicians who are not doctors provide abortions.

“I think this is very risky, and I think it puts the woman’s health at risk,” O’Connor says.

In contrast, advanced-practice clinicians say the legislation merely allows them to operate to the full scope of their expertise and expands patients’ access to important health procedures. The measure also has the backing of physician groups, including the Maine Medical Association.

Just as state laws restricting abortion are being challenged, so are Maine’s new laws. Days after Maine’s law regarding Medicaid and abortion passed, organizations that oppose abortion rights announced they would mount an effort to put the issue on the ballot for a people’s veto.

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The federal government’s rule designed to support health workers who opt out of providing care that violates their moral or religious beliefs will not go into effect in July as scheduled. The effective date has been delayed by four months, according to court orders.

The “Protecting Statutory Conscience Rights in Health Care” rule was originally issued in May by the Department of Health and Human Services’ Office for Civil Rights. It aligns with that office’s religious freedom priorities and would put new emphasis on existing laws that give health care workers the ability to file a complaint with that office if they are forced to participate in medical care that violates their conscience — such as abortion, gender confirmation surgery, and assisted suicide.

As NPR has reported, the rule also expands the type of workers who are able to file this kind of complaint to billing staff and receptionists and anyone else who in any way “assist[s] in the performance” of a procedure.

Complaints of “conscience rights” violations are relatively rare — for a decade, the office would receive an average of one complaint like this each year. Last year, that number jumped to 343. That number is dwarfed by the number of complaints the Office for Civil Rights receives over issues like health privacy or race, sex and age discrimination, which typically number in the thousands.

Several groups sued the federal government over the rule immediately after it was issued. New York state led a coalition of 23 cities and states in one suit, and three jurisdictions in California also sued, including California state and San Francisco. Yet another plaintiff, Santa Clara County in California’s Bay Area, made the case that the rule put patient safety at risk, since it gave health workers the right to opt out of providing care without prior notice — potentially even in an emergency.

“If the rule goes through as it’s written, patients will die,” Santa Clara’s county executive, Dr. Jeff Smith, told NPR last month. “We will have a guaranteed situation where a woman has had a complication of an abortion, where she’s bleeding out and needs to have the services of some employee who has moral objections. That patient will die because the employee is not providing the services that are needed.”

Santa Clara and several other plaintiffs had filed for a preliminary injunction to prevent the rule from going into effect while the legal process played out.

“The federal government actually reached out to all the plaintiffs in all of the different cases and basically said that they didn’t want to have to deal with a preliminary injunction,” says James Williams, county counsel for Santa Clara. He says the government is seeking “summary judgment,” which means the judge could rule in its favor based on the arguments and documents it files with the court. According to Williams the government told the plaintiffs that it “would be willing to stipulate to a delay in the effective date to allow that to happen.”

That new effective date is Nov. 22 — the federal judge in the California cases made that official over the weekend, and in the New York case, the federal judge certified the change on Monday.

HHS made clear in its court filing that by agreeing to this delay, it is not suggesting that the plaintiffs are likely to succeed in ultimately blocking the rule. Instead, the agency says, it’s a logistical move.

“In light of significant litigation over the rule, HHS agreed to a stipulated request to delay the effective date of the rule until November 22, 2019,” an HHS spokesperson wrote in a statement to NPR, adding that the delay will “allow the parties more time to respond to the litigation and to grant entities affected by the rule more time to prepare for compliance.”

For plaintiffs, like Santa Clara County, the delay gives some “breathing room” while the lawsuits continue, according to county counsel James Williams.

“The delay is certainly good news because it means that this rule isn’t going to take effect and that the harms are not going to happen now,” Williams says. “But it’s just an interim step, and we’re going to be pressing forward very vigorously with getting a decision and summary judgment to vacate the rule.”

All parties are hopeful that the judges will make their decisions in these cases before the new effective date in November.

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Government officials are bickering over hundreds of millions of dollars in settlements paid by Big Pharma, stemming from the nation’s deadly opioid epidemic.

The pharmaceutical industry paid out more than half a billion dollars over the last year alone. All sides expect the scale of settlements to grow fast as more cases go to trial.

Drug companies are accused of kick-starting the addiction crisis by aggressively marketing opioid pain medications over the past two decades. During the epidemic, roughly 218,000 Americans have died from overdoses tied to prescription pain pills, according to the Centers for Disease Control and Prevention.

Federal, state and local officials have filed hundreds of lawsuits against drug companies, using different teams of lawyers, while often making substantially different claims and legal arguments.

A growing number of sources have told NPR they’re concerned that the effort to hold the pharmaceutical industry accountable could unravel into a legal fight between governments.

There’s no agreement in place for how payouts will be distributed. In recent days, feuding between local, state and federal agencies has begun to spill into the open.

In an Ohio courtroom this week, a federal judge suspended work on a plan to compensate 24,000 local governments for their opioid-related costs, after state attorneys general weighed in strongly against the proposal.

“If we get money, how are going to use it?” asked Joe Rice, an architect of the proposal, who leads a team of attorneys representing more than 1,200 local governments suing Big Pharma.

Their cases have been consolidated into a single trial set to begin in federal court in Ohio in October. “Let’s get a plan in place. Because it also has to fit together,” Rice added.

The federal judge overseeing the consolidated trial, Dan Polster, has repeatedly urged officials to come up with just such a roadmap for compensation that will hasten a “global” settlement with the drug industry.

But after Rice’s group came up with a concept that would involve every local government in the U.S. — creating a kind of super-sized class action lawsuit – state attorneys general cried foul.

“To certify a negotiation class so quickly and so early in the process, before everyone’s had a chance to determine what their best interest is, constitutes a new and novel procedure that could result in a grave miscarriage of justice,” cautioned Texas Attorney General Ken Paxton, in a June 24 letter to Judge Polster.

The letter was co-signed by 26 other state attorneys general. Judge Polster delayed action on the plan until August.

Meanwhile, the federal government has entered the money fray, seeking to garnish “a portion” of Oklahoma’s recent $270 million settlement with Purdue Pharmaceuticals.

The demand came in a June 12 letter from the Centers for Medicare and Medicaid Services, which argued that part of Purdue’s payout was meant to cover alleged Medicaid fraud, which harmed federal as well as state taxpayers.

“We are aware of the letter and are reviewing it,” wrote Alex Gerszewski, a spokesman for Oklahoma Attorney General Mike Hunter, in an email to NPR. “This will not affect state revenue,” he added.

Even within individual states there are growing tensions over how opioid money will be allocated. When Hunter won Oklahoma’s settlement with Purdue in March, he agreed unilaterally to a plan for how the money would be spent.

The lion’s share won’t go to fund programs designed to aid people who are opioid-dependent, or to help local governments struggling with the crisis. Instead, Hunter agreed to divert roughly $200 million to pay for a new addiction research center at the Oklahoma State University in Tulsa.

State lawmakers in Oklahoma were furious. “Rose petals were not strewn in my path,” Hunter acknowledged in a speech before the Bipartisan Policy Council in Washington DC last month. “There was a great consternation with me going around the appropriations process.”

Now that the federal government is asking for its slice of the money, his plan has become even more controversial.

Oklahoma’s legislature has since passed a state law requiring that future opioid settlements go into the state’s general fund. Last week, the state’s politicians narrowly averted a legal clash over an $85 million payout from another drug firm called Teva Pharmaceuticals.

This money fight is playing out against the troubled history that followed the tobacco settlements of the 1990s. Cigarette makers agreed to pay more than $240 billion to end their liability for cancer deaths caused by their products.

But much of that cash has since been diverted by government officials away from health programs and campaigns aimed to reduce smoking rates.

Critics worry that drug industry settlements could also be used to fill budget gaps or to pay for local, state and federal programs unrelated to the opioid epidemic.

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This article was produced in partnership with nonprofit news organization MLK50, which is a member of the ProPublica Local Reporting Network.

This year, a hospital housekeeper left her job just three hours into her shift and caught a bus to Shelby County General Sessions Court in Memphis, Tenn.

Wearing her black and gray uniform, she had a different kind of appointment with her employer, Methodist Le Bonheur Healthcare: The hospital was suing her for unpaid medical bills.

In 2017, the nonprofit hospital system based in Memphis sued the woman for the cost of hospital stays to treat chronic abdominal pain she experienced before the hospital hired her.

She now owes Methodist more than $23,000, including around $5,800 in attorney’s fees.

It’s surreal, she says, to be sued by the organization that pays her $12.25 an hour. “You know how much you pay me. And the money you’re paying, I can’t live on,” says the housekeeper, who asked that her name not be used for fear that the hospital would fire her for talking to a reporter.

From 2014 through 2018, the hospital system, which is affiliated with the United Methodist Church, has filed more than 8,300 lawsuits against patients, including some of its own workers. After winning judgments, it has sought to garnish the wages of more than 160 Methodist workers and has actually done so in more than 70 instances over that time, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records, online docket reports and case files.

Some of the debts were accrued while the employees worked at Methodist; others predated their time there. The figures do not include debts incurred by onetime Methodist employees who have since moved on.

It’s not uncommon for hospitals to sue patients over unpaid debts. In fact, as NPR reported Tuesday, recent research shows that more than a third of hospitals in Virginia do so. And earlier reporting from NPR and ProPublica found the practice in several other states.

But what is striking at Methodist, the largest hospital system in the Memphis region, is how many of the patients being sued are the hospital’s own employees. Hardly a week goes by in which Methodist workers aren’t on the court docket fighting debt lawsuits filed by their employer.

Between January and mid-June, a reporter observed more than a dozen Methodist employees in court to defend themselves in suits brought by the hospital over hospital bills.

That includes a Methodist Le Bonheur employee who owes more than $1,200. In January, she proposed paying $100 a month, even though her sworn affidavit listed monthly expenses that exceeded her $1,650 monthly income. After conferring with an attorney for Methodist, Judge Betty Thomas Moore agreed to the worker’s proposal, but she has already missed a payment.

A few weeks later, a Methodist employee appeared for an initial hearing wearing hospital scrubs. The hospital had sued her for more than $4,000. When she left the courtroom, she was annoyed. Her employer knew where she worked, she said, and should have contacted her before suing her.

“I don’t know why they can’t come upstairs,” she said outside the courtroom.

And in May, an employee who has worked for Methodist for more than four years carried a large envelope full of bills with her into the courtroom. She owed more than $5,400, which included a 2017 hospital charge from the newborn unit. That is the same year that her daughter was born, according to her sworn affidavit, which also listed a checking account balance of less than $4.

The woman offered to pay $10 biweekly, or $20 most months, but Methodist’s attorney wanted $200 per month. The judge ordered her to pay $100 per month.

What makes matters worse, employees say, is that Methodist’s health insurance benefits only allow employees to seek medical care at Methodist facilities, even though the financial assistance policies at its competitors are more generous.

A specialist in hospital billing practices says that if the hospital is suing a fair number of its own employees, it’s time to examine both the insurance provided to workers and the pay scale.

Given that the hospital is suing some of its own employees, “one would hope … the hospital would look at the insurance they provide workers,” says Mark Rukavina, a former nonprofit hospital consultant and currently a manager at Community Catalyst, a health care advocacy organization.

Methodist declined requests for an interview. It did not respond to specific written questions about the lawsuits it files against its workers or about how its policies reflect the values of the United Methodist Church. Instead, in a written statement, it said it is committed to working with patients who are having trouble paying their medical bills.

“As the second largest private employer in Shelby County, we recognize the responsibility we have as an organization to contribute to the success of the diverse communities we serve and are purposeful about creating jobs in our community — intentionally choosing to keep services like printing, laundry and others in-house that are typically outsourced by the health care industry,” the hospital said.

Methodist also declined to answer a question about whether it has any policy that prohibits employees being sued by Methodist from talking to a reporter about the lawsuits filed against them by the hospital.

Employer and legal adversary

On a single January day, there were 10 defendants on the docket whose place of employment was listed in court records as Methodist.

Employees in scrubs sat just feet away from the attorneys in dress suits — attorneys their employer had hired to sue them. The hospital’s role as a tax-exempt organization that both employs the defendants and is suing them went unremarked upon by judges, attorneys and the defendants themselves.

Methodist’s financial assistance policy stands out from peers in Memphis and across the country, MLK50 and ProPublica found. The policy offers no assistance for patients with any form of health insurance, no matter their out-of-pocket costs. Under Methodist’s insurance plan, employees are responsible for a $750 individual deductible and then 20% of inpatient and outpatient costs, up to a maximum out-of-pocket cost of $4,100 per year.

The housekeeper’s story is documented in Shelby County General Sessions Court records, including online docket reports and online payment history. A reporter interviewed the housekeeper multiple times in person and on the phone. The employee gave the reporter six years of itemized Methodist hospital bills, her credit report and other past-due medical bills. Most of her debts were incurred before she started working at Methodist.

Five times between 2012 and 2014, she visited the hospital for stomach problems, according to the itemized bills. (Years later, she had surgery to treat diverticulitis.) At those times, she had insurance through her job at a hotel, where she cleaned rooms for $10.66 an hour. After insurance paid its share, she owed just over $17,500.

In 2015, the housekeeper left the hotel job and lost her insurance. Three times that year she went to Methodist’s ER, but since she was uninsured and had little income, she qualified for financial assistance. Methodist wrote off more than $45,000 in hospital bills.

In a statement, Methodist said it gives an automatic 70% discount to uninsured patients and free care to uninsured patients at or below 125% of the federal poverty guidelines. For a single adult with two dependents, that would be just over $26,600. Uninsured patients who earn more than that, but less than twice the poverty limit, are also eligible for discounts, it said.

In 2016, unable to find work, the housekeeper left Memphis. For more than a year, she says, she and her son were homeless, bouncing between relatives in Chicago, where she was born, and Texas.

But she missed her daughter and grandchildren in Memphis. So in 2017, she returned. In August 2017, Methodist sued her for the bills she accumulated when she was insured years earlier. Later that month, she was hired at a Methodist hospital, starting at $11.95 an hour.

The hospital’s collections agency, which it owns, didn’t have her correct address and was unable to serve notice that she had been sued, but last year, Methodist tried again. This time, it had the right address.

In November, a process server handed her the civil warrant at her South Memphis apartment.

At the process server’s recommendation, she called the hospital’s collection agency and offered to pay $50 every two weeks. “But they said it wasn’t enough,” she recalls. “I would just have to go to court. They said I’d be owing them all my life.”

In a sworn affidavit filed with the court this year, the housekeeper listed her dependents as a grandson and her 27-year-old son, who she says has bipolar disorder and schizophrenia. She told the court she earned $16,000 in 2017, which puts her more than $4,000 below that year’s federal poverty level for a family of three. (Because she had insurance, though, she was ineligible for assistance under the hospital’s policy.)

Fred Morton, a retired Methodist minister in Memphis, says he was surprised to learn that Methodist is suing its own employees.

“The employees should be paid an adequate minimum wage at the very least,” he says. “Certainly they should not be predatory to their own employees on medical bills. That’s very much contrary to Scripture.”

He said that Methodist bishops who serve on its board bear responsibility for reminding it of the denomination’s values.

“It’s a matter of the church pushing on its own,” Morton says.

Three United Methodist Church bishops serve on the hospital’s board. Bishop Gary Mueller’s office referred a reporter to Methodist Le Bonheur Healthcare’s communications office. Bishop Bill McAilly declined to comment. Bishop James E. Swanson did not respond to multiple requests for comment.

When the housekeeper appeared before a General Sessions Court judge this year, she’d filed a motion offering to pay $50 biweekly, or $100 in most months. When the hospital’s attorney asked for a $200 per month, she was stunned.

“This is my only job, this is my only income, so how am I supposed to live?” she remembered thinking.

Nervous that the judge would side with the hospital, the housekeeper made another offer.

“I could do $75 every two weeks,” she said quickly.

The attorney agreed and the judge signed the order.

Being an employee and defendant is “really kind of sad,” the housekeeper says. Asked how she manages to make ends meet, she says she doesn’t: “It’s killing me — killing me softly.”

She says she didn’t reach out to the hospital’s payroll department or a manager about the hospital bills she’s being sued for. “They don’t care about that. … That I do know.”

‘I don’t want to be homeless again’

Part of what makes paying medical bills so hard for some Methodist employees is that their wages are low, lagging behind several other large employers in the Memphis market. In December, St. Jude Children’s Research Hospital announced it was raising its minimum pay for full and part-time workers to $15 an hour. St. Jude’s decision followed a similar commitment by the Shelby County government, Shelby County Schools and Blue Cross Blue Shield of Tennessee.

At Methodist, which operates five hospitals in Shelby County, the lowest-paid employees make $10 an hour and about 18% of workers make less than $15 an hour, the hospital reported in response to MLK50’s 2018 Living Wage Survey.

As recently as 2017, the Greater Memphis Chamber advertised on its website that the city offered a workforce at “wage rates that are lower than most other parts of the country.”

The United Methodist Church’s Social Principles, which state the denomination’s position on everything from climate change to the death penalty, speak directly to what employees should earn. “Every person has the right to a job at a living wage,” it states. The Living Wage Model statement on the church’s website says, “Exploitation or underpayment of workers is incompatible with Christ’s commandment to love our neighbor.”

Methodist, which made Forbes’ 2019 list of Best Employers by State, did not answer specific questions about pay for employees. On its website, it says, “It is the policy of Methodist Le Bonheur Healthcare to pay its employees competitive, market-based wages.”

Neither Methodist, nonprofit Baptist Memorial Healthcare nor Regional One, the public hospital, pay all their employees at least $15 an hour. Even that figure would make it impossible to make ends meet for an employee trying alone to support a household with dependents, according to MIT’s Living Wage Calculator and another created by the Economic Policy Institute, both of which take into account local living expenses.

The housekeeper’s $12.25 an hour pay falls well short of that. Without overtime, she says, her take-home pay would be around $1,600 per month. Her rent is $610.

Even with as much overtime as she gets, she’s turned to payday loans. Since December, she’s renewed a $425 payday loan every two weeks, paying $71 each time. “You have to rob from Paul to pay Peter,” she says. “It doesn’t never seem like you can get ahead.”

The housekeeper applied for a job at Walmart but was told the store nearest her is not accepting applications. She doubts the pay will be any better, but she hopes it will be less stressful.

“Times be hard, because sometimes my body feels like I can’t make it,” she says. “But I get up anyway, because I don’t want to be homeless again.”

Wendi C. Thomas is the editor of MLK50: Justice Through Journalism. Email her at wendicthomas@mlk50.com and find her on Twitter at @wendi_c_thomas.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

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There’s a green van parked on the edge of downtown Miami on a corner shadowed by overpasses. The van is a mobile health clinic and syringe exchange where people who inject drugs like heroin and fentanyl can swap dirty needles for fresh ones.

One of the clinic’s regular visitors, a man with heavy black arrows tattooed on his arms, waits on the sidewalk to get clean needles.

“I’m Arrow,” he says, introducing himself. “Pleasure.”

This mobile unit in Miami-Dade County is part of the only legal needle exchange program operating in the state. But a new law in Florida — a needle exchange law that won the support of Florida’s conservative legislature, and was signed by Gov. Ron DeSantis Wednesday — aims to change that.

Needle exchanges have been legal in many other states for decades, but southern, Republican-led states like Florida have only recently started to adopt this public health intervention.

The timing of the statewide legalization of needle exchanges comes as Florida grapples with a huge heroin and fentanyl problem. When people share dirty needles to inject those drugs, it puts them at high risk for spreading bloodborne infections like HIV and hepatitis C. For years, Florida has had America’s highest rates of HIV.

Even so, Arrow says he and every user he knew always put the drugs first. Clean needles were an afterthought.

“Every once in a while, I did use someone else’s and that was a thrill ride — wondering whether or not I was going to catch anything. But I’m blessed; I’m 57 and I don’t have anything,” says Arrow, whose full name NPR has agreed not to use because of his use of illegal drugs.

“Now I can shoot with a clean needle every time,” he says.

The Miami experiment

According to the Centers for Disease Control and Prevention, needle exchanges prevent the spread of viruses among users of injection drugs.

But the advocates who want to offer needle exchanges face challenges. For example, carrying around loads of needles to hand out without prescriptions can violate drug paraphernalia laws. Many states mapped out legal frameworks decades ago to handle this particular public health intervention. But it was illegal to operate exchanges in Florida until 2016. That’s when the state legislature gave Miami-Dade County temporary permission to pilot a needle exchange program for five years.

“This is more than just a needle exchange,” says Democratic state senator Oscar Braynon. “This has become a roving triage and health center.”

Braynon has been sponsoring needle exchange bills — including the bill for the pilot project — since 2013. This year he introduced Senate Bill 366 to allow the rest of Florida’s counties to authorize similar programs.

In three years of operation, Miami’s pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health. By handing out Narcan — the drug that reverses opioid overdoses — the exchange has prevented more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C, which is how Arrow knew he was negative. Finally, the program connects people to medical care and drug rehab.

“We have made it so easy for people to get into HIV care now, and we have so many people who we never would have known were infected — and would have infected countless other people — who are on their medications,” says Dr. Hansel Tookes, head of Miami’s needle exchange pilot program He has been pushing legislators to legalize needle exchanges since he was a medical student six years ago.

Tookes was in Tallahassee, the state capital, this May when the expansion bill passed its final vote. He said he spent the return flight home to Miami staring out the window.

“I looked down at Florida the entire ride,” he says, “and I just had this overwhelming feeling like, ‘Oh my God, we just did the impossible and we’re going to save so many people in this state.’ “

Why harm reduction trumped politics

When Republican state senator Rob Bradley first deliberated over needle exchanges in Florida six years ago, he was critical.

“You’re trying to make sure the person has a clean needle, which is outweighing the idea of the person breaking the law,” he declared back in 2013, before casting his vote against the idea.

This is the primary objection of conservative lawmakers — the concern that these programs promote illegal drug abuse.

Responding to this skepticism with data has been central to changing lawmakers’ minds. Decades of research show needle exchanges do not encourage drug abuse, and that they lower other health risks to people who are vulnerable and often hard to reach. It’s part of a public health approach known as “harm reduction.”

At a recent meeting ahead of the vote on statewide legalization, Ron Book — a powerful Florida lobbyist who chairs the Miami-Dade County Homeless Trust — voiced a question that comes up a lot about the needle exchange and heroin use.

“Doesn’t that help encourage it?” he asked Tookes.

“Nobody who used our program — and we collect a lot of data — was a first-time user of opioids when they came there,” Tookes told him. “Not one person.”

In Miami, the needle exchange pilot project has also earned the support of law enforcement. Officers say it’s a relief to know more injection drug users are keeping their syringes in special sharps containers, provided by the exchange, to safely dispose of dirty needles.

“Now, for our officers, when they’re doing a pat down … that sharps container is really protecting you from a loose needle 100 percent of the time,” says Eldys Diaz, executive officer to the Miami Chief of Police. “That’s an extraordinary source of comfort for us.”

This year, when state senator Bradley heard discussion of the needle exchange bill again, he had a different response.

“I just want to say, when I started my career in the Senate, I voted against the pilot project — and I was wrong,” he said as he voted for the bill this time. “And the results speak for themselves. It’s very good public policy.”

The state’s new needle exchange law passed unanimously in the Florida Senate and 111 to 3 in the Florida House, and goes into effect July 1.

Arrow gets a future

If it weren’t for the tattoos running down his arms, it would be hard to recognize Arrow as the man who once slept under highway overpasses. His skin is now clear, and he has some meat on his bones — he looks healthier.

“How have you been?” Tookes asks, greeting Arrow at a clinic where needle exchange clients can get follow-up care.

“Wonderful,” Arrow says. “I feel good.”

He looks and feels better, but it’s been a rough year.

Last May, Arrow’s girlfriend died from a heart infection — a serious condition that can happen to people who inject drugs. After that, Arrow says, he overdosed on purpose. Narcan from the needle exchange brought him back.

But he kept using.

Arrow says he doesn’t remember a lot from this period, but does remember using so much heroin that he ran out of fresh needles between visits to the exchange. So he grabbed other people’s used needles.

And then he tested positive for HIV and hepatitis C.

Tookes and his colleagues threw Arrow another life raft: They got him an inpatient drug treatment bed.

At Arrow’s checkup with Tookes, a string of keychains from Narcotics Anonymous clicked at his waist.

“My chain of sobriety,” he says of the links. “I got 30-days, 60-days, and 90-days chips,” he says.

Arrow’s HIV is under control. And he’s connected to health services for people living with HIV, including getting medication that cured his hepatitis C.

Now, he’s focused on staying sober, one day at a time. And he’s starting to want new things. “Thanks to this man right here,” he says, nodding to his doctor — Tookes.

As more Florida counties elect to begin needle exchanges, there’s no guarantee that every person who turns to them will get as far as Arrow. But Tookes, Braynon and other supporters hope such services will at least give more people the chance to recover from addiction — and protect themselves from needle-borne illnesses.

This story is part of NPR’s reporting partnership with WLRN and Kaiser Health News, a nonprofit news service of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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Today, antiretroviral medicines allow people with HIV, the virus that causes AIDS, to live long, productive lives. But at the onset of the AIDS epidemic in the early 1980s, the disease was considered a death sentence. No one was sure what caused it or how it was spread. Some doctors and nurses refused to treat patients with the disease; others protected themselves by wearing full body suits.

Cliff Morrison, a nurse at San Francisco General Hospital at the time, remembers being appalled by what he was seeing: “I would go in patients’ rooms and you could tell that they hadn’t had a bath,” he says. “They weren’t being taken care of.”

In 1983, Morrison organized a team of healthcare providers to open Ward 5B, an in-patient AIDS special care unit at San Francisco General Hospital. The medical team on the unit encouraged patients to make their rooms like home, and allowed families and partners to visit whenever they could. They comforted patients by touching them, and would even sneak in pets.

5B was the first unit of its kind in the nation — and it became a model for AIDS treatment, both in the U. S. and overseas. Now, a new documentary, called 5B, tells the story of the doctors and nurses who cared for patients on the ward.

Dr. Paul Volberding was a doctor on Ward 5B and went on to co-create an AIDS clinic at the hospital, which was one of the first in the country. He emphasizes how critically ill the patients on the unit were.

“These were people that were really, sometimes literally, dying when they came into the hospital, so whatever we could do to make them more comfortable was really important,” he says.

The work on 5B was emotionally draining, and death was a constant reality. Still, Volberding describes his time there as a “blessing.”

“The care that patients were getting was really special and very different than the rest of the hospital,” he says. “It was always a complete privilege to do this work.”

Morrison adds, “I had some really wonderful experiences with people in their passing, and they taught me a great deal. It really put in perspective the fact that life is on a continuum, and death is just part of that continuum. I saw people have beautiful deaths, and that was wonderful.”

Interview highlights

On how everyone who came into the hospital with the virus in the early 1980s died

Volberding: I don’t think most people can understand today how devastating a disease AIDS was back in those days. … It’s just impossible to appreciate that HIV, if it’s untreated, kills essentially 100 percent of the people. It’s much worse than Ebola, much worse than smallpox. So, everyone died. Every patient that was sick enough to come to us to look for medical care would die from this disease. And people knew that there was a lot of education to be done, but they knew that this was a really bad situation.

On how they didn’t know if what they were seeing was infectious when the first patients came in with the rare cancer, Kaposi’s sarcoma, which ended up being one of the symptoms of the as-yet-unknown AIDS virus

Volberding: I wasn’t worried about catching anything from the patients because that’s not what I expected in taking care of cancer patients. I didn’t expect to be worried about anything, and wasn’t really. But the care that the patients were getting was pretty spotty in the hospital. I think that was one of the things that led Cliff and the others to really put together the nursing unit.

Morrison: In my experience, in already what had been seen and what I was hearing from the specialists around us with the information that was coming out, was that I wasn’t at risk providing care to people by touching people. And everybody around us was saying, “Oh you’re just being cavalier. This is really not what you should be doing, and you’re giving the wrong message.” And our response always was, “We’re giving the right message.” So we were dealing with a lot of hysteria and misinformation and just outright discrimination, I think, very early on.

On expanding the hospital’s family and visitors’ policy for Ward 5B

Morrison: We also noticed right away … that we needed to really look at issues around family and visitation, because healthcare was very rigid and was really stuck on this whole idea [regarding] visiting hours that it could only be immediate family. Most of our patients didn’t have family around. … We almost immediately began talking about, in all of these regular meetings and sessions that we had, that maybe we needed to start letting our patients tell us who their family was, and that we needed to kind of move away from this whole idea of traditional family and biological family.

Volberding: I think that the patients were so sick — and they were so in need of support — that the idea of visiting hours and keeping people away didn’t make sense.

Morrison: There were times when they were alone in their rooms and they always needed something. They were very anxious. It not only made them more comfortable, it made our lives a lot easier having people that were there in the rooms most of the time.

On the bond that existed among 5B staff members

Volberding: It was a family. The physicians, the staff and the clinic and in the inpatient unit — we all worked so closely together because those were our patients. As physicians, those were our patients. And we were on the unit every day seeing our patients, and it was, again, a very special group of people.

On how the homophobia of the time influenced patient care

Morrison: That was, I think, probably the most glaring reality of the situation. Even in San Francisco — which, even at that time was considered the gay mecca — gay people had very established careers and homes and families, and yet all of that started coming apart. And it really was centered around homophobia. There were people in the hospital that should have known better. … There was a group of nurses that basically said that what we were doing was crazy and that we were putting all of them at risk. It went before the labor board — but that was all homophobia.

On the evolution of AIDS treatment

Volberding: In 1987 we began to have some drugs that were doing something. … And then, by 1996, the so-called triple therapy was developed and that was really a turning point in the epidemic. We could suddenly start seeing some of our patients actually get better — not just die more slowly, but actually get better.

And some of those people are still alive today. The effort since ’96 has been to take those potent drugs and make them less toxic and more convenient. Today, we treat this very typically with what we call single tab regimens — one pill taken once a day that contains two, three or even four drugs — all in the same pill. Many of my patients don’t have any side effects at all from the medicines they’re taking. The change from the early days, and seeing the drugs being developed, and now seeing that this is truly a chronic condition is, I think, one of the most amazing stories we’ll ever hear from in medicine.

Amy Salit and Mooj Zadie produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the Web.

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