Bloodwork was supposed to be the last step in Isela’s application for life insurance. But when she arrived at the lab, her appointment had been canceled.

“That was my first warning,” Isela says. She contacted her insurance agent and was told her application was denied because something on her medication list indicated that Isela uses drugs. Isela, a registered nurse who works in an addiction treatment program at Boston Medical Center, scanned her med list. It showed a prescription for the opioid-reversal drug naloxone — brand name Narcan.

“But I’m a nurse, I use it to help people,” Isela remembers telling her agent. “If there is an overdose, I could save their life.”

That’s a message public health leaders aim to spread far and wide. “BE PREPARED. GET NALOXONE. SAVE A LIFE,” was the message at the top of a summary advisory from the U.S. surgeon general in April.

But some life insurers consider the use of prescription drugs when reviewing policy applicants. And it can be difficult, some say, to tell the difference between someone who carries naloxone to save others and someone who carries naloxone because they are at risk for an overdose.

Primerica is the insurer Isela says turned her down. (NPR has agreed to use just Isela’s first name because she is worried about how this story might affect her ongoing ability to get life insurance.) The company says it can’t discuss individual cases. But in a prepared statement, Primerica notes that naloxone has become increasingly available over the counter.

“Now, if a life insurance applicant has a prescription for naloxone, we request more information about its intended use as part of our underwriting process,” says Keith Hancock, the vice president for corporate communications. “Primerica is supportive of efforts to help turn the tide on the national opioid epidemic.”

After Primerica turned her down, Isela applied to a second life insurer and was again denied coverage. But the second company told her it might reconsider if she obtained a letter from her doctor explaining why she needs naloxone. So, Isela did contact her primary care physician — and then realized that her doctor had not prescribed the drug.

Isela had bought naloxone at a pharmacy. To help reduce overdose deaths, Massachusetts and many other states have established a standing order for naloxone — one prescription that works for everybody. Isela couldn’t just give her insurer that statewide prescription; she had to find the doctor who signed it. As it happens, that physician — Dr. Alex Walley — also works at Boston Medical Center.

Walley is an associate professor of medicine at Boston University; he also works in addiction medicine at Boston Medical Center and is the medical director for the Opioid Overdose Prevention Pilot Program at the Massachusetts Department of Public Health.

“We want naloxone to be available to a wide group of people — people who have an opioid use disorder themselves, but also [those in] their social networks and other people in a position to rescue them,” Walley says.

He says he’s written a half dozen letters for other BMC employees denied life or disability insurance because of naloxone, and that troubles him.

“My biggest concern is that people will be discouraged by this from going to get a naloxone rescue kit at the pharmacy,” Walley says. “So this has been frustrating.”

The life insurance hassle — and threat of being turned to down — has discouraged Isela and some of her fellow nurses. She is not carrying a naloxone kit outside the hospital right now because she doesn’t want it to show up on her active medication list until the life insurance problem is sorted out.

“So if something were to happen on the street, I don’t have one — just because I didn’t want another conflict,” Isela said.

BMC has alerted the state’s Division of Insurance, which has said in a written response that it is reviewing the cases and drafting guidelines for “the reasonable use of drug history information in determining whether to issue a life insurance policy.”

But Isela isn’t a drug user. And yet, she is being penalized as if she were.

Michael Botticelli, who runs the Grayken Center for Addiction Medicine at BMC, says friends and family members of patients with an addiction must be able to carry naloxone without fear that doing so will send them to the insurance reject pile.

“It’s incumbent on all of us to make sure that we try to kind of nip this in the bud,” he says, “before it is any more wide-scale.”

Botticelli says increased access to naloxone across Massachusetts is one of the main reasons overdose deaths are down in the state. The most recent state report shows 20 fewer fatalities this year compared to last.

Botticelli relayed his concerns in a letter to Dr. Jerome Adams, the U.S. surgeon general, who says he contacted the National Association of Insurance Commissioners. That group says it has not heard of any cases of life insurance applicants being denied because they purchased naloxone.

Adams says it’s good to, as Botticelli suggests, nip the problem in the bud.

“Naloxone saves lives,” Adams says, “and it is important that all Americans know about the vital role bystanders can play in preventing opioid overdose deaths when equipped with this lifesaving medication.”

Isela says the second company that rejected her has agreed to let her reapply, in light of Walley’s letter stating that she carries the drug so that she can reverse an overdose. Isela is in the process of reapplying.

This story is part of a reporting partnership with NPR, WBUR and Kaiser Health News.

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Tim Green first noticed the symptoms about five years ago.

The former NFL player, whose strength was a job requirement, suddenly found his hands weren’t strong enough to use a nail clipper. His words didn’t come out as fast as he was thinking them.

“I’m a strange guy,” Tim says. “I get something in my head and I can just run with it. I was really afraid I had ALS. But there was enough doubt that I said, ‘Alright, I don’t. Let’s not talk about it. Let’s not do anything.’ “

Denying pain and injury had been a survival strategy in football.

“I was well trained in that verse,” he says.

But a diagnosis in 2016 made denial impossible. Doctors confirmed that Tim, also a former NPR commentator, had ALS, known as Lou Gehrig’s disease. The degenerative illness attacks the body’s motor nerve cells, weakening muscles in the arms and legs as well as the muscles that control speech, swallowing and breathing.

Tim tried to keep it private — he didn’t want people feeling sorry for him.

But he says, “I got to a point where I couldn’t hide it anymore.”

So Tim went on 60 Minutes and revealed his illness.

“What we said is, you either write your own history or someone’s going to write it for you,” says his 24-year-old son, Troy Green.

When one isn’t enough

I was one of Tim Green’s producers for his Morning Edition commentaries back in the 1990s. We went to dinner once when he was in Washington, D.C., for a game — his Atlanta Falcons were playing Washington. Tim had a huge plate of pasta. When we finished, the waiter came over and asked, “Anything else?” Tim pointed to his clean plate and said, “Yeah. Let’s do it again.”

That was him. One entree wasn’t enough. One high-profile career wasn’t enough — he’s also a prolific author, has a law degree and works for two firms.

And ultimately, it wasn’t enough for Tim to deal with ALS in silence. Last month, in conjunction with his 60 Minutes appearance, Tim helped launch a fundraising website, Tackle ALS.

Writing his own story

I recently visited Tim at his lakeside home in upstate New York, in the village of Skaneateles.

We sat down in a room with a huge picture window that normally offers a gorgeous view of Skaneateles Lake. On the day I visited, all you could see was driving snow. Troy Green sat next to his dad — Tim’s speech is slow and raspy, and sometimes Troy helps repeat or reinforce Tim’s words. During our talk, a tube connected to a port in Tim’s chest provided an infusion of Radicava. Last year, the FDA approved the new drug, which has been shown to slow the progress of what’s currently a fatal disease.

The history Troy encouraged Tim to write is positive and hopeful. They stress that ALS can be cured, it’s just underfunded.

The history certainly includes family. Tim and his wife Illyssa have been married for 29 years. They have five kids — all with first names starting with “T” — that’s Illyssa’s doing, Tim says. And the family is incredibly close. Literally.

“My brother lives on the same lane as us. I’m their neighbor,” Troy says, adding, “My little sister’s at school, my little brother lives here and then my older sister lives the furthest away. She’s about a three-minute drive.”

“We’re going to reel her in,” Tim laughs.

Football, a complicated love

Of course, any Tim Green history has to include football.

For better and worse.

Tim believes football gave him the disease. His eight years in the NFL in the 1980s and 90s, as a defensive lineman and linebacker, were before protective rule changes and concussion protocols.

There were “countless” head collisions, Tim says. I mention that he had decades of those collisions, from an early age through the NFL.

“But in the NFL,” he says, “the violence and the impacts are extraordinary. Every day.”

Troy adds, “when [Tim] played, practices were worse than the games. Because in the game, you typically would see 45 to 65 plays. In practice, you could run 100, 200 by the time you’re done with drills.”

Researchers say repetitive head blows may play a part in causing ALS. The recent NFL concussion settlement acknowledged a link by including payouts to former players with the disease, including Tim.

His Morning Edition commentaries regularly took listeners inside the violent game. In 1992, Tim wrote one about a teammate, former Atlanta defensive end Rick Bryan, who’d had enough of the physical toll and was retiring.

The piece ended with this:

“Back at the locker room, I checked my protective neck padding and pumped some extra air into the padding of my helmet. Like a gypsy gazing into a crystal ball, I looked at my own distorted reflection in the glossy black surface of my helmet. The smile let me know I was glad to be there, but there was nothing I could see that told me how long it would last.”

Tim could articulate what many players couldn’t. Why, I asked him, with his insights, would he play a sport that had the potential to do permanent damage?

Tim says as a kid, he had two passions: writing and football. From the earliest age, he says, he worked incredibly hard to succeed at both, and he did.

“I was just impassioned,” he says. “That’s what I wanted, and that’s what I got.”

“If [this disease] is part of the bargain, I don’t know,” he continues. But back then, he says, he had “no idea” of the potential long-term damage of football. “So the temporary pain and discomfort, I knew that was worth it. Some pain in the future with my back, neck, knees, I knew that was worth it.”

“Can I say getting ALS was worth it? I don’t know. I don’t know.”

His ambivalence illustrates Tim’s profound and complicated love for the game. Still. He says it gave him the disease. But it also taught him so many life lessons growing up. It allowed him to vent anger and violence in an acceptable way.

“I’m not indicting football or the NFL,” he says.

He passed on his love — his two oldest sons played football. His 12-year-old, Ty, plays now. And it has split the close-knit Greens. Illyssa doesn’t like it. Tim says he wants Ty to play if he wants to.

Tim and Troy say the game now is different than it was. It’s much safer with less contact in practice. Both of them coached Ty’s junior team.

“We trained [so in] every tackling drill your head’s out of the play,” Troy says. “In practice we would penalize our players if they had their head in the drill. We really just encouraged the modern day football, not the 1980s edition.”

Still, football is inherently dangerous, and so far Ty wants to play.

“I don’t want to wrap him up in a bubble,” says Tim, “because where do you stop?”

But there’s a deeper, more complex reason behind Tim’s support. Troy says his dad doesn’t want the illness to be a burden on anyone. So Tim doesn’t want Ty not to play just because the game hurt him.

Translating science into treatment

“I do want to point out that most people who play football don’t develop ALS.”

So says Dr. Merit Cudkowicz, who treats Tim’s disease. Cudkowicz has researched ALS for nearly 25 years. She thinks football probably is a factor that led to his illness, but not the only one. The studies so far haven’t established a direct cause and effect.

“And that’s why we think there’s something else,” Cudkowicz says. “It’s a combination perhaps in someone’s immune system or something in their genetics that makes it more likely that if you also hit your head repetitively that you might come down with the disease.”

Cudkowicz directs the Healey Center for ALS at Massachusetts General Hospital in Boston. She says Tim’s and other prominent people’s involvement and publicity present a great opportunity, as a follow up to the viral ice bucket challenges that raised money for ALS a few years ago.

“Absolutely I think this is a huge next step,” Cudkowicz says. “The ice bucket challenge came at the right time. The science was exploding, but there were no resources for it. And suddenly there’s this $220 million resource for ALS, and it fed this great science and drew in all these new people and new companies for the field.”

“But there’s still a [funding] gap in getting that great science to patients. And that’s where Tim’s Tackle ALS initiative and the Healey Center are going to partner and hopefully with many other groups, translate that great science into treatment for people.”

‘If you have a good life, it’s never long enough’

Later, on the day I visited, Tim sat down at a desk in a large wood-paneled den, indulging his other passion in life — writing.

He can’t type, so he has a sensor on his glasses that highlights letters. Then he clicks a mouse and the letters show up on his laptop screen. He’s working on a kid’s baseball book. It’s a third collaboration with former New York Yankees star Derek Jeter, and Tim says they both provide specific areas of expertise. Jeter brings baseball realism to the book; Tim draws on his many years of being surrounded by young people. Disgusting young people, he laughs.

“These are kids 10 to 14 years old. Tweens,” he says. “They think vomit is funny. [So] somebody has to throw up [in the book], and it’s best when they throw up on someone.”

“Writing [these scenes] is easy. It’s convincing Derek to keep them is where I earn my money.”

On cue, Troy looks up from his phone and makes an announcement.

“Just got an email that Jeter, and [his] Turn 2 Foundation donated $10,000 [to Tackle ALS]. His ears are ringing,” Troy says, laughing. “He heard about the vomit scenes!”

Tim says the fundraising is a chance to help others. He says he’s one of the luckier people with the disease. It’s relatively slow-moving.

I ask Tim what keeps him positive through this time. He answers by recounting a period 12 years ago, when Illyssa was diagnosed with cancer.

“She was out of her mind,” Tim says, “and I remember saying to her, ‘You’ve got great doctors, we’re gonna beat this and do everything we can. But in the meantime, I don’t want you to wallow in fear and anxiety and misery.’ I said, ‘because we have a very good life and if you have a good life … and a lot of people do, maybe they don’t realize it, but they do … but if you have a good life, it’s never long enough. We all know it’s finite.’ “

“So whenever the end point is, I ask to be strong enough to maintain that positive attitude no matter what the challenges are.”

Today, Illyssa is cancer-free. And it’s Tim trying to live by his own advice.

As I leave, I stop to look at two large sculptures outside their house. One is of five kids, playing. The other is a lone figure. A helmeted football player, running and catching a pass over the shoulder. Tim says it’s an homage to the game that let him “buy this amazing property and build a comfortable home.”

A home, and family, that now mean even more than they have all along.

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Lindsay Bunker woke up from a nightmare.

The 32-year-old lives with her sixth-month-old daughter on the Lac Courte Oreilles Indian Reservation in northern Wisconsin. She’s struggled with addiction for over 10 years, mostly to heroin. Then came the nightmare: She dreamt two men were attacking her baby while she could think only about drugs.

“In my mind I was thinking, ‘If I can just get one hit, if I can get one line, I can save her,'” she recalls, pausing before continuing, “I woke up and I was panicking. How can a mother think like that?”

It was a wake-up call. Bunker says she realized in that moment that heroin was “evil” and she resolved to get into treatment. In a lot of rural America, that’s where the story could have ended.

Many rural communities lack basic resources for substance abuse. There are fewer services available than in urban areas—as many as 82 percent of rural Americans may live in counties that lack detoxification services, for example.

But Bunker was lucky. She found a community health center only about an hour from her home that recently expanded its addiction treatment services.

The clinic, NorthLakes Community Clinic,serves Medicaid and Medicare patients, and offers sliding scale payments for those with low-income. It expanded its addiction recovery program with the help of state and federal grants targeting opioid use. Though rural communities across the country struggle with addiction, community health centers like this one are modeling an approach to managing — and funding — treatment programs.

“We were seeing substance use disorders killing our community and we felt it was our job to step up,” says Reba Rice, the clinic’s CEO. “We feel that all of our patients and community members deserve a life worth living.”

Not just opioids

Rice says addiction has torn apart rural communities in Northern Wisconsin in the last five years or so, with an increase in crime, problems in schools, trauma in families.

“It was amazing how many things we were seeing changed,” she says. “The way people looked at each other, the level people were willing to trust each other, and it was all about the changes that this disease makes on its victims”

A recent poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health shows that opioid and other drug abuse is the top health concern for rural Americans.

NorthLakes has long provided primary care, dental and behavioral health services for low-income residents in Ashland, Wisconsin, and in several nearby towns. But as the opioid addiction problem worsened, Rice says she felt a responsibility as a health care provider to do something about it.

“We contributed to the problem so we needed to contribute to the solution,” she says.Rice says opioids were just part of the puzzle: meth and alcohol were huge problems too. In fact, meth use in Wisconsin it has grown by 250 percent in recent years, according to the FBI. But new funds were becoming available for opioid treatment so the clinic applied for those — and is using them to build a comprehensive addiction treatment program that addresses all the substances people there struggle with.

To fund its expanded addiction treatment services, NorthLakes applied for and won a grant from the state of Wisconsin three years ago. It also got other federal grants intended for mental health and addiction. Central to their plan was hiring a physician who could lead the new program, and could prescribe the addiction treatment buprenorphine, known by the trade-name Suboxone.

Suboxone treatment is one of the most effective ways to treat opioid addiction. But it is hard to find in rural areas, because only providers who’ve received special training are allowed to prescribe it. One 2015 study found that more than 80 percent of rural counties in the U.S. do not have a single physician able to prescribe it.

NorthLakes found a physician who could prescribe it and more than that, who had a vision for a comprehensive addiction program.

Building treatment capacity

Dr. Mark Lim says he is surprised he’s here in this 8,000 person port-town on Lake Superior. He’d dreamed of living in a big city since he moved to the U.S. from the Philippines. When he got the call about the job, he was hesitant at first. “I didn’t know where that was on a map,” he recalls.

But he saw this part of Wisconsin, where the death rate from drug and alcohol abuse is nearly twice as high as the state average, as a place where he could make a difference.

Lim’s been board certified in addiction medicine since it was officially recognized as a subspecialty in 2016, but he’s been working in the field since about 10 years ago when he started working in an addiction practice in Maine.

He took the Wisconsin job, with one stipulation: He would start a program to address addiction as a whole. His expertise would be just one part of the treatment approach.

“If I’m just going to be the Suboxone doctor I’m not doing the full practice of addiction,” Lim says.

Because while the medication can be effective for treating opioid use disorder, Lim says addiction is not just about opioids.

“Opioids are big right now,” Lim says. “But you have to work with alcohol too. You have to work with marijuana too. You have to work with methamphetamine, cocaine.”

Rice says she and Lim developed the program together with community partners including educators, law enforcement and tribal leadership. “We were successful because we had a vision for creating a program and so did he,” Rice says.

While it’s rare to have a doctor who can prescribe Suboxone in a rural area like this one, Lim says only about 40 of his more than 200 patients take it. For the rest, his program relies on a combination of counseling, group therapy for addiction and underlying mental health issues, and case management. Staff help to remove barriers to being successful in recovery, helping patients with things like, transportation to the clinic, daycare for parents during therapy, and even job placements.

This kind of recovery program that combines clinical and counseling services is exactly what rural communities need, says John Gale of the Maine Rural Health Research Center.

“That’s exactly the way it should be done. Because most people with a substance use disorder have co-occurring mental health and substance use problems,” Gale says. “If we take care of [a patient’s] heroin problems and we don’t treat the underlying mental health and substance abuse problems, they’re going to go to go to alcohol, they’re going to do something else.”

And while most of the attention and dollars are focused on opioid abuse right now, he says rural communities struggling to address addiction can use those resources to build a larger treatment capacity.

“They can use [those resources] to say, ‘Wait a minute, let’s build a treatment capacity for other people,’ ” Gale says. “And they begin to create a community where you can treat all sorts of substance use disorders.”

Lindsay Bunker gets a ride to and from the NorthLakes clinic from a medical transportation company — it’s about an hour’s drive each way from the reservation. The clinic has a baby sitter who looks after her daughter when Bunker is in appointments. She makes the trip nearly every day.

“I love being here. I feel safe. I feel strong. I feel supported,” Bunker says.

But she only sees Dr. Lim about once a week. Instead, like all of the patients here, she spends most of her time in one-on-one and group counseling sessions. There’s the early relapse prevention group (from which Bunker recently graduated), then there’s the relapse recovery group, the family group, the engaged-in-recovery group. There’ll be a trauma group soon as well.

Bunker says those group sessions are really important in helping her stay in recovery.

“I get cravings and the cravings are being taken away with that medicine [suboxone]. But being here with my peers, I love it. I really do,” Bunker says.

And she says, recovery agrees with her.

“I look good, I feel good, I’m taking care of my kid,” she says. “I’m doing very well.”

Bram Sable-Smith (@besables) is a health reporter based in Madison, Wis.

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Japanese lawmakers have passed controversial legislation expanding the number of semi-skilled foreign workers who can live and work in the notably insular nation for up to five years.

Japan has been pressed to make the change because of a critical labor shortage that results from its rapidly aging society and low birth rate.

Japan’s upper house of parliament passed the law 161 to 76 just after 4 a.m. Saturday local time, after a day when the opposition parties tried to unsuccessfully to block the measure.

The law will go into effect in April 2019.

The legislation has been viewed as a last-resort measure by Prime Minister Shinzo Abe’s ultra-conservative government to address a severe shortage of workers in 14 industries, including restaurants, nursing, construction and agriculture.

According to the Associated Press, two categories of workers will be accepted, with conditions that will discourage them from trying to immigrate permanently.

The law will apply to as many as 345,000 less-skilled workers who will be allowed to stay for up to five years, but not bring in family members. It will also permit higher-skilled workers to enter with their families for 10 years and will provide them a path to Japanese citizenship. Both categories will have requirements for Japanese language competency.

Japan’s population is expected to decline from about 127 million to about 88 million by 2065, according to the National Institute of Population and Social Security. In September, Japan’s Internal Affairs and Communications Ministry released data showing that for the first time, one in five people in the nation is older than 70.

Japan has felt the pressure of an aging population and declining birthrates for decades. The government has tried to meet labor shortages by encouraging more employment of women and older workers, and using more robots and other automation.

And it does have foreign workers. Their number has more than doubled since 2000 to nearly 1.3 million last year, out of a working-age population of 67 million, according to the AP.

“Workers from developing Asian countries used to stay mostly behind the scenes, but not anymore. Almost all convenience stores are partly staffed by Asian workers and so are many restaurant chains.”

Many foreigners are working in Japan on training visas “that don’t allow them to switch jobs even if they are abused or underpaid,” says The Wall Street Journal editorial board. Thousands of student visa holders also work in Japan, often for longer than the 28 hours a week legally allowed.

But until now the government has resisted opening the door to a legal influx of semi-skilled foreign laborers, as many Japanese, particularly Abe’s right-wing supporters, fear a loss of cultural distinctiveness and homogeneity. It’s one reason the government has been careful not to characterize the new visa program as immigration.

But, as The Washington Post reports, Abe’s government is “closely entwined with the business community, and the message it hears from every quarter — shipbuilding and construction, agriculture and fishing, elder-care establishments and convenience-store owners — is ever more insistent: We need more workers.”

A report by Tokyo Shoko Research showed the number of bankruptcies in Japan caused by staff shortages doubled between 2016 and 2017, according to The Wall Street Journal.

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In 2009, the body that accredits medical schools issued a new requirement: All medical schools must implement policies that help them attract and retain more diverse students. Failure to do so can lead to citations from this body, the Liaison Committee on Medical Education, and can affect their status as accredited institutions.

This effort appears to be working. In a research letter published today in JAMA, researchers examine the changing demographics of medical students from 2002 to 2017. They found an increase in diversity in enrollment, especially since 2012, which the researchers think may be the first year new standards could be expected to have an effect.

But the rate of change, some medical educators say, is too slow. Medical student bodies were still 58.9 percent white in 2017.

“We see the trend going up, but it’s going up very slowly,” says Dr. Dowin Boatright, an assistant professor of emergency medicine at Yale University and coauthor of the study. “If we’re trying to get some degree of representation that matches the proportion of black people in the population as a whole … We’re talking 20 to 50 years.”

The pattern of change over the period studied is noteworthy, Boatright says. Between 2002 and 2012, the proportion of female and black students decreased each year.

In that same time period, the percentage of Latino and Asian students increased. White students were the majority of medical school enrollees throughout that time period.

In 2012, the percentage of female and black students starting medical school began a steady, albeit slow, increase.

Don’t see the graphic above? Click here.

By 2017, 7.3 percent of new medical students identified as black, up from 6.8 percent in 2002. Students identifying as female made up 50.4 of matriculants, up from 49 percent in 2002.

Hispanics represented 8.9 percent of students, up from 5.4 percent in 2002 and Asian students were 24.6 percent of students, up from 20.8 percent.

Boatright hypothesizes that the improved numbers reflect that the new requirement that schools have formal programs to attract diverse students.

“I think there’s a strong incentive now to have at least some kind of benchmark to promote diversity,” Boatright says. “Programs actually are being held accountable.”

Many medical schools have hired dean-level administrators who focus on attracting and retaining minority students.

“When you tell people they should do something, they’re like, ‘Oh, we don’t have to do something,’ ” says Dr. John Paul Sanchez, the associate dean for diversity and inclusion at Rutgers New Jersey Medical School. “It makes people think differently when you say you must do something … People have more concrete direction.”

The Liaison Committee on Medical Education also requires that medical schools develop programs to improve the “pipeline” of minority applicants, which usually take the form of science education and mentorship programs for minority college and high school students.

Representatives of the Liaison Committee on Medical Education don’t interpret the data the same way Sanchez and Boatright do. The organization’s co-secretary, Dr. Veronica M. Catanese, said in a written statement that the organization has explicitly promoted diversity in its standards for “more than two decades” and while the organization’s expectations may encourage medical schools to pay attention to diversity, “it likely does not account for the correlation suggested by the authors of the letter.”

This trend the study identified is confirmed by the latest medical school enrollment data also released today by the Association of American Medical Colleges.

In 2018, 8.6 percent of first-year medical students are black, and more women than men started medical school: 51.7 percent identified as female.

The number of black men enrolling in medical school in 2018 — a group that has been significantly underrepresented compared to the general population — increased by 7.3 percent in 2018. Black men made up about 3.4 percent of first-year medical students this year.

This latest data differs from the data the JAMA study authors presented. To assess the effect of the new accreditation requirement, the authors excluded historically Black medical schools and all schools in Puerto Rico because they felt felt the new diversity standards would not affect them in the same way as predominantly white schools.

Sanchez says he thinks the accreditation standards are important, and encourage medical schools to devote money and time to supporting minority students. Still, he says, there’s a difference between meeting the standards and developing long-lasting programs that help minority students feel welcome in medical school.

“That takes decades to build. You can’t train someone to be passionate,” Sanchez says. “But you can hire them and bring them together to serve as faculty at the medical school.”

Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine.

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The federal government took a new step this week to reduce avoidable hospital readmissions of nursing home patients. The move targets the homes’ bottom lines by lowering a year’s worth of payments to nearly 11,000 nursing homes, and giving bonuses to nearly 4,000 others.

These financial incentives, determined by each home’s readmission rates, significantly expand Medicare’s effort to pay medical providers based on the quality of care instead of just the number or condition of their patients.

Until now, Medicare mostly limited these kinds of incentives to hospitals, which have gotten used to facing financial repercussions if too many of their patients are readmitted, suffer infections or other injuries, or die.

“To some nursing homes, it could mean a significant amount of money,” says Thomas Martin, director of post-acute care analytics at CarePort Health, which works for both hospitals and nursing homes. “A lot are operating on very small margins.”

The new Medicare program is altering a year’s worth of payments to 14,959 skilled nursing facilities, based on how often their residents ended up back in hospitals within 30 days of leaving.

Hospitalizations of nursing home residents, while decreasing in recent years, remain a problem: Nearly 11 percent of patients in 2016 were sent to hospitals for conditions that might have been averted with better medical oversight.

These bonuses and penalties are also intended to discourage nursing homes from discharging patients too quickly — something that is financially tempting as Medicare fully covers only the first 20 days of a stay and generally stops paying anything after 100 days.

Over this fiscal year, which began Oct. 1 and goes through the end of September 2019, the best-performing homes will receive 1.6 percent more for each Medicare patient than they would have otherwise. The worst-performing homes will lose nearly 2 percent of each payment. The others will fall in between. (You can check the scores for individual nursing facilities in your area here.)

For-profit nursing homes, which make up two-thirds of the nation’s facilities, face deeper cuts on average than do nonprofit and government-owned homes, a Kaiser Health News analysis of the data found.

In Arkansas, Louisiana and Mississippi, 85 percent of homes will lose money, the analysis found. More than half in Alaska, Hawaii and Washington state will get bonuses.

Overall, 10,976 nursing homes will be penalized, 3,983 will get bonuses and the remainder will not experience any change in payment, the KHN analysis found.

Medicare is reducing payments to 12 of the 15 nursing homes run by Otterbein SeniorLife, an Ohio faith-based nonprofit. Pamela Richmond, Otterbein’s chief strategy officer, says most of its readmissions occurred with patients after they went home, not while they were in the nursing facilities. Otterbein anticipates losing $99,000 over the year.

“We’re superdisappointed,” Richmond says about the penalties. She says Otterbein has started to follow up with former patients or with the home health agencies that send nurses and aides to patients’ houses to care for them. If there are signs of trouble, Otterbein will try to arrange care or bring patients back to the nursing home if necessary.

“This really puts the emphasis on us to go out and coordinate better care after they leave,” Richmond says.

Congress created the Skilled Nursing Facility Value-Based Purchasing Program incentives in the 2014 Protecting Access to Medicare Act. In assigning bonuses and penalties, Medicare judged each facility’s performances in two ways: how its hospitalization rates in calendar year 2017 compared with other facilities and how much those rates changed from calendar year 2015.

Facilities received scores of 0 to 100 for their performances and 0 to 90 for their improvements; the higher of the two scores was used to determine their overall score. Facilities were then ranked highest to lowest.

Medicare is not measuring readmission rates of patients who are insured through private Medicare Advantage plans, even though in some regions, the majority of Medicare beneficiaries rely on those to afford their care.

Through the incentives, Medicare will redistribute $316 million from poorer-performing to better-performing nursing homes. Medicare expects it will keep another $211 million that it would have otherwise paid to nursing homes if the program did not exist.

The new payments augment other pressures nursing homes face from Medicare and state Medicaid programs to lower readmissions to hospitals.

“Skilled facilities have been working toward this and knew it was coming,” says Nicole Fallon, vice president of health policy and integrated services at LeadingAge, an association of nonprofit providers of services for seniors.

The American Health Care Association, a trade group of nursing homes, reports in a written statement that it has supported the program and is gratified to see that more than a quarter of facilities received bonuses.

While most researchers believe that readmissions can be reduced, some consumer advocates fear that nursing homes will be reluctant to admit very infirm residents or to rehospitalize patients even when they need medical care.

“It may end up causing great pain to residents who actually need to be hospitalized,” says Patricia McGinnis, executive director of California Advocates For Nursing Home Reform, which is based in San Francisco.

Fallon says Medicare eventually may penalize homes that have done all they can to prevent return trips to the hospital. But because of the program’s design by Congress, Medicare still will need to punish large numbers of homes.

“There are always going to be winners and losers, even if you make good progress,” Fallon says. “At what point have we achieved all we can achieve?”

Meanwhile, Medicare is looking to expand financial incentives to other kinds of providers. Since 2016, it has been testing quality bonuses and penalties for home health agencies in nine states. Richmond, the nursing home executive, applauded that kind of expansion.

“There are a whole bunch of people in this chain” of institutions caring for patients at different stages, she says, “and we all need to be working in a common direction.”

Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation and is not affiliated with Kaiser Permanente. KHN data editor Elizabeth Lucas contributed to this report.

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