The insurance broker President Trump nominated to lead the Indian Health Service, Robert Weaver, is firing back at the White House and the media after his nomination was withdrawn last week.

“The allegations raised against me in the media are baseless, irrelevant, and in the most important cases simply incorrect,” Weaver said in a press release Tuesday.

In January, The Wall Street Journalquoted a former colleagues of Weaver alleging that he had exaggerated his prior work experience.

More recently, there were reports that he voluntarily withdrew his nomination to head the IHS. But Weaver said in a letter to tribal leaders and supporters published Feb. 22 that the characterization was inaccurate.

“Regardless of what the press reports may say, I was forced out,” Weaver wrote. “I was involuntarily withdrawn.”

In his letter he said he “received a call giving me two minutes this past Friday afternoon at 4:30pm, on a three day holiday weekend, to decide to withdraw or face the public humiliation of having the White House withdraw my nomination, as demanded by a staff person from HHS.”

Weaver hasn’t replied to an interview request from NPR.

The Trump administration hasn’t named a new nominee to lead IHS, which has been without a permanent leader since 2015.

Democrats and Republicans on the Senate Committee on Indian Affairs are both urging the White House to name a new nominee quickly.

“I’m expecting better, and I hope the administration will send us a highly qualified candidate,” said Montana Republican Sen. Steve Daines. He said he didn’t get a favorable impression of Weaver when they met after he was nominated.

Sen. Jon Tester, a Democrat from Montana who is also on the Indian Affairs Committee, said Senate “due diligence” revealed problems with Weaver’s statements about his education and work history.

But Tester said he doesn’t fault the Trump administration for sending them a candidate who was not properly vetted.

“I think this can happen,” Tester said. “What I think is really important moving forward is that they get us somebody much sooner than later. So we can get them confirmed. … If they dilly-dally on this, and this position’s left open it’s a major problem for Indian Health Service and not good for our Native American folks that are depending upon Indian Health Service for their health care.”

An estimated 3.7 million American Indians and Alaska Natives eligible to receive care from the IHS. In treaties, Tribes were promised health care in return for giving up nearly all of their ancestral lands to the federal government.

This month the National Indian Health Board told Congress that the current IHS budget of $4.8 billion dollars will meet less than 47 percent of the need for Native American health care nationwide. But that group of tribal leaders says that bigger picture, the agency needs far more funding. A report it published last year says the real health care needs in Indian Country require a $32 billion infusion the IHS, phased in over 12 years.

Daines isn’t convinced money is the problem, and wouldn’t commit to whether he thinks IHS can function properly on its current budget. “Throwing more money at it isn’t going to solve the fundamental problem of lack of accountability and lack of leadership,” he said.

“You need to prioritize and look at where we spend the money,” Daines said. “One of the areas we need to address is to insure that the compensation structure for the health professionals that serve, the folks that are right there on the front line, delivering health care in Indian Country, that the wages they’re provided are competitive, so that we can attract and retain good health care professionals. That is an area that needs to be addressed, and that’s what we need to prioritize.”

For his part, Tester said, “It’s well documented that IHS has been underfunded now for decades, and you can’t get blood out of a turnip, you can’t get health care out of an agency that doesn’t have enough money to be able to do the job that they’re required to do.

“Congress also needs to do its job and make sure IHS has the dollars it needs, no more, no less, to do the job that’s required, and that’s to take care of the Indian people,” he said.

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

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Heidi Schultz grew up traveling from one end of South Dakota to the other, tagging along as her sister saw doctors and specialists in the “big cities” to treat her diabetes.

Schultz thought she knew rural America well when she took a position as a rural health care program officer for the Helmsley Charitable Trust in Wyoming and Montana.

But even she has been surprised by how she can drive hours on country highways seeing few cars and just “a handful of gravel driveways going somewhere you can’t see.”

“It’s almost scary,” Schultz says. “You’re thinking, ‘If something happened to me here on this road now, how long would it take for someone to get to me? An ambulance? And where would they take me for care?’ “

Now part of her job is to help organizations apply for grants to provide care in rural areas. She understands that people living in these places must come up with creative solutions to deal with their health care needs — whether it’s getting help in an emergency, receiving treatment for ongoing illnesses or softening the natural consequences of old age.

It’s a quickly changing landscape as more rural hospitals close, and some health policy analysts say it’s time communities made some hard decisions — starting with completely changing the health care structure in small towns.

For example, says a recent report by the Bipartisan Policy Center, instead of making sure each rural resident can easily get to a full-service hospital, some communities should consider what kind of primary care and more specialized care they could offer at a facility instead — short of having a full-service hospital.

Hospitals tend to be cornerstone institutions in rural communities. They provide jobs and contribute to a town’s economy. For many citizens in small-town America, losing the local hospital would threaten the livelihood of the town and its people, says Patrick Roche, chief operating officer at Faith Regional Health Services based in Norfolk, Neb.

“There are two things they don’t want to lose. The first one is their school, the second one is their hospital,” says Roche.

But there are big challenges to keeping these hospitals open. They cost money and it’s difficult to find a qualified workforce.

There are other concerns, including limited funding, regulatory restrictions, problems with transportation, broadband internet accessibility and the unique characteristics of the population, according to Dr. Anand Parekh, chief medical advisor with the Bipartisan Policy Center and one of the report’s authors.

“Rural America,” Parekh says, “is a little bit older, a little bit sicker, a little bit poorer.”

In 2016, the Census Bureau reported that 19.3 percent of the U.S. population lived in rural areas, which cover 97 percent of the country. Up to this point, the medical needs of that group have been addressed by a system that has medical facilities, many of which do receive some federal support, including about 1,300 small hospitals known as critical access hospitals.

A hospital is designated as critical access by the Centers for Medicare and Medicaid Services if has 25 beds or fewer, is more than 35 miles from another hospital and provides 24-hour emergency services.

The National Rural Health Association says 673 rural hospitals are at risk to close, and 210 of those are at “extreme risk”— 60 rural hospitals closed between 2010 and February 2016.

One of the main reasons for the significant rural hospital closures is that the average number of in-patients is low, says Schultz.

“Running a full hospital is very expensive — the overhead, 24/7 staffing, the facilities,” she says. “Think of a 25-bed hospital, and you’re only using four of your beds and how expensive that is.”

Residents of Tilden, Neb. — a town of less than 1,000 — know what happens when the town hospital can’t make ends meet. They lost their critical access hospital in 2014 and had to find a different solution for their medical care.

Roche explains that Faith Regional Health Services in Norfolk, just 22 miles away from Tilden, worked out an agreement to lease the hospital and clinic from the little town; Faith Regional then provided the medical operations—staffing, providers and equipment.

“The operations are, in effect, owned by Faith Regional and are operated just like any other clinic that is owned and operated by our system,” Roche says. But the facility in Tilden is no longer a full hospital.

“There’s been a fear in the air and you read a lot, and you hear a lot about hospitals closing,” says Schultz, who travels often to rural communities. “And that’s rightfully so. But if you look at the communities that are losing their hospitals, you need to look at, ‘What do they still have?’ “

The Bipartisan Policy Center and Helmsley Charitable Trust partnered to propose a possible solution for communities struggling to keep facilities afloat and provide quality care miles away from city and suburban hospitals and clinics.

Their January 2018 report, which surveyed health care professionals in seven states in the upper Midwest, says that the whole rural health care system needs to be addressed. Each community should determine the best health care structure, the report suggests, not the other way around. And that difficult analysis may lead to closing a small town hospital.

Darrold Bertsch, chief executive officer of Sakakawea Medical Center in Hazen, N.D., says he agrees with the idea of catering health care facilities to the population — whether it’s with an outpatient clinic, urgent care center, a hospital or something else.

“If communities had a little bit more flexibility,” he says, “then they could adapt a health care delivery system in their area that is more relevant to the needs that they have, rather than trying to make a hospital fit in a community where it might not be able to be supported anymore.”

The critical access hospital in Cody, Wyo., has stayed open — partially because of this idea of flexibility, says Jeanine Brus, who works as the laboratory director for the hospital.

Cody sits outside the eastern edge of Yellowstone National Park and is a town of about 10,000 people. Cody Regional Health, which includes the hospital and other health care facilities, such as a surgical center, a cancer center and a dialysis center, serves the town and the farms and ranches in a 200-mile radius, as well as tourists from the park.

Brus says that the key to adapting has been collaboration between the different facilities. And that’s been good for the health care workers, as well as the community, she says.

Bertsch from the North Dakota hospital says federal regulations and the way hospitals are reimbursed mean there’s no one-size-fits-all fix for every community.

Still, Parekh underscores his hope for the possibilities that can come when communities are open to new kinds of solutions.

“You know, you don’t have to close your hospital,” he says. “You can transform the hospital to meet your community needs, improve health and still continue to improve your local economy. Rural America can thrive as health care transforms.”

This story is part of NPR’s reporting partnership with Kaiser Health News.

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Health plans that don’t meet the standards of the Affordable Care Act; work requirements for Medicaid coverage; changes to Medicare’s approved drug lists: As the ground continues to shift on health care coverage, I’m answering readers’ queries this week about these three different types of plans:

I lost my job last year and my employer coverage ended in January. I bought a new plan through the marketplace that went into effect last month. I just received policy information, and it states that because the plan does not cover major medical services, I may have to pay additional taxes to the government. I was told that the plan didn’t cover major medical, but wasn’t told about any taxes. Will I be fined next year?

It sounds like you bought a plan that doesn’t comply with the Affordable Care Act’s requirements, and if that’s the case you may indeed have to pay a penalty for not having comprehensive coverage when you file your taxes next year.

The tax reform law repealed the individual penalty for not having health insurance, but that provision doesn’t take effect until 2019. So for 2018 you may be charged the greater of $695 or 2.5 percent of your household income.

The federal- and state-run marketplaces established by the ACA sell only comprehensive plans that cover 10 essential health benefits, including “major medical” services like hospitalization and prescription drugs.

But some insurance broker websites call themselves marketplaces too, says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. And that can be confusing. These companies may sell other insurance products — like short-term or accident coverage — alongside comprehensive plans that comply with the law.

Ever since the health law was passed, “There have been opportunistic companies trying to take advantage of consumer confusion to make money,” Corlette says.

If you aren’t happy with your plan, you may still be able to switch. Losing your employer coverage qualifies you for a 60-day special enrollment period to pick a new plan. Since it appears you’re still in that window, you may be able to choose a comprehensive plan.

To ensure you’re using your state’s official marketplace, go to healthcare.gov and click on “see if I can change.” That will take you to your state marketplace, even if you live in one of the dozen or so states that run their own exchanges.

I’m in a state that is looking into work requirements for Medicaid. At sign-up time, can I simply tell the exchange that I intend to be ineligible for Medicaid by refusing to work and get the premium tax credit to buy a private plan on the insurance marketplace?

Federal health law regulations don’t clearly address the situation you describe, but the short answer is probably not, according to policy analysts.

In general, people who are eligible for employer coverage or Medicaid — the federal-state health program for people with little income — can’t qualify for federal tax credits that help pay for premiums on plans sold on the health insurance exchanges.

This year, Kentucky and Indiana became the first states to receive federal approval to require some Medicaid recipients to put in 80 hours each month at a paid job, school or volunteer work (among other activities), to receive benefits. Nearly a dozen other states have made similar requests.

If you refuse to work, does that make you ineligible for Medicaid? The rules aren’t clear, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

States might argue that someone in your situation is eligible for Medicaid — you just have to fulfill the work requirements, says Timothy Jost, a professor emeritus of law at Washington and Lee University in Virginia, who is an expert on the health law.

There are other actions people could take — or fail to take — where this issue might come up. “You could argue that someone is not eligible because they haven’t completed the Medicaid application or provided the required documentation,” Jost says. “There are any number of requirements, but I can’t imagine someone saying they didn’t do those things and so they’re not eligible for Medicaid.”

Whatever the rules, it’s unlikely that many people will be in a position to consider taking this stance. To qualify for premium tax credits, your income must be between 100 and 400 percent of the federal poverty level (about $12,000 to $48,500 for an individual in 2018). But you’d also have to be eligible for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. In addition, the Medicaid work requirements in your state would have to apply to you.

I picked a Medicare Part D drug plan that covered all the drugs I take. But as soon as I got my first Novolin R prescription filled, they notified me that they don’t cover it anymore. Can they just switch it like that?

Medicare drug plans can change their list of covered drugs, called formularies. If they’re doing so at the start of the new calendar year, as appears to have happened in your case, the plan may notify you of the change when you fill the prescription for the first time in the new year. At that time, the plan would typically give you a 30-day transition refill so you can switch to another drug that’s on the formulary or start the appeals process to continue taking your current insulin drug, Novolin R.

If you and your doctor think it’s important that you have Novolin R and not another drug that is similar, you can ask your plan to make an exception to allow you to continue to take the drug.

To go that route, you would need to get your doctor to “make the case for why that formulary drug is not the right drug” for you, says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

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In Great Britain, midwives deliver half of all babies, including Kate Middleton’s first two children, Prince George and Princess Charlotte. In Sweden, Norway and France, midwives oversee most expectant and new mothers, enabling obstetricians to concentrate on high-risk births. In Canada and New Zealand, midwives are so highly valued that they’re brought in to manage complex cases that need special attention.

All of those countries have much lower rates of maternal and infant mortality than the U.S. Here, severe maternal complications have more than doubled in the past 20 years. Shortages of maternity care have reached critical levels: Nearly half of U.S. counties don’t have a single practicing obstetrician-gynecologist, and in rural areas, the number of hospitals offering obstetric services has fallen more than 16 percent since 2004. Nevertheless, thanks in part to opposition from doctors and hospitals, midwives are far less prevalent in the U.S. than in other affluent countries, delivering about 10 percent of babies, and the extent to which they can legally participate in patient care varies widely from one state to the next.

Now a new study, a systematic look at what midwives can and can’t do in the states where they practice, offers new evidence that empowering them could significantly boost maternal and infant health. The five-year effort by researchers in Canada and the U.S., published Wednesday, found that states that have done the most to integrate midwives into their health care systems, including Washington, New Mexico and Oregon, have some of the best outcomes for mothers and babies. Conversely, states with some of the most restrictive midwife laws and practices — including Alabama, Ohio and Mississippi — tend to do significantly worse on key indicators of maternal and neonatal well-being.

“We have been able to establish that midwifery care is strongly associated with lower interventions, cost-effectiveness and improved outcomes,” said lead researcher Saraswathi Vedam, an associate professor of midwifery who heads the Birth Place Lab at the University of British Columbia.

Many of the states characterized by poor health outcomes and hostility to midwives also have large African-American populations, raising the possibility that greater use of midwives could reduce racial disparities in maternity care. African-American mothers are three to four times more likely to die in pregnancy or childbirth than their white counterparts; black babies are 49 percent more likely to be born prematurely and twice as likely to perish before their first birthdays.

“In communities that are most at risk for adverse outcomes, increased access to midwives who can work as part of the health care system may improve both outcomes and the mothers’ experience,” Vedam said.

That’s because of the midwifery model, which emphasizes community-based care, close relationships between providers and patients, prenatal and postpartum wellness, and avoiding unnecessary interventions that can spiral into dangerous complications, said Jennie Joseph, a British-trained midwife who runs Commonsense Childbirth, a Florida birthing center and maternal care nonprofit. “It’s a model that somewhat mitigates the impact of any systemic racial bias. You listen. You’re compassionate. There’s such a depth of racism that’s intermingled with [medical] systems. If you’re practicing in [the midwifery] model you’re mitigating this without even realizing it.”

The study, published in the peer-reviewed journal PLOS ONE, analyzes hundreds of laws and regulations in 50 states and the District of Columbia — things like the settings where midwives are allowed to work, whether they can provide the full scope of pregnancy- and childbirth-related care, how much autonomy they have to make decisions without a doctor’s supervision, and whether they can prescribe medication, receive insurance reimbursement or obtain hospital privileges. Then researchers overlaid state data on nine maternal and infant health indicators, including rates of cesarean sections, premature births, breastfeeding and neonatal deaths. (Maternal deaths and severe complications were not included because data is unreliable).

The differences between state laws can be stark. In Washington, which has some of the highest rankings on measures such as C-sections, premature births, infant mortality and breastfeeding, midwives don’t need nursing degrees to be licensed. They often collaborate closely with ob/gyns, and can generally transfer care to hospitals smoothly when risks to the mother or baby emerge. They sit on the state’s perinatal advisory committee, are actively involved in shaping health policy, and receive Medicaid reimbursement even for home births.

At the other end of the spectrum, North Carolina not only requires midwives to be registered nurses, but it also requires them to have a physician sign off on their application to the state for approval to practice. North Carolina scores considerably worse than Washington on indices such as low-birthweight babies and neonatal deaths.

Neel Shah, an assistant professor at Harvard Medical School and a leader in the movement to reduce unnecessary C-sections, praised the study as “a remarkable paper — novel, ambitious, and provocative.” He said licensed midwives could be used to solve shortages of maternity care that disproportionately affect rural and low-income mothers, many of them women of color. “Growing our workforce, including both midwives and obstetricians, and then ensuring we have a regulatory environment that facilitates integrated, team-based care are key parts of the solution,” he said.

To be sure, many other factors influence maternal and infant outcomes in the states, including access to preventive care and Medicaid; rates of chronic disease such as diabetes and high blood pressure; and prevalence of opioid addiction. And the study doesn’t conclude that more access to midwives directly leads to better outcomes, or vice versa. Indeed, South Dakota, which ranks third from the bottom in terms of midwife-friendliness, scores well on such key indicators as C-sections and preterm births. Even North Carolina is average on C-section rates, breastfeeding, and prematurity.

The findings are unlikely to quell the controversies over home births, which are almost always handled by midwives and comprise a tiny but growing percentage of deliveries in the U.S., or fears among doctors and hospitals that closer collaborations with midwives will raise malpractice insurance rates. In fact, said Ann Geisler, who runs the Florida-based Southern Cross Insurance Solutions, which specializes in insuring midwives, her clients’ premiums tend to be just one-tenth of premiums for an ob/gyn because their model of care eschews unnecessary interventions or technology. Far from being medical renegades, the vast majority of midwives want to be integrated into the medical system, she said.

Generally, licensed midwives only treat low-risk women, Geisler said. If the patients become higher risk, midwives are supposed to transfer them to a doctor’s care. Since many ob/gyns only see midwife patients when a problem emerges, she said, they may develop negative views of midwives’ skills.

You can read a full report from our partner, ProPublica, here.

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Measles is highly contagious, but easily preventable with a vaccine.

However, the numbers of measles cases sharply jumped up in Europe in 2017, according to new data released by the World Health Organization.

In 2017, the disease affected 21,315 people, compared to 5,273 in 2016. Last year, 35 people died in Europe because of measles.

“Every new person affected by measles in Europe reminds us that unvaccinated children and adults, regardless of where they live, remain at risk of catching the disease and spreading it to others who may not be able to get vaccinated,” said Zsuzsanna Jakab, WHO’s Regional Director for Europe. She describes the loss of lives as a “tragedy we simply cannot accept.”

The WHO says that 15 countries in Europe saw outbreaks of 100 or more cases. Romania had the most, with 5,562, followed by Italy, with 5,006, and Ukraine, with 4,767.

“These countries have experienced a range of challenges in recent years, such as declines in overall routine immunization coverage, consistently low coverage among some marginalized groups, interruptions in vaccine supply or underperforming disease surveillance system,” the WHO report stated.

According to the BBC, Romania has a shortage of the vaccine. “It is also thought that the country’s large Roma population, who often live in severe poverty, are at particular risk of contracting and spreading the virus,” the broadcaster added.

In response to the burgeoning outbreak in Italy last year, the country made vaccines mandatory for measles and a number of other diseases for school children.

“Kids up to 6 years old won’t be accepted into nursery schools without them,” reporter Christopher Livesay told NPR. “And parents sending their children to school after that age without vaccinating them first will now face fines of up to $8,380.”

That was controversial and sparked protest. Like many other countries, some politicians in Italy have argued against the policy by referencing widely discredited research that suggests a link between vaccines and autism.

The WHO says other European countries that saw large outbreaks in 2017 are:

“Greece (967), Germany (927), Serbia (702), Tajikistan (649), France (520), the Russian Federation (408), Belgium (369), the United Kingdom (282), Bulgaria (167), Spain (152), Czechia (146) and Switzerland (105).”

As NPR’s Michaeleen Doucleff has reported, measles cases have generally seen a dramatic drop worldwide since the 1980s, from more than 4 million cases annually to less than 500,000. However, she adds that health workers have struggled to push vaccination rates past 78 percent, though they say rates of 90 to 95 percent are needed to stop outbreaks.

Poor countries such as Guinea, Mongolia and Nigeria are seeing a high number of cases, she adds. As NPR’s Jason Beaubien reports, Rohingya camps in Bangladesh have also seen recent outbreaks.

There have also been several recent outbreaks in the U.S., primarily impacting people who were never vaccinated for measles. The U.S. saw 118 cases of measles in 2017, according to the CDC. A 2015 outbreak across multiple states is believed to have originated with a traveler who visited Disneyland.

An outbreak hit Minnesota in 2017, sickening at least 79 people. A large number of those impacted are members of the Somali-American community in Minneapolis, many of whom are wary of vaccines.

Patients with measles have symptoms such as fever, cough and runny nose at the onset, according to the CDC. After about 3 days, a rash of “flat red spots” appears on the infected person’s body.

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After Elizabeth Moreno had back surgery in late 2015, her surgeon prescribed an opioid painkiller and a follow-up drug test that seemed routine — until the lab slapped her with a bill for $17,850.

A Houston lab had tested her urine sample for a constellation of legal and illicit drugs, many of which Moreno says she had never heard of, let alone taken.

“I was totally confused. I didn’t know how I was going to pay this,” said Moreno, 30, who is finishing a degree in education at Texas State University in San Marcos, and is pregnant with twins.

Her bill shows that Sunset Labs LLC charged $4,675 to check her urine for a slew of different types of opioids: $2,975 for benzodiazepines, a class of drugs for treating anxiety, and $1,700 more for amphetamines. Tests to detect cocaine, marijuana and phencyclidine, an illegal hallucinogenic drug also known as PCP or angel dust, added $1,275 more.

The lab also billed $850 to test for buprenorphine, a drug used to treat opioid addiction, and tacked on an $850 fee for two tests to verify that nobody had tampered with her urine specimen.

Total bill: $17,850 for lab tests that her insurer, Blue Cross and Blue Shield of Texas, refused to cover, apparently because the lab was not in her insurance network. The insurer sent Moreno an “explanation of benefits” that says it would have valued the work at just $100.92.

Moreno’s father, in a complaint to the Texas attorney general’s office about the bill, identified the Houston surgeon who ordered the costly test as Dr. Stephen Esses. His office told Kaiser Health News the surgeon would have no comment.

Sunset Labs is part of a network of pain clinics and other medical businesses founded by Houston anesthesiologist Phillip C. Phan, according to Texas secretary of state filings and court records. Court records say Phan’s companies also own the facility where Moreno had her operation.

Three experts contacted by KHN said the lab grossly overcharged; they also doubted the need for the test.

“This just blows my mind,” said Jennifer Bolen, a former federal prosecutor and lab and pain management consultant. “It’s very high and incredibly out of the norm.”

Dan Bowerman, a medical fraud expert, called the lab bill “outrageous” and “unconscionable” and said it should have prompted an investigation.

“Sounds real fishy,” added Charles Root, a veteran industry adviser. He wondered if the lab had “misplaced the decimal point,” because such a test should cost a few hundred dollars, tops.

The lab disagrees.

Sunset’s billings “are in line with the charges of competing out-of-network labs in the geographical area,” lab attorney Justo Mendez said in an emailed statement.

Mendez said pain doctors agree that extensive urine testing is “the best course of action” and that a lab “is not in the position” to question tests ordered by a doctor.

Testing Booms As Opioid Epidemic Rages

Urine testing for patients with chronic pain has grown explosively over the past decade amid a rising death toll from opioid abuse. Pain doctors say drug testing helps them make sure patients are taking the drugs as prescribed and not mixing them with illegal substances.

Yet the testing boom costs billions of dollars annually and has raised concerns that some labs and doctors run urine tests needlessly — or charge exorbitant rates — to boost profits.

Some insurers have refused to pay, which can leave patients like Moreno threatened with ruinously high bills they had no idea they had incurred.

“Surprise bills larded with unexpected expenses and little explanation inflict sticker shock on vulnerable patients,” said James Quiggle, communications director of the Coalition Against Insurance Fraud, whose members include insurers, consumer groups and government agencies. Quiggle said many “puffed-up bills straddle a fine line between abuse and outright fraud.”

Moreno said her insurance covered the disc removal surgery in December 2015. She said the operation went well and she weaned herself off the hydrocodone pain pills. To her surprise, during a second appointment return about a month later, the surgeon’s office asked her to leave a urine sample.

“I didn’t think anything of it,” Moreno said of the test. “I said fine, whatever.”

More than a year later, she said, the lab phoned while she was driving and asked her to pay the $17,850 bill. The lab then sent her an invoice, dated March 10, 2017, which states: “based upon information from your health plan, you owe the amount shown.”

Luckily, her father, Dr. Paul Davis, was visiting her in Texas at the time. Davis, 66, is a retired family practice doctor from Findlay, Ohio.

Davis doubted the need for the test, not to mention what he thought was a sky-high price. He said the University of Findlay, where he helped train physician assistants, gave applicants a basic drug test at a cost of $174, while the local juvenile courts in Ohio paid $10 for a simple drug screen.

Fearing the bill would ruin his daughter’s credit scores, Davis said, he called Sunset and settled it in April 2017 by paying $5,000, which he said he now regrets. The lab sent Moreno a receipt that said it discounted her bill because of “financial need/hardship.”

Asked for comment, Blue Cross spokesman James Campbell said he couldn’t discuss a specific case but noted:

“We are disappointed as well as concerned about transparency whenever [any] member is surprised by an excessive charge for a seemingly routine service or received services that may not have been medically necessary.”

Campbell also said the lab was out-of-network and “we do not control how much they charge for services rendered.” The insurer encourages patients to confirm that all medical care they seek comes from medical providers in the Blue Cross network, he added.

Prices for urine tests can vary widely depending upon complexity and the technology used. Some doctors’ offices use a simple cup test, which can detect several classes of drugs on the spot. These tests rarely cost more than $200, and typically much less.

Bills climb higher when labs check for levels of multiple drugs and bill for each one, a practice insurers argue is seldom medically justified. But even labs sued by insurers alleging wildly excessive testing typically have billed $9,000 or less, court records show. One insurer sued a lab for charging $1,845 for a drug test, for instance.

Davis said Sunset Labs ignored his requests for a full explanation of the charges. In May, he filed a written complaint about the bill with the Texas attorney general’s office that included a copy of the bill and accused the lab of “price gouging of staggering proportions.”

“Young people just starting out, such as my daughter, may not have the ability to pay and this could result in damaged credit ratings or even bankruptcy,” he wrote.

Davis got a letter back from Attorney General Ken Paxton, who said the office would “review the information.” A spokesperson for Paxton told KHN: “We have received complaints about that business, but we can’t comment on anything else.” Sunset attorney Mendez said the lab is “not aware” of any such complaints.

In an interview, Davis also questioned the need for his daughter’s urine test because she received opioids only for a short period and the results would have had no impact on her treatment. In his complaint to the attorney general, Davis said the surgeon told him he ordered the tests because he feared possible retribution from the state medical licensing board for not testing patients who had been prescribed an opioid. The Texas Medical Board doesn’t require urine tests for patients receiving opioids for short-term pain, said spokesman Jarrett Schneider. That’s a “question of independent medical judgment as to whether the physician believes a drug test should be required,” he said.

Negative Reviews

Sunset Labs has an “F” rating with the Houston Better Business Bureau, which on its website posts an August 2017 complaint from a patient charged $16,150 for a urine test.

“This is not covered under my health insurance so I am expected to pay this excessive bill,” the complaint reads.

A second website that publishes government billing numbers of doctors and medical businesses includes a comment section with more than a dozen negative “reviews,” mostly complaints that the lab slammed patients with thousands of dollars in fees their insurers balked at paying.

In a pair of lawsuits filed in 2015, three doctors seeking to quit working at pain clinics operated by Phan accused the facilities of improper billing practices, including unnecessary urine testing. The doctors said they feared losing their medical licenses unless they severed their ties.

In one suit, Drs. Purvi Patel and Lance LaFleur also alleged that the pain clinics “pressured” doctors to overprescribe medical gear and genetic tests to insured patients “regardless of medical necessity.” The case did not go forward because the doctors did not pursue it. Neither doctor would comment.

In the second legal case, pain specialist Dr. Baominh Vinh said he resigned in April 2015 “based on certain questionable business practices … that are inconsistent with my ethical boundaries.” Vinh also alleged urine testing was overused. In a countersuit against Vinh, the pain clinics called his allegations a “falsehood” to justify violation of his employment contract.

The parties settled in March of last year. Terms are confidential, but a lawyer for the pain clinics said Vinh paid money to the company “and not vice versa.”

This is the debut of a monthly feature from Kaiser Health News and NPR that will dissect and explain real medical bills in order to shed light on prices in U.S. health care and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize? Submit it here and tell us the storybehind it.

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It’s barely been two weeks since Idaho regulators said they would allow the sale of health insurance that doesn’t meet all of the Affordable Care Act’s requirements — a controversial step some experts said would likely draw legal scrutiny and, potentially, federal fines for any insurer that jumped in.

And on Wednesday, Blue Cross of Idaho unveiled a menu of new health plans that break with federal health law rules in several ways, including setting premiums based on applicants’ health.

“We’re trying to offer a choice that allows the middle class to get back into insurance coverage,” said Dave Jeppesen, the insurer’s executive vice president for consumer health care.

The insurer filed five plans to the state for approval and hopes to start selling them as soon as next month.

The Blue Cross decision ups the ante for Alex Azar, the Trump administration’s new Health and Human Services secretary. Will he use his authority under federal law to compel Idaho to follow the ACA and reject the Blues plans? Or will he allow state regulators to move forward, perhaps prompting other states to take more sweeping actions?

At a congressional hearing Wednesday, even as Blue Cross rolled out its plans, Azar faced such questions. “There are rules,” Azar said. “There is a rule of law that we need to enforce.”

However, he didn’t specifically indicate whether the federal government would step in.

Robert Laszewski, a consultant and former insurance industry executive, says it should. “If Idaho is able to do this, it will mean other … states will do the same thing,” he said. “If a state can ignore federal law on this, it can ignore federal law on everything.”

Idaho’s move stirs up more issues about the stability of individual insurance markets.

Policy analysts say that allowing lower-cost plans that don’t meet the ACA’s standards to become more widespread will pull younger and healthier people out of Obamacare, raising prices for those who remain. Supporters say that is already happening, so the lower-cost plans provide more choices for people who earn too much to qualify for subsidies to help them purchase ACA coverage.

Idaho’s move to allow such plans, announced in January, drew harsh and swift criticism.

“Crazypants illegal,” tweeted Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, who said that states can’t pick and choose which parts of federal law to follow. Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, pointed out that health insurers could be liable for sharp fines if they are found to be in violation of the ACA.

But both Idaho regulators and Blue Cross officials say they aren’t worried.

Jeppesen said the ACA gives states regulatory authority “to make sure the market works and is stable,” and the insurer is simply “following what the state has given us guidance” to do.

Other insurers in Idaho are taking a much more cautious approach, telling The Wall Street Journal they aren’t stepping up immediately to offer their own plans.

Laszewski said they are likely waiting to see what legal challenges develop. “If I were running an insurance company, there’s no way I would stick my neck out until the high court has ruled in favor of this — and they’re not going to,” he said.

Jeppesen said his company has consulted with legal experts and is moving ahead with confidence. The aim is to bring people back into the market, particularly the young, the healthy and those who don’t get a tax credit subsidy and can’t afford an ACA plan.

For some people — especially younger or healthier applicants — the new plans, which the insurer has named Freedom Blue, cost less per month than policies that meet all ACA rules.

They accomplish that by limiting coverage. If they are allowed to be sold, consumers will need to weigh the lower premiums against some of the coverage restrictions and variable premiums and deductibles, policy experts say.

The plans, for example, will include a “waiting period” of up to 12 months for any pre-existing conditions if the applicant has been without coverage for more than 63 days, Jeppesen said.

Additionally, they cap total medical care coverage at $1 million annually. And premiums are based, in part, on a person’s health: The healthiest consumers get rates 50 percent below standard levels, while those deemed unhealthy would be charged 50 percent more.

All those conditions violate ACA rules, which forbid insurers from rejecting coverage of preexisting conditions or setting dollar caps on benefits or higher premiums for people with health problems.

But the rates may prove attractive to some.

Premiums for a healthy 45-year-old, for example, could be as low as $195 a month, according to a comparison issued by the insurer, while a 45-year-old with health problems could be charged $526. In that case, the 45-year old would find a lower price tag — $343 a month — for an ACA-compliant bronze plan.

While Freedom Blues plans cover many of the “essential health benefits” required under the ACA, such as hospitalization, emergency care and mental health treatment, they do not include pediatric dental or vision coverage. One of the five plans doesn’t include maternity coverage.

When compared with one of the Blues’ ACA-compliant plans — called the Bronze 5500 — the new standard Freedom Blue plan’s annual deductibles are a mixed bag.

That’s because it has two separate deductibles — one for medical care and one for drugs. If a consumer took only generic drugs, the new plan would be less expensive, according to details provided by the plan. But with a $4,000 deductible for brand-name drugs, the Freedom Blue plan requires more upfront money before full coverage kicks in than the ACA-compliant plan it was compared with.

Jeppesen said the insurer hopes to attract many of the “110,000 uninsured state residents who cannot afford [ACA] coverage.”

That’s the total number of uninsured people who earn more than 100 percent of the federal poverty level in the state, he said.

Sarah Lueck, senior policy analyst for the Center on Budget and Policy Priorities, cautioned that some of those residents might actually be eligible for subsidies under the ACA, which are available to people earning up to four times as much.

“Many … could be getting subsidies for more comprehensive coverage through the [ACA-compliant state exchange] and would be better off,” Lueck said.

Kaiser Health Newsis a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Richard Klein switched doctors last year. The new doctor put him on a new blood pressure drug.

But it didn’t help.

The failure was entirely predictable.

Klein, an associate professor at Florida International University in Miami, realized later that he had tried the same medicine unsuccessfully a few years before, but he hadn’t remembered that fact during the appointment.

It was an understandable mistake for Klein and his doctor.

Klein’s prescription history was hidden somewhere in the hundreds of pages of medical records his new doctor had to go through.

“If I had been able to go into an app sitting in his office and look through my prescription history, I would have known that, yeah, we tried that a couple years back and it didn’t work well,” he says.

A feature like that will soon be available for some patients with iPhones.

In the upcoming release of Apple’s iOS operating system for iPhones this spring, the Health app will include health records, so patients can take information about their immunizations, medications, lab results and more with them.

The feature will first be available to patients of medical providers who partnered with Apple, including Johns Hopkins Medicine; OhioHealth; Ochsner Health System in Jefferson Parish, La.; and Cedars-Sinai in Los Angeles. It won’t cost those patients anything to use this feature, assuming they’re already iPhone users.

Apple’s announcement says more medical facilities will offer this feature in the coming months.

Some doctors hail it as a big shift away from patients having to handle a big pile of paper records every time they see a new doctor. But Google offered a similar service before and it failed. The search giant shut it down in 2012.

Can Apple succeed where Google didn’t?

Dr. Jonathan Slotkin says yes; he is a medical director handling digital patient engagement at Geisinger Health System in Pennsylvania, one of Apple’s partners. Unlike even a few years ago, a lot more people now use smartphones and the phones are more secure. There’s now also a technical standard for transferring electronic medical records.

“Even if I get care at three different places and maybe they use three different electronic systems, now in one place that I possess in an encrypted way, I have all of that information at my fingertips,” he says.

He adds this will make transferring information easier for patients who have to move, or go to a specialist.

The health records feature could also change doctors’ habits in some ways, says Dr. Isaac Kohane, chair of the department of biomedical informatics at Harvard Medical School and a professor of pediatrics.

“For some reason, and I say this as a physician, most physicians, if they don’t actually know how a test was done, somehow imagine it was done wrongly, and therefore repeat a test, not only at a cost but at some pain to the patient,” Kohane says. “If you have a reliable authoritative description of the test and its results, that uncertainty goes away and that excuse to repeat tests goes away as well.”

Kohane called Apple’s new feature a “tectonic shift” in a commentary for member station WBUR’s CommonHealth.

But Apple will have to address one big problem that Google had with Google Health, a similar health records service: It was popular with only a niche audience — tech-savvy patients and their caregivers, and fitness enthusiasts. The product didn’t attract a wide base of users.

This time will be different, says Dr. Ida Sim, a co-director of biomedical informatics at the University of California, San Francisco Clinical and Translational Sciences Institute. Why? Because unlike with Google Health, patients no longer have to do the heavy lifting of entering or scanning their own data. Also, the 21st Century Cures Act of 2016 pushed federal agencies and providers to use electronic health records, and now there is a data standard for personal health records, which wasn’t the case in 2011.

However, she writes in an email that wider adoption will still be an issue.

“We’ll probably see huge numbers of people getting their initial Health Records populated. The issue is, then what?… The value will come from third party apps that use Health Records to provide meaningful value to patients, and until this value is demonstrated, I think Health Records uptake will be large but retention and continued engagement of patients will be challenging.”

Alan Yu reports forThe Pulse, WHYY’s health and science show.

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The maker of OxyContin, one of the most prescribed and aggressively marketed opioid painkillers, will no longer tout the drug or any other opioids to doctors.

The announcement, made Saturday, came as drugmaker Purdue Pharma faces lawsuits for deceptive marketing brought by cities and counties across the U.S., including several in Maine. The company said it’s cutting its U.S. sales force by more than half.

Just how important are these steps against the backdrop of a raging opioid epidemic that took the lives of more than 300 Maine residents in 2016, and accounted for more than 42,000 deaths nationwide?

“They’re 20 years late to the game,” says Dr. Noah Nesin, a family physician and vice president of medical affairs at Penobscot Community Health Care.

Nesin says even after Purdue Pharma paid $600 million in fines about a decade ago for misleading doctors and regulators about the risks opioids posed for addiction and abuse, it continued marketing them.

“I think it’s similar to the tobacco industry learning they could sell tobacco without spending a lot of money on advertising. My guess is this decision is in their self-interest,” he says.

A nationwide lawsuit against Purdue Pharma for deceptive marketing continues to grow. Seven cities in Maine have joined, including Portland, Lewiston and Bangor, along with five counties, to recoup some of the costs of addressing the addiction crisis.

A spokesman for Purdue Pharma said in an email that the decision to stop marketing to prescribers is voluntary and independent of any litigation.

Nesin says that at the very least, the company’s decision to refrain from promoting opioids to doctors reinforces the need for caution when prescribing the drugs.

Maine Medical Association President Dr. Robert Schlager agrees that Purdue Phama’s move is a good, if small, step to fight the opioid epidemic. “I wouldn’t expect it to have a very large role in limiting opioids further,” he says. “Because most of us, as prescribers, do limit our information exchange with the drug representatives who have been marketing opioids.”

Since 2016, doctors in Maine have also adhered to prescribing limits enacted by the Legislature. As of December 2017, legislatures in 17 states had enacted prescribing limits and nine others had authorized other state entities to enact them.

Schlager says Purdue Pharma should go further and suspend opioid marketing worldwide. “It seems a little bit not honest to just limit it here in the United States,” he says.

In an email, Purdue Pharma’s spokesman says that the company operates only in the United States, and that an associated company, Mundipharma, has not marketed opioids in Europe since 2013.

A Los Angeles Timesinvestigation in 2016 found that the family that owns Purdue Pharma has a network of international companies that employ the same kinds of marketing practices that made OxyContin a blockbuster seller in the U.S.

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

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