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Doctors want to give their cancer patients every chance. But are they pushing off hard talks too long?
A new generation of immune-boosting therapies has been hailed as nothing short of revolutionary, shrinking tumors and extending lives. When late-stage cancer patients run out of other options, some doctors are increasingly nudging them to give immunotherapy a try.
But that advice is now coming with unintended consequences. Doctors who counsel immunotherapy, experts say, are postponing conversations about palliative care and end-of-life wishes with their patients — sometimes, until it’s too late.
“In the oncology community, there’s this concept of ‘no one should die without a dose of immunotherapy,’” said Dr. Eric Roeland, an oncologist and palliative care specialist at University of California, San Diego. “And it’s almost in lieu of having discussions about advance-care planning, so they’re kicking the can down the street.”
Medicaid fueling opioid epidemic? New theory is challenged
http://abcnews.go.com/Health/wireStory/medicaid-fueling-opioid-epidemic-theory-challenged-49540513
An intriguing new theory is gaining traction among conservative foes of the Obama-era health law: Its Medicaid expansion to low-income adults may be fueling the opioid epidemic.
If true, that would represent a shocking outcome for the Affordable Care Act. But there’s no evidence to suggest that’s happening, say university researchers who study the drug problem and are puzzled by such claims. Some even say Medicaid may be helping mitigate the consequences of the epidemic.
Circulating in conservative media, the Medicaid theory is bolstered by a private analysis produced by the Health and Human Services Department for Sen. Ron Johnson, R-Wis. The analysis says the overdose death rate rose nearly twice as much in states that expanded Medicaid compared with states that didn’t.
Independent experts say the analysis misses some crucial facts and skips standard steps that researchers use to rule out coincidences.
Johnson has asked the agency’s internal watchdog to investigate, suggesting that unscrupulous individuals may be using their new Medicaid cards to obtain large quantities of prescription painkillers and diverting the pills to street sales for profit. Diversion of pharmacy drugs has been a long-standing concern of law enforcement.
“These data appear to point to a larger problem,” Johnson wrote. “Medicaid expansion may be fueling the opioid epidemic in communities across the country.” He stopped just short of fingering Medicaid, saying more research is needed.
But if anything, university researchers say Medicaid seems to be doing the opposite of what conservatives allege.
“Medicaid is doing its job” by increasing treatment for opioid addiction, said Temple University economist Catherine Maclean, who recently published a paper on Medicaid expansion and drug treatment. “As more time passes, we may see a decline in overdoses in expansion states relative to nonexpansion states.”
Johnson is a conservative opponent of “Obamacare” who backed GOP efforts to curtail the Medicaid expansion. Wisconsin officials have urged him to push for changes in the health law to ensure the state wouldn’t be penalized for rejecting federal dollars to expand Medicaid.
Trump administration officials, including Health Secretary Tom Price and Seema Verma, head of the Centers for Medicare and Medicaid Services, have strongly criticized Medicaid, saying the program doesn’t deliver acceptable results.
Price’s agency would not answer questions about the analysis for Johnson, and released a statement instead.
“Correlation does not necessarily prove causation, and additional research is required before any conclusions can be made,” the statement said.
Translation: Just because something happens around the same time as something else, you can’t assume cause and effect. The statement said the administration is committed to fighting the opioid crisis.
Medicaid is a federal-state program that covers more than 70 million low-income people, from newborns to elderly nursing home residents and the disabled. Thirty-one states have expanded Medicaid to serve able-bodied adults, while 19 have not. The expansion went into effect in January, 2014, and the most recent national overdose death numbers are for 2015.
That leaves researchers with just a small slice of data. Both sides agree more research is needed.
Still, some patterns are emerging.
Prescriptions for medications used to treat opioid addiction in outpatient settings increased by 43 percent in Medicaid expansion states compared with states that didn’t expand, according to Maclean’s research with Brendan Saloner of Johns Hopkins Bloomberg School of Public Health. That indicates Medicaid is paying for treatment.
Maclean and Saloner also found another piece of the puzzle: Overdose death rates were higher to begin with in states that expanded Medicaid.
That’s important because it suggests that drug problems may have contributed to state decisions to expand Medicaid. States such as Ohio with high overdose rates might have wanted to leverage more federal money to help fight addiction
Maclean and Saloner looked at deaths from overdoses and fatal alcohol poisoning from 2010-2015, starting well before the Medicaid expansion. The HHS analysis for Sen. Johnson missed that underlying trend because it started with 2013 data.
When Gov. John Kasich, R-Ohio, talks about why he expanded Medicaid, “it has a lot to do with mental health and substance use disorders,” said Republican labor economist Craig Garthwaite of Northwestern University’s Kellogg School of Management.
Garthwaite finds the claim that Medicaid expansion fueled drug deaths “fundamentally flawed.”
Still another problem with the Medicaid theory is that it lumps all drug overdoses together. But illicit drugs — heroin and fentanyl — have been driving surges in deaths since 2010. A Medicaid card doesn’t provide access to illegal drugs.
“It’s worrisome because this is the type of numerical evidence that’s used to propose bad policy,” Garthwaite said.
Maclean, who reviewed the HHS analysis, said it seemed to rely on raw numbers without controlling for a range of differences among states, a standard technique.
Some researchers see hints that Medicaid expansion may be helping to mitigate the overdose epidemic.
Vanderbilt University economist Andrew Goodman-Bacon and Harvard’s Emma Sandoe drilled down to the county level in an informal analysis. From 2010 through 2015, counties with the largest insurance coverage gains experienced smaller increases in drug-related deaths than counties with smaller coverage gains.
More research is needed to provide conclusive evidence.
Relying on faulty research is “dangerous,” said Maclean. “It can lead to bad policies and people’s lives are at stake here.”
Governors urge keeping US health law’s individual mandate
A bipartisan governor duo is urging Congress to retain the federal health care law’s unpopular individual mandate while seeking to stabilize individual insurance markets as lawmakers work on a long-term replacement.
The recommendation is part of a compromise plan that’s designed to be palatable to both parties. It was endorsed by six other governors.
Ohio Gov. John Kasich, a Republican, and Colorado Gov. John Hickenlooper, a Democrat, shared their plan in a letter to congressional leaders Thursday. They acknowledge that retaining the mandate may be a difficult sell for Congress, which has failed so far to pass a replacement health care bill.
“The current mandate is unpopular, but for the time being it is perhaps the most important incentive for healthy people to enroll in coverage,” they wrote to House and Senate leaders of both parties.
Experts concur that keeping younger, healthier people in the insurance pool protects against costs ballooning out of control.
The penalty and coverage requirement, or individual mandates, were intended to nudge healthy people into the insurance market. They have consistently polled negatively with Americans. In an Associated Press-NORC Center for Public Affairs Research poll conducted in July, 48 percent of those surveyed favored repealing the mandate, while 35 percent opposed repeal.
Kasich and Hickenlooper’s letter was signed by Republican Gov. Brian Sandoval of Nevada; Democratic Govs. Tom Wolf of Pennsylvania, John Bel Edwards of Louisiana, Steve Bullock of Montana and Terry McAuliffe of Virginia; and Alaska Gov. Bill Walker, a one-time Republican no longer affiliated with a political party.
After Republicans’ failure to pass a replacement of President Barack Obama’s health care law, Kasich and Hickenlooper teamed up to push for health care exchanges that would stabilize the market and assure affordability. Both took pains to quash speculation that their collaboration and public appearances suggested a bipartisan presidential ticket was in the making for 2020.
Hickenlooper emphasized Thursday that steadying individual markets is a top — and time-driven — priority. Addressing Medicaid expansion costs and other health care elements can follow, he told reporters in Denver.
“Is this going to fix all that is broken with our health care system? No,” he said. “If we can demonstrate success at stabilizing the individual markets, then we can move to the other parts of health care as well.”
Kasich and Hickenlooper also recommended that President Donald Trump commit to cost-sharing reduction payments to insurers and that Congress fund those offsets at least through 2019. Those payments reimburse insurers for providing low-income people with legally required reductions on copays and deductibles. If Trump follows through on threats to pull the plug, premiums would jump about 20 percent.
Kasich said the proposal satisfies the concerns of all parties studying the health care law.
“If you want to keep what you have, you can,” the Ohio governor said Thursday. “We’ve stabilized everything up front, but then over time, we open up the doors to innovation and individual plans, within guardrails.”
The governors support creating a temporary stability fund that states could tap to reduce premiums and limit losses; continuing to fund educational outreach and enrollment efforts under the Affordable Care Act; exempting insurers that agree to cover underserved counties from the federal health insurance tax; and supporting states’ efforts to find creative solutions for covering the uninsured.
The governors said states can pursue lots of options without federal assistance, but in some cases they are “constrained by federal law and regulation from being truly innovative.”
Kasich and Hickenlooper are expected to be in Washington next week to testify on their proposal. But congressional action on even a modest compromise is expected to be difficult following years of harsh partisan battling over the Republican drive to dismantle the health care law.
Why One California County Went Surgery Shopping
http://khn.org/news/why-one-california-county-went-surgery-shopping/
Retiree Leslie Robinson-Stone and her husband enjoyed a weeklong, all-expenses-paid trip to a luxury resort — all thanks to the county she worked for.
The couple also received more than a thousand dollars in spending money and a personal concierge, who attended to their every need. For Santa Barbara County, it was money well spent: Sending Robinson-Stone 250 miles away for knee replacement surgery near San Diego saved the government $30,000.
“The only difference between our two hospitals is one is expensive and the other is exorbitant,” said Andreas Pyper, assistant director of human resources for Santa Barbara County, referring to the local options.
Frustration with sky-high hospital bills and a lack of local competition is common to many employers and consumers across the country after years of industry consolidation. Fed up with wildly different price tags for routine operations, some private employers are steering patients they insure to top-performing providers who offer bargain prices. Santa Barbara County, with about 4,000 employees, is among a handful of public entities to join them.
The county has saved nearly 50 percent on four surgery cases since starting its out-of-town program last year, officials said. The program is voluntary for covered employees.
At a Scripps Health hospital in the San Diego area, the county paid $61,600 for a spinal fusion surgery that would have cost more than twice as much locally. It avoided two other operations altogether after patients went outside the area for second opinions.
Typically, employers are seeking deals through “bundled payments” — in which one fixed price covers tests, physician fees and hospital charges. And if complications arise, providers are on the hook financially. Medicare began experimenting with this method during the Obama administration.
Santa Barbara County is among about 400 employers on the West Coast working with Carrum Health, a South San Francisco start-up that negotiates bundled prices and chooses surgeons based on data on complications and readmissions.
“Not all surgeons are equal. We don’t want to give Scripps a blank check. That defeats the whole purpose,” said Sachin Jain, Carrum’s chief executive.
Santa Barbara officials try to persuade workers and their family members to participate in its program by waiving copays and deductibles. The county pays about $2,700 in travel costs and still comes out way ahead.
“If that doesn’t speak to the inefficiencies in our health care system, I don’t know what does,” Pyper said. “It’s almost like buying a Toyota Corolla for $50,000 and then going to San Diego to buy the same Corolla for $16,000. How long would the more expensive Toyota dealership last?”
Even as more employers and insurers embrace bundled payments, the Trump administration is applying the brakes. In August, Medicare officials proposed cancelingmandatory bundled payments for certain surgeries and scaling back the program for knee and hip replacements. Health and Human Services Secretary Tom Price, when he was still a member of Congress, accused Medicare of overstepping federal authority and interfering in the doctor-patient relationship. Hospital trade groups have voiced similar objections.
That leaves some health-policy experts dismayed.
“These bundled payments put pressure on medical providers … and the savings are astonishing,” said Bob Kocher, a former health official in the Obama administration and now a partner in the venture capital firm Venrock.
Santa Barbara County officials said they had no choice after seeing their medical costs soar by 15 percent in each of the past two years. Like many local governments, it has an older workforce prone to chronic illness, blocked arteries and bum knees.
But health costs run higher than the state average in this scenic coastal county of about 450,000 people, according to data from Oakland-based Integrated Healthcare Association. By one measure, the average health insurance premium in the individual market runs $660 a month in Santa Barbara, 27 percent higher than in Los Angeles.
Still, Maya Barraza, the county’s manager for employee benefits and rewards, knew the program would be a hard sell to workers. “You don’t want to be away from your family and what’s familiar,” she said.
Cottage Health, the county’s largest health system, says it wants to keep patients in town for treatment and follow-up care.
Established in 1891, it’s grown from a single hospital to more than 500 beds across three hospitals, and annual revenue hit $746 million last year.
Valet attendants greet visitors at two entrances outside the group’s white, Spanish-style hospital in the city of Santa Barbara. In the main lobby, the names of wealthy donors are splashed across one wall, including billionaire investor and Donald Trump confidant Thomas Barrack.
“We are continually looking at reducing costs and improving quality,” said Cottage Health spokeswoman Maria Zate. “Cottage Health has some of the top surgeons in California.”
Sixty miles north in Santa Maria, the state’s largest hospital chain, Dignity Health, offers another option: Marian Regional Medical Center.
Both Cottage and Dignity hospitals in Santa Barbara County have quality scores of fair to excellent for joint replacements, spinal procedures and coronary bypass surgeries, according to three years of Medicare data analyzed by research firm Mpirica Health.
Dignity Health didn’t respond to requests for comment.
Carrum tries to help employers like Santa Barbara County find more affordable options. It has struck bundled price deals for various procedures with Scripps hospitals in the San Diego area, Stanford Health Care in the Bay Area and Swedish Medical Center in Seattle, part of the Providence Health chain.
Several other companies, such as Health Design Plus, are also assisting employers, insurers and patients with the logistics of surgery shopping. Boeing and other large employers are the most aggressive at pursuing bundled pricing and sending workers across the country for care.
Since 2014, more than 2,000 joint replacement and spinal surgeries have been performed for fixed prices through the Pacific Business Group on Health’s “centers of excellence” program, which includes employers such as JetBlue and Lowe’s. It added gastric bypass and other bariatric surgeries last year, and the employer group is working on bundled prices for cancer treatment.
Some companies have gone so far as to send patients overseas for cheaper care, but most employers favor a more regional approach, experts say. Workers still rely on local physicians for follow-up care.
Municipalities, school districts and other public employers have been slower to adopt some of these strategies, perhaps to avoid the political risk of antagonizing local providers, some researchers suggest.
For some hospitals, there are advantages in offering deep discounts: They get patients they otherwise would never see and are paid in full right after the patient is discharged, avoiding the onerous billing and collections process.
They also have the financial capacity to offer such sharply reduced prices.
Michael Bark, assistant vice president of payer relations at Scripps Health, said most hospitals significantly mark up their commercial rates for orthopedic procedures and cardiac surgeries to compensate for lower government reimbursements.
Robinson-Stone, a Santa Barbara County retiree, sits on her front step at her home in Lompoc, Calif. Her former employer sent her 250 miles away for knee replacement surgery at a hospital near San Diego and saved $30,000. (Heidi de Marco/California Healthline)
“There are immense profit margins built into those cases,” Bark said.
Robinson-Stone, a former county sheriff’s deputy and a computer support specialist, was initially wary of traveling for her surgery. But the 62-year-old Lompoc resident had ongoing pain that kept her from biking, walking her dogs and tending to her fruit trees. Medication and cortisone shots didn’t work, and she had no ties to local surgeons. So she signed up online and was given a choice of six orthopedic surgeons at Scripps Green Hospital in La Jolla.
In June 2016, she and her husband, Frank Stone, checked in at the Estancia La Jolla Hotel and Spa.
Robinson-Stone met the surgeon on a Wednesday, had the operation the next day and returned to her hotel room by Saturday. She continued physical therapy at the hotel and returned to the hospital a few days later to have the staples removed.
She was back on her bike within two months and eventually lost about 20 pounds.
“I just celebrated one year from surgery,” she said, “and I’m a happy camper.”
Cartoon – To facilitate the transition
Cartoon – Leading by Example
Cartoon – I spent hours writing down
Cartoon – Office Equipment Budget
Cartoon – I’m laughing at the idea
HENRY KOTULA 