It was supposed to be a fun evening out for Katy and Michael Branson. But their daughter Lucy, who was 3 at the time, apparently had other ideas.

The couple had tickets for a Saturday night show in April in their hometown of Las Vegas and had arranged for a sitter to watch their two girls. But as Mom and Dad were getting dressed, Lucy came upstairs to their bedroom coughing and looking rather uncomfortable.

“I think she has something up her nose,” Michael said.

For reasons she couldn’t quite explain, Lucy had shoved a matching pair of pink Polly Pocket doll shoes up her nose — one in each nostril.

Her parents tried to get her to blow her nose to dislodge the plastic footwear, but Lucy could do no better than a few sniffs. Katy found a pair of tweezers and was able to remove one shoe, but the second was too far up her tiny nose for them to reach.

Michael took Lucy to a nearby urgent care center, where the doctors had no more luck with the tweezers — called forceps in medical parlance — they had on hand and suggested he take her to the emergency room. There, a doctor was able to remove the shoe in less than a second, as Michael recalled it, with a longer set of forceps. The doctor typically finds Tic Tac mints up there, he told them. This was his first doll shoe extraction.

“All in all, it was an eventful evening,” Katy said. “My husband makes it back, we go to the show, my daughter’s fine.”

The Bransons figured they had weathered another typical night of parenting and didn’t give it much more thought. Then the bill came.

The patient: Lucy Branson, now 4, a precocious girl with a fondness for any sort of doll. She is insured through her father’s high-deductible plan with UnitedHealthcare.

Total bill: $2,658.98, consisting of a $1,732 hospital bill and a $926.98 physician bill.

Service provider: St. Rose Dominican, Siena Campus, in Henderson, Nev., part of the not-for-profit Dignity Health hospital system.

Medical procedure: Removal of a foreign body in the nose, using forceps.

What gives: The Bransons negotiated a reduction of the physician’s bill by half by agreeing to pay within 20 days. But Dignity Health declined multiple requests for an interview or to explain how it arrived at the $1,732 total for the ER visit.

“Not every urgent situation is an emergency,” the hospital said in an emailed statement. “It is important for patients to understand the terms of their health insurance before seeking treatment. For example, those with high-deductible plans may want to consider urgent care centers in nonemergency situations.”

The hospital billed the Bransons $1,143 for the emergency room visit and an additional $589 for removing the shoe. The entire $1,732 hospital bill was applied against their deductible.

For public health plans like Medicare or Medicaid, the hospital generally bills an average of $526 for removing a foreign body from the nose and gets an average payment of $101, according to WellRithms, a medical billing review firm.

According to cost reports submitted to Medicare, the hospital’s average cost for the procedure comes to less than $48. That’s less than a quarter of the $222 fee WellRithms recommended and well below the $589 St. Rose charged the Bransons.

The Bransons had options as they chose their employer-sponsored health plan. They picked one with a high deductible of $6,000 per year. So instead of paying $500 more a month in premiums, the family could pocket that difference if it avoided any major health problems.

“I’d rather gamble that I might have to pay it, versus commit to paying it every month,” Katy said.

The Bransons were ready to cover the full deductible for any emergency that might arise. They just never thought something as simple as extracting a plastic shoe with tweezers would garner such a big bill.

Removing a foreign body from a child’s nose or ear is a fairly common procedure in emergency rooms, with the variety of objects removed from noses limited only by the size of the nostrils.

“Kids like to put things in their nose or their ears, for whatever reason,” said Dr. Melissa Scholes, an ear, nose and throat specialist with the University of Colorado School of Medicine.

Scholes recently reviewed records for 102 children who came to Children’s Hospital Colorado from 2007 to 2012 with objects stuck in their noses. About a third of those patients were referred to an ear, nose and throat clinic, and about half of those required surgery to remove the object. Doctors were able to remove the object in the emergency room in the remaining two-thirds of cases.

Scholes said pediatricians don’t often have the necessary tools to remove the object. Those can include extralong tweezers or a catheter with a balloon on the end. The tip of the catheter is snaked past the object, then the balloon is inflated and the catheter is pulled out, dislodging the foreign body.

“People don’t really have a good grasp of the anatomy of the nose, because a lot of people think it’s just like a tube,” Scholes said. “It’s a big cave once you get past the nostrils. So once things get back far enough, you kind of lose them.”

Resolution: The Bransons are still fighting to get a detailed explanation of how Dignity Health calculated its bill.

“It’s not even so much that we can’t pay that if we absolutely have to,” Katy said. “It doesn’t make sense that it costs that much. A human being needs to look at this and say, ‘Why are we charging $3,000 to take a Barbie shoe out of the kid’s nose?’ ”

After all, Katy doesn’t own a single pair of shoes worth anywhere close to $3,000 herself.

“Well, apparently, now I have one,” she said. “But they’re not in my closet; they’re in the playroom.”

The takeaway: Check with your doctor if you can about whether a medical issue constitutes an emergency or if it can wait until morning.

Sometimes your pediatrician’s office can recommend a do-it-yourself method for removing an object in the nose to avoid a costly emergency room visit.

Known as the “mother’s kiss,” Mom covers the child’s mouth with her mouth to form a seal, blocks the clear nostril with her finger and then blows into the mouth. The pressure from the breath may then expel the object. (The technique works equally well when performed by dads.)

For parents whose children have put things up their noses, Scholes said such objects rarely move much and can generally wait until an appointment the next morning. Having the object removed without the ER facility fee will be cheaper.

In terms of the bill, the Bransons were smart to negotiate right away, and they succeeded in getting a significant discount from the original. Many hospitals offer what they like to call “prompt-pay discounts” (often 10% to 25%). For hospitals, getting the cash quickly is valuable and even billing clerks may be able to approve the discount on the spot.

But don’t jump at the first discount they offer. And don’t let an outrageous bill sit on the kitchen table as you get angrier and angrier. Start haggling and hassling ? and keep it up. After all, a 25% percent discount off a highly inflated bill results in one that is only slightly less outrageous, as the Bransons found out the hard way.

NPR produced and edited the interview with KHN Editor-in-Chief Elisabeth Rosenthal for broadcast. Freelance reporter Stephanie O’Neill provided audio reporting.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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When Matthew Braun gets out of medical school, he’ll be able to prescribe opioids.

A decade ago, he was addicted to them.

“The first time I ever used an opioid, I felt the most confident and powerful I’d ever felt,” Braun says. “So I said, ‘This is it. I want to do this the rest of my life.’ “

Opioids took away his anxiety, his inhibitions, his depression. And they were easy to get.

“I just started breaking into houses,” Braun says. “I found it amazing how trusting people were in leaving windows open and doors unlocked, and I found a lot of prescriptions.”

Vicodin, OxyContin, tramadol. The drugs were everywhere. At the time, more than a decade ago, doctors and dentists were writing lots of prescriptions — even to Braun.

“I didn’t need 20 Vicodin when I got my wisdom teeth out,” he says. “So I just saved them.”

Braun, who hasn’t used opioids in years, is now a first-year medical student at Pacific Northwest University of Health Sciences in Yakima, Wash. He told his story at a two-day summit on opioids held in Yakima.

One goal of the event was to get past the angry rhetoric that often surfaces in discussions of opioids.

“It can get very hostile,” says Edward Bilsky, a pain researcher and the university’s provost and chief academic officer.

Bilsky has heard people in the addiction community blame chronic pain patients for opioid overdoses. The logic is that widespread use of opioids for pain has fueled addiction and abuse.

“And on the flip side,” Bilsky says, “pain groups are saying, ‘No, it’s [people in the addiction community] that abuse these drugs, and now I can’t get access to something that did give me some semblance of quality of life.’ “

Bilsky says the summit was designed to help the pain and addiction communities acknowledge common barriers — such as stigma and access to care — and encourage them to work together to find solutions.

So in addition to people like Braun, who has experienced addiction, the event included people like Katie Buckman, a third-year medical student at the university who gets severe migraines.

“It feels like your head is going to explode,” Buckman says. “And on top of that, you can’t tolerate light, and the nausea and vomiting — you’re just miserable.”

Migraines almost forced Buckman to leave medical school. But she has been able to continue with help from a primary care doctor who understands the severity of her pain.

“If I’m lucky enough to have the migraine between Monday and Friday from 8 to 5,” she says, “I can call him and get a shot of Demerol,” which is an opioid.

That’s rare, Buckman adds. Her migraines have largely disappeared since she started on a new preventive drug a few months ago. When they do crop up, her usual remedy is Benadryl and fluids.

But Buckman still remembers the stigma that pain patients can face when they show up in a hospital’s emergency department.

“One time I had a doc, before he even came in and introduced himself as my caregiver, he just popped his head in, said, ‘Well, you’re not going to be receiving any narcotics today,’ ” Buckman says.

Then there are doctors like Tom Eglin, an emergency physician who also participated in the opioid summit.

Eglin is a faculty member at the university and works at Virginia Mason Memorial hospital in Yakima. So he knows what can happen to drug users who take a powerful opioid like fentanyl thinking it’s something less potent.

“They go into respiratory arrest,” he says. “And if they’re lucky, [a first-responder] has naloxone and can reverse that.”

But Eglin also sees patients who clearly need an opioid. They may have excruciating pain from a kidney stone, a fracture or a bad burn.

“Pain is the primary reason that people come to the emergency department,” he says. “A typical night we’re always writing prescriptions for pain medications.”

The big challenge for an emergency physician is deciding whether a patient with no detectable injury is seeking drugs, Eglin says.

“Sometimes it’s obvious,” he says. “But the majority of the time, it’s not just difficult — it’s impossible.”

Disabling back pain, for example, often occurs in patients with normal X-rays and CT scans.

And maybe, Eglin says, looking for drug-seeking behavior isn’t a doctor’s most important job when someone comes to them in distress.

“I try not to make that judgment,” Eglin says. “Whether they’re addicted or whether they’re a migraine sufferer, they are still there for pain relief. And most people who are addicted still have the perception of bad pain.”

What’s frustrating, Eglin says, is that even when patients end up in the emergency room from an overdose, there’s no easy way to get them into a treatment program. “Most of the time they get discharged to the street,” he says.

People addicted to opioids and people in chronic pain have a lot in common: Both groups face stigma, often struggle to get treatment and need doctors who understand their problem.

That’s a lesson medical students Buckman and Braun have embraced.

Once she’s a doctor, Buckman says, “I’ll be able to empathize at a different level because I have experienced severe pain.”

And Braun says his own history of addiction will help him treat people with that condition.

But even someone in recovery may need an opioid for certain types of pain, he says, adding that he’d write a prescription if it were appropriate and the patient was taking active steps to avoid relapse.

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Insurance regulators across the country are taking action against a Georgia-based company that markets and administers programs on behalf of health care sharing ministries.

State officials in Texas, Colorado, Washington and most recently New Hampshire accuse Aliera, as well as Trinity HealthShare, an entity with which it contracts, of violating state and federal requirements. Those violations include failing to make its religious affiliations clear and selling plans outside the markets allowed by statute.

Members of health care sharing ministries pay monthly premiums, with the expectation that the money will be shared when medical bills arise. Though no exact figures exist, industry groups say close to 1 million Americans get their health coverage through these Christian-based entities.

“There are legitimate health care sharing ministries that offer coverage for their members, but Aliera and Trinity are not one of them,” said New Hampshire Insurance Commissioner John Elias, who accuses the companies of selling illegal insurance products.

One New Hampshire customer who signed up for Trinity’s health care sharing ministry is Keith Meehan, 49, an international rice salesman whose company doesn’t provide health insurance.

After his doctor recommended back surgery for a disk issue, Aliera and Trinity HealthShare assured Meehan the procedure didn’t require preapproval. But after the surgery, it declined to pay approximately $200,000 in medical bills, contending his back pain was a preexisting condition.

“I feel like I was sold a bad bill of goods,” Meehan says. “I had no idea.”

Health care sharing ministries don’t have to follow the same rules as insurers, and they face no requirements to pay claims. To industry watchers, their marketing materials don’t lay out these risks clearly enough.

“Having a disclaimer somewhere on Page 17 saying this is not insurance and there is no guarantee to pay is not necessarily going to turn people away,” says JoAnn Volk, a researcher at Georgetown’s Center on Health Insurance Reforms.

But to many families, health care sharing ministries offer a lower-cost alternative for coverage that also aligns with their values.

“The cost was typically a fraction, typically well under half and usually closer to a third of what the cost of conventional insurance was,” says Fenton Groen, a builder in Rochester, N.H., who has been happily enrolled in health care ministries since the early 1990s.

Along with the lower sticker price, Groen believes the popularity of health care sharing has grown in recent years because most ministries won’t cover abortion services. Many also offer prayer hotlines for members.

Groen says he supports regulators stepping in to stop a company like Aliera if, as alleged, it is not adhering to the few regulations these entities must follow.

“Given the explosive growth of health care sharing ministries, it is not surprising to me that someone would try to cut in on that,” says Groen.

Other health care sharing groups say Aliera’s actions are harming the reputation of the broader industry.

“The sharing ministries have been very alarmed, very concerned about the press reports and the misconceptions that people can have about the sharing ministries and the legitimate work they actually do,” said Dr. Dave Weldon, president of the Alliance of Health Care Sharing Ministries.

Investigative reporting by the Houston Chronicle revealed that the co-founder of Aliera, which is based in Georgia, previously served time in prison for securities fraud. The company is facing a proposed class-action lawsuit in Washington state for alleged deceptive practices.

Aliera and Trinity both deny violating New Hampshire law. Aliera says it plans to appeal the cease-and-desist order.

“Aliera will continue to vigorously defend against false claims made about the administrative, marketing and other support services we provide to health care sharing ministries (HCSMs), and we’re confident the HCSMs we support will defend the right of their members to exercise their religious convictions in making health care choices,” wrote the company in a statement.

Meehan, the rice salesman with $200,000 in unpaid medical bills, says he wishes he had read the fine print before signing up.

“I mean, I’m not trying to skate on my responsibilities,” he says. “Had I known that this was the way it was going to turn out, I would have suffered. I can endure some pain, both physical and mental. But I would have never gone through with the surgery.”

More pain is on the way. Meehan says he is considering filing for bankruptcy.

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When Lorraine Griggs’ 86-year-old father was diagnosed with prostate cancer, he was treated with 35 rounds of radiation, though he had a long list of other serious medical issues, including diabetes, kidney disease and high blood pressure. The treatment left him frailer, Griggs recalls.

A few years later, when his prostate cancer reoccurred, Griggs’ father received a different kind of cancer care. Before his doctor devised a treatment plan, she ordered what’s known as a geriatric assessment. It included a complete physical and medical history, an evaluation by a physical therapist, a psychological assessment and a cognitive exam. The doctor also asked her father about his social activities, which included driving to lunch with friends and grocery shopping with some assistance.

“When the doctor saw how physically active and mentally sharp my father was at 89 years of age, but that he had several chronic, serious medical problems, including end stage kidney disease, she didn’t advise him to have aggressive treatment like the first time around,” says Griggs, who lives in Rochester, N.Y.

Instead, his oncologist placed her dad on one pill a day that just slowed down his cancer. Griggs’ father was able to enjoy his activities for another three years until he died at the age of 92.

Geriatric assessment is an approach that clinicians use to evaluate their elderly patients’ overall health status and to help them choose treatment appropriate to their age and condition. The assessment includes questionnaires and tests to gauge the patients’ physical, mental and functional capacity, taking into account their social lives, daily activities and goals.

The tool can play an important role in cancer care, according to clinicians who work with the elderly. It can be tricky to predict who will be cured, who will relapse and who will die from cancer treatment. Geriatric assessments can help physicians better estimate who will likely develop chemotherapy toxicities and other serious potential complications of cancer treatment, including death.

Geriatric assessment includes an evaluation by a physical therapist, a psychological assessment, a cognitive exam and a complete physical and medical history. The doctor takes all these factors into account and tallies a score for their patient to help guide their decision-making about the patient’s treatment.

Although the geriatric assessment is not 100% accurate, “it’s better than the clinician eyeball test,” says Supriya Gupta Mohile, a geriatric oncologist and professor of medicine at the University of Rochester. “If I didn’t do a geriatric assessment and just looked at a patient I wouldn’t have the same information,” she says.

A vulnerable population

More than 60% of cancers in the U.S. occur in people older than 65. As the population grows older, so will the rate of cancer among seniors. The cancer incidence in the elderly is expected to rise 67% from 2010 to 2030, according to a 2017 study in the Journal of Clinical Oncology. Yet many oncologists don’t have geriatric training.

Mohile, who treated Griggs’ father during his cancer relapse, explains that geriatric oncologists take a different approach than many other oncologists.

“We want to help older adults successfully undergo cancer treatment without significant toxicities, so it leads to a survival benefit,” she says. “What we don’t want to do is treat patients who will be harmed.”

Mohile says when she saw that Griggs’ dad was frail because of his other health issues, she explained that the standard treatment of care would be difficult for him.

“We went through the decision-making together and I was able to explain how it could cause harm and it would have no risk benefit. He wanted to live and not suffer toxicities,” she says.

A growing body of evidence supports the notion that cancer care for older adults can be improved with geriatric assessments.

A study published in the Journal of Geriatric Oncology in November found that in 197 cancer patients 70 years and older, 27% of the treatment recommendations patients received from the tumor board were different from those received after completing a geriatric assessment. Patients who received a geriatric assessment were recommended to have less intensive treatment or palliative care.

Overall, geriatric assessments have been found valuable for helping older adults with health conditions achieve higher quality of life. A 2017 Cochrane review of 29 studies of geriatric assessments on patients who’d been hospitalized found that patients were more likely to be alive and at home a year later compared to those who had standard care.

One of the reasons geriatric assessments can be so useful to clinicians treating cancer is that doctors don’t have enough information at their fingertips about how older patients respond to the drugs commonly used for chemotherapy. This is partly because there’s less research on this age group.

“You’re playing a guessing game most of the time. Older patients on chemo can get in more trouble than younger patients. The real issue is the patient’s capacity to tolerate care. I think geriatric assessments can improve how we tailor therapy,” says Efrat Dotan, associate professor of hematology/oncology at Fox Chase Cancer Center in Philadelphia and chair of the National Comprehensive Cancer Network, NCCN.

But other experts caution that geriatric assessments can backfire because of a dominant culture in medicine that tends to try to cure patients at all costs, even when treatments may be dangerous.

“Sometimes you don’t want to ask questions because you’re afraid you may have to deal with the answers,” says Otis Brawley, Bloomberg distinguished professor of oncology and epidemiology at Johns Hopkins University in Baltimore.

“The test tends to give us answers that scare us from treatment, and we are supposed to treat patients,” he says.

Often, if a cancer patient is turned away from treatment, they try to find a doctor that will offer it anyway.

“This happens all the time. The irony is that by going away from a doctor really doing the appropriate thing and then going to another doctor who doesn’t do the appropriate thing, sometimes that second doctor is actually hastening death,” says Brawley, former chief medical and scientific officer at the American Cancer Society.

An underutilized tool

Though geriatric assessments were developed about two decades ago and hailed as one of the clinical cancer advances of 2012 by the American Society of Clinical Oncology, they are still not widely used by oncologists.

The Surgical Task Force at the International Society of Geriatric Oncology found that only 6.4% of surgeons use comprehensive geriatric assessments in daily practice, and only 36.3% collaborate with geriatricians, according to a 2016 study in the European Journal of Surgical Oncology.

Many major academic centers have adopted the use of geriatric assessments. However, they’re still fairly scarce in community practices where staffing shortages, financial constraints, lack of institutional support and technology are major barriers to use. They are also time-consuming to complete — taking about two hours.

But these days, “the geriatric assessment is a tool anyone can print out and use,” Mohile says. It’s recently been streamlined and will soon be built into the online health record, EPIC, she says.

Still, lack of training among oncologists is an issue, Mohile says.

“Geriatric assessments have been around for a long time, but they have not been traditionally used by oncologists because they haven’t been trained how to do it or use it,” she says.

Finding treatment options for frail patients

Matthew LoBiondo Sr. from Conesus, N.Y., was being treated with chemotherapy for a gastrointestinal tumor when Mohile first met him as an inpatient. The 89-year-old was hospitalized because he was weak, dehydrated and not eating. Mohile says the dose of the medication he was on was too toxic for him.

Once she took over his care, she weaned him off that treatment, did a geriatric assessment with him and tailored a less toxic treatment plan.

One of the tenets of geriatric assessments is to help physicians select treatments that are best suited for a patient by getting to the core of their physical and mental capacity, regardless of their chronological age.

That’s ultimately the best way to treat older cancer patients, says Armin Shahrokni, a geriatrician and medical oncologist at Memorial Sloan Kettering Cancer Center in New York.

“The data are clear that the fitness of an older cancer patient, rather than age per se, should be the factor considered” when it comes to cancer treatment, he wrote in an editorial in the Annals of Surgical Oncology.

“Age is a meaningless number. I can see a very active 85-year-old very healthy cancer patient who runs marathons. I can also see a 65-year-old with a lot of other comorbid illnesses who is not as functional. How I treat them for cancer would be different,” Shahrokni says.

When he assesses a patient to be too frail for cancer surgery, he says it doesn’t mean that a patient would automatically go on palliative care.

“You would be amazed at how many other options open,” he says.

A frail patient with lung cancer, for instance, can be redirected from surgery to radiation, which is less toxic than chemotherapy and less invasive than surgery.

Geriatric assessments are a way to guide better cancer decision-making, he says.

As more studies about the value of geriatric assessments come out, Shahrokni says he hopes more people will become aware of their importance and find a way to implement them in their practice.

Health problems are less obvious among older adults because of atypical presentations, or because of communication problems due to hearing loss or cognitive impairment. Problems such as psychosocial status, or the environment, increase in importance in older patients because they frequently coexist with health problems and can interfere with their management.

“I think things are moving forward very nicely. In the next 10 years my hope is that not only surgeons and oncologists will do these types of assessments, but patients and their families will demand the health care system to provide a more comprehensive assessment of their functional status before cancer treatment. I think this is going to lead to better outcomes for patients,” Shahrokni says.

Cheryl Platzman Weinstock is an award-winning health and science journalist. This article was written with the support of a fellowship from the Gerontological Society of America, Journalists Network on Generations and the Retirement Research Foundation.

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Babies born to mothers who used opioids during pregnancy represent one of the most distressing legacies of an opioid epidemic that has claimed almost 400,000 lives and ravaged communities.

In fact, many of the ongoing lawsuits filed against drug companies make reference to these babies, fighting through withdrawal in hospital nurseries.

The cluster of symptoms they experience, which include tremors, seizures and respiratory distress, is known as neonatal abstinence syndrome, or NAS. Until recently, doctors rarely looked for the condition. Then case numbers quadrupled over a decade. Hospital care for newborns with NAS has cost Medicaid billions of dollars.

Studies indicate more than 30,000 babies with the condition are born every year in the U.S. — about one every 15 minutes. Although their plight is mentioned in opioids-related litigation, there are growing concerns that those same children will be left out of financial settlements being negotiated right now.

Robbie Nicholson, a mother in Eagleville, Tenn., tried to comfort her second child while the baby slowly underwent withdrawal from drugs Nicholson had taken during pregnancy.

“The whole experience is just traumatizing, really,” Nicholson says.

Nicholson’s ordeal actually began right after her first pregnancy. To help with postpartum recovery, her doctor prescribed her a pile of Percocets. That was the norm.

“Back then, it was like I was on them for a full month. And then he was like, ‘Ok, you’re done.’ And I was like, ‘Oh my god, I’ve got a newborn, first time mom, no energy, no sleep, like that was getting me through,’ ” she says. “It just built and built and built off that.”

After developing a full-blown addiction to painkillers, Nicholson eventually found her way into recovery. In accordance with evidence-based guidelines, she took buprenorphine, a medication that helps keep her opioid cravings at bay. And then came another pregnancy.

But buprenorphine — as well as methadone, another drug used in medication-assisted addiction treatment — is a special kind of opioid. Its use during pregnancy can still result in withdrawal symptoms for the newborn, although increasingly physicians have decided that the benefits of keeping a mother on the medication, to help her stay sober and stable during pregnancy, outweighs the risk of her giving birth to a baby with neonatal abstinence syndrome.

Treatment protocols for NAS vary from hospital to hospital, but over time doctors and neonatal nurses have become better at diagnosing the condition and weaning newborns safely. Sometimes the mom and her baby can even stay together if the infant doesn’t have to be sent to the neonatal intensive care unit.

But not much is known about the long-term effects of NAS, and both parents and medical professionals worry about the future of children exposed in utero to opioids.

“I wanted her to be perfect, and she is absolutely perfect,” Nicholson says. “But in the back of my mind, it’s always going to be there.”

There are thousands of children like Nicholson’s daughter entering the education system. Dr. Stephen Patrick, a neonatologist in Nashville, says schools and early childhood programs are on the front lines now.

“You hear teachers talking about infants with a development delay,” he says. “I just got an email this morning from somebody.”

Studies haven’t proven a direct link between in utero exposure to opioids and behavior problems in kids. And it’s challenging to untangle which problems might stem from the lingering effects of maternal drug use, as opposed to the impacts of growing up with a mother who struggles with addiction, and perhaps unemployment and housing instability as well. But Patrick, who leads the Center for Child Health Policy at Vanderbilt University, says that’s what his and others’ ongoing research wants to find out.

As states, cities, counties and even hospitals go after drug companies in court, Patrick fears these children will be left out. He points to public discussion of pending settlements, and the settlement deals struck between pharmaceutical companies and the state of Oklahoma, which make little or no mention of children.

Settlement funds could be used to monitor the health of children who had NAS, to pay for treatment of any developmental problems, and to help schools serving those children, Patrick explains.

“We need to be in the mix right now, in schools, understanding how we can support teachers, how we can support students as they try to learn, even as we work out was there cause and effect of opioid use and developmental delays or issues in school,” he says.

But it’s a nuanced problem with no consensus on where money is most needed, even among those who’ve been working on the problem for years.

Justin Lanning started Nashville-based 180 Health Partners, which works with mothers at risk of delivering a baby dependent on opioids. Most are covered by Medicaid. And those Medicaid departments in each state pay for most of the NAS births in the U.S.

“We have a few departments in our country that can operate at an epidemic scale, and I think that’s where we have to focus our funds,” he says.

Lanning sees a need to extend government-funded insurance for new mothers, since in states like Tennessee that never expanded Medicaid, these moms can lose health coverage just two months after giving birth. That often derails the mother’s own drug treatment funded by Medicaid, he says.

“This consistency of care is so key to their recovery, to their productivity, to their thriving,” Lanning says of new mothers in recovery.

Robbie Nicholson now has a job at 180 Health Partners, assisting and mentoring pregnant women struggling with addiction. Nicholson says their biggest need is a stable place to live and reliable transportation.

“I just feel kind of hopeless,” she says. “I don’t know what to tell these women.”

There are many needs, Nicholson says, but no simple fix. Those who work with mothers in recovery fear any opioid settlement money may be spread so thin that it doesn’t benefit their children — the next generation of the crisis.

This story comes from NPR’s reporting partnership with Nashville Public Radio and Kaiser Health News.

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Herman Ware sits at a small, wobbly table inside a large van that’s been converted into a mobile health clinic. The van is parked on a trash-strewn, dead-end street in downtown Atlanta where homeless residents congregate.

Ware is here for a seasonal flu shot.

“It might sting,” he says, thinking back on past shots.

Ware grimaces slightly as the nurse injects his upper arm.

After filling out some paperwork, he climbs down the van’s steps and walks back to a nearby homeless encampment where he’s been living. The small cluster of tents sits below an interstate overpass, next to a busy rail line.

Ware hasn’t paid much attention to his medical needs lately, which is pretty common among people living on the street. For those trying to find a hot meal or a place to sleep, health care can take a backseat.

“Street medicine” programs, like the outfit giving Ware his flu shot, aim to change that. Mercy Care, a health care nonprofit in Atlanta, operates a number of clinics throughout the city that mainly treat poor residents, and also has been sending teams of doctors, nurses and other health care providers into the city’s streets since 2013. The idea is to treat homeless people where they live.

This public health strategy can now be found in dozens of cities in the U.S. and around the world, according to the Street Medicine Institute, which works to spread the practice.

Building relationships to give care

Giving shots and conducting exams outside the walls of a health clinic comes with unique challenges.

“When we’re coming out here to talk to people, we’re on their turf,” says nurse practitioner Joy Fernandez de Narayan, who runs Mercy Care’s Street Medicine program.

A big challenge is getting patients to accept help, whether it comes in the form of a vaccination or something simpler — like a bottle of water.

“We’ll sit down next to someone, like ‘Hey, how’s the weather treating you?’ ” she says. “And then kind of work our way into, like, ‘Oh, you mentioned you had a history of high blood pressure. Do you mind if we check your blood pressure?’ “

The outreach workers spend a lot of time forging relationships with homeless clients, and it can take several encounters to gain someone’s trust and get them to accept medical care.

Their persistent encouragement was helpful for Sopain Lawson, who caught a debilitating foot fungus while living in the encampment.

“I couldn’t walk,” Lawson says. “I had to stay off my feet. And the crew, they took good care of my foot. They got me back.”

“This is what street medicine is about — going out into these areas where people are not going to seek attention until it’s an emergency,” says Matthew Reed, who’s been doing social work with the team for two years.

“We’re trying to avoid emergencies, but we’re also trying to build relationships.”

“Go to the people”

The street medicine team uses the trust they’ve built with patients to eventually connect them to other services, such as mental health counseling or housing.

Access to those services may not be readily available for many reasons, says Dr. Stephen Hwang, who studies health care and homelessness at St. Michael’s Hospital in Toronto. Sometimes the obstacle — say, lacking enough money for a bus ticket — seems small, but is formidable.

“It may be difficult to get to a health care facility, and often there are challenges, especially in the U.S., where people don’t have health insurance,” Hwang adds.

Georgia is one of a handful of states that has not expanded Medicaid to all low-income adults, which means many of its poorest residents don’t have access to the government-sponsored health care program. But even if homeless people are able to get health coverage and make it to a hospital or clinic, they can run into other problems.

“There’s a lot of stigmatization of people who are experiencing homelessness,” Hwang says, “and so often these individuals will feel unwelcome when they do present to health care facilities.”

Street medicine programs are meant to break down those barriers, says Dr. Jim Withers. He’s medical director of the Street Medicine Institute and started making outreach visits to the homeless back in 1992, when he worked at a clinic in Pittsburgh.

“Health care likes people to come to it on its terms,” Withers says, while the central tenet of street medicine is, “Go to the people.”

Help, with respect

Mercy Care in Atlanta spends about $900,000 a year on its street medicine program. In 2018, that sum paid for direct treatment for some 300 people, many of whom got services multiple times. Having clinics on the street can help relieve the care burden of nearby hospitals, which Withers says don’t have a great track record when it comes to treating the homeless.

“We’re not dealing with them well,” Withers admits, speaking on behalf of American health care in general. In traditional health settings, homeless patients do worse compared to other patients, he says. “They stay in the hospital longer. They have more complications.”

Those extra days and clinical complications mean additional costs for hospitals. One recent estimate cited in a legislative report on homelessness suggested that more than $60 million in medical costs for Atlanta’s homeless population were passed on to taxpayers.

Mercy Care says its program makes homeless people less likely to show up in local emergency rooms and healthier when they do — which saves money.

It’s past sundown when the street medicine team rolls up to their final stop: outside a church in Atlanta where homeless people often gather. A handful of people have settled down for the night on the sidewalk. Among them is Johnny Dunson, a frequent patient of the street medicine program.

Dunson says the Mercy Care staffers have a compassionate style that makes it easy to talk to them and ask for help.

“You gotta let someone know how you’re feeling,” Dunson says. “Understand me? Sometimes it can be like behavior, mental health. It’s not just me. It’s a lot of people that need some kind of assistance to do what you’re supposed to be doing, and they do a wonderful job.”

Along with the medical assistance, the staff at Mercy Care give every patient big doses of respect and dignity. When you’re living on the street, it can be hard to find either.

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

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During Wednesday night’s Democratic presidential debate, candidates touched on “Medicare for All,” “Medicare for all who want it” and other ways to reform the American health system.

But in the backdrop, it’s once again sign-up season for Affordable Care Act health plans.

Despite repeated efforts by Republicans in Congress to undo the ACA, the controversial law’s seventh open-enrollment period launched earlier this month to relatively little fanfare. It ends Dec. 15.

Individual plans for 2020 are cheaper — premiums are lower, on average, and in some areas, people who qualify for government subsidies could end up with no monthly payment. Do check the fine print of your policy — in some cases, the patient’s share of other costs may have gone up.

Meanwhile, a pending court case threatens to overturn the entire law, with no clear replacement plan in the works. The result has been a cloud of confusion and misunderstanding — some even say misinformation — about the availability of this health coverage.

Here’s what consumers need to know.

The ACA is intact — at least for now.

The Affordable Care Act is still the law of the land.

The GOP-led Congress gutted a key part of the law — the penalty for the so-called individual mandate — that required everyone to have coverage. But other key tenets of the ACA remain in place, including the individual marketplace it created where people can shop for health coverage.

You might not hear much about that this year. The Trump administration has dramatically scaled back its outreach and marketing budget for open enrollment — allotting about $10 million for such efforts, compared with the more than $100 million the Obama administration spent.

Lack of outreach, combined with Republican efforts to overturn or undermine the law, could give consumers a wrong impression, says Katie Keith, a health policy consultant who frequently writes about the health law.

So far, about 930,000 people have signed up for coverage. That’s still slightly lower than where things were last year — and first-day Website glitches may have played a role, suggests Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

In week two of the sign-up period, enrollment was about 10% below what it was in last year’s second week – but the number of new customers has gone up.

“The irony is, things are really stable, and depending on your state, you can really save,” Keith says. “Without advertising and information, folks are going to miss out on the deals they could get.”

You can get a cheaper plan this year, but it will probably require a bit of work.

Those deals can be pretty significant. On average, premiums are down 4% nationally over last year for silver-level plans sold through the federal marketplace. In some states, they’re even cheaper.

Many people don’t realize that if their incomes are below 400% of the federal poverty level (just under $50,000 for an individual or about $103,000 for a family of four) they qualify for federal subsidies — tax credits that help them pay for individual marketplace plans, Corlette says. The federal government has an online calculator that indicates if you fit into this bracket.

That tax break can make it easier to find affordable, comprehensive coverage, Corlette says, and she recommends that people who already have 2019 ACA plans shop around the marketplace to make sure they get the best deal going into 2020. (What plans charge can change each year.)

People who bought coverage last fall and don’t shop around will be automatically reenrolled in those health plans — which may not be the best for their needs and may be more expensive than other options.

Also worth noting: Federal courts recently blocked a rule that would have penalized recent legal immigrants who use those subsidies. Known as the “public charge” rule, it would have counted that subsidy against people looking to stay longer in the United States.

The court ruling means that, at least for now, legal immigrants should also be able to purchase subsidized health insurance with no penalty, Corlette says.

“If you have concerns or are worried, you should consult an immigration attorney. But assuming you are a legal resident, nothing has changed in terms of your entitlement,” she says.

Not everything that looks like an ACA plan actually is one.

Consumers should be wary of plans that look like they meet ACA standards but actually fall short.

The Trump administration has loosened restrictions on non-ACA policies — “short-term plans” — so that they can last up to 12 months. (Previously they lasted only three months and were treated as bare-bones, stopgap insurance.)

Pitched as a cheaper alternative to ACA coverage, they are allowed to factor in preexisting medical conditions — and can deny insurance to people because of their medical history. They also generally cover a much narrower range of benefits. Some have lifetime caps on benefits, and they typically don’t cover prescription drugs.

These plans are not eligible for federal subsidies.

“If you were to Google something like ‘ACA plan’ or ‘Obamacare plan,’ the first results will return insurances that are not ACA coverage,” Corlette warned. “A lot of it is going to be junky, skimpy coverage.”

One easy way to distinguish ACA-compliant plans from others: Make sure you’re shopping through healthcare.gov or an alternative set up by some states. Consumers who work with an insurance broker should be sure to communicate their desire to choose an ACA-compliant plan.

Meanwhile, federal courts are weighing a legal challenge that could strike down the ACA.

It’s not clear what would happen if that attempt to overturn the federal health law succeeds. But, for now, the case shouldn’t affect your coverage decisions, all sides agree.

A group of Republican attorneys general and governors filed a lawsuit in 2018 that argues that since the Supreme Court upheld the ACA in 2012 specifically because its individual mandate was deemed a valid exercise of Congress’ taxing power, reducing that tax to zero — as Congress did — makes the entire law unconstitutional. It’s an argument that many legal experts say is shaky, but a federal judge in Texas agreed with those who brought the suit.

The case, known as Texas v. Azar, is awaiting a ruling from the 5th Circuit Court of Appeals. The Trump administration, meanwhile, has declined to defend the federal health law. A group of Democratic attorneys general has stepped in, in their stead.

If the appellate court sides with the trial judge to overturn the ACA, the decision would likely be stayed and the case appealed to the Supreme Court. That could drag things out until next summer at the earliest.

The administration hasn’t indicated what it might do if the health law is struck down — a scenario that would gut the individual marketplace and eliminate the ACA’s consumer protections. But most experts agree it is also not likely to affect the 2020 coverage year.

Earlier this month, Joe Grogan, who heads the White House’s Domestic Policy Council, reiterated that the administration “will be prepared after that decision comes down” — adding that “nothing’s going to happen immediately.”

“This will surely go to the Supreme Court,” Grogan said. “It may or may not be decided — probably not decided — before the election.”

But it’s unclear what a White House response would involve. Neither President Trump nor Republicans in Congress have put forth a health care proposal that would maintain the protections the Affordable Care Act put in place.

That could be worrisome down the line, Keith and Corlette say. But any impact is far enough away that it shouldn’t influence the way consumers choose health insurance for the next year.

“Nothing will change right away, and it shouldn’t affect anybody anytime soon,” Keith says. “Go enroll. Pay your premiums.”

Emmarie Huetteman contributed to this report.

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

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Right now, there are dozens of patients — U.S. citizens — in New Zealand hospitals who are fighting the clock. They have only a few weeks to recover and get home to the tiny island of American Samoa, a U.S. territory in the South Pacific.

“We have a cancer patient that is coming back in December,” says Sandra King Young, who runs the Medicaid program in American Samoa. “We can only give him six weeks of chemo, radiation and surgery. He has a good chance of survival if he has the full year of treatment, but not six weeks. The patient and family understand, and since they have no money, they have agreed to come back.”

The federal money to fully fund the Medicaid program in American Samoa and in all other U.S. territories is about to run out. As a consequence, the off-island referral program to treat conditions that the territory doesn’t have the local capacity or facilities to treat — the program that brought these patients to New Zealand — is getting shut down.

“It’s devastating for those people who need those lifesaving services,” King Young says. “People who need cancer treatment won’t get it. Children with rheumatic heart disease won’t get the heart surgeries that they need.”

All five of the U.S. territories affected — collectively home to more than 3 million Americans — are now desperately trying to figure out how to keep Medicaid running with only a fraction of the money they’ve had for the last several years. If Congress doesn’t increase the amount of designated money by the end of the year, the U.S. Virgin Islands and Guam say they would need to cut their Medicaid rolls in half; Puerto Rico says it would need to cut back dental and prescription drug services.

This is what people working on the issue have come to call the “Medicaid cliff.”

How did we get here?

When it comes to Medicaid, the federal government treats U.S. territories differently from how it treats states.

In U.S. states, the amount that the federal government contributes to Medicaid varies based on a formula in the law that relies on per capita income in each state. For instance, Alabama has a match rate of 72%; what this translates to is that for every dollar Alabama spends on Medicaid, the federal government contributes about $2.57 to the program.

But that’s not how it works in the territories, where even though the populations are all low income, the federal government’s match rate is set in statute at 55%. What this translates to is that for every dollar a U.S. territory spends on Medicaid, the federal government contributes $1.25.

The other significant difference is that the federal contribution to Medicaid in the territories is capped, with a set allotment of federal funds every year. Federal spending on Medicaid in states is not.

The low matching rate and the annual cap — that’s pretty much how it has always been for Medicaid in the territories, says Robin Rudowitz, who co-directs the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. “These particular provisions historically have always been part of how they have been financed,” she says.

Here’s how the territories found themselves peering over the “Medicaid cliff.” For the last few years, the territories have had billions of dollars more in federal funding to run their programs than their usual capped allotments. First, the Affordable Care Act provided a one-time grant of $7.3 billion (which kicked off in 2011) for the territories’ Medicaid programs. Then, in 2017, after two Category 5 hurricanes ravaged Puerto Rico and the U.S. Virgin Islands, an extra $4.9 billion designated for their Medicaid programs was added to the 2018 Bipartisan Budget Act.

Now, we’ve come to the cliff’s edge. Most of these two pots of money ran out at the end of September, with just a bit of funding from the ACA still available through the end of 2019.

That leaves, essentially, just the capped allotment of federal dollars for each of the territories — far less than what the territories have come to rely on to provide care to their Medicaid enrollees in recent years.

“The capped financing amounts were low and did not meet all of the needs of the population in the territories,” says Rudowitz. If the additional federal contributions are gone for good, she says, “given the share that they represent of the financing for Medicaid in these territories, it would mean major changes and reductions in care.”

The territories have known that this funding cliff was coming for years — the end to a major portion of the money was written into the ACA. Island health officials and care providers hoped Congress would have legislated a more permanent solution by now, but it hasn’t.

In recent months, Congress has passed continuing resolutions that have allowed the territories’ Medicaid programs to keep limping along. But without legislation that appropriates more money, the territories’ Medicaid programs all are in serious trouble.

The Medicaid and CHIP Payment and Access Commission, known as MACPAC, a nonpartisan government group that advises Congress on Medicaid policy, projected in July that all the territories will have budget shortfalls in 2020. When considered altogether, according to MACPAC’s report, their Medicaid programs will be more than $1 billion short.

This is why Medicaid directors in the U.S. territories are all sounding the alarm. King Young, of American Samoa, points to news coverage as far back as the 1960s that described her island as “America’s Shame in the South Seas” because of rampant pollution and neglect.

“Right now, this is the United States’ shame in the islands,” she says. “Tell me if that’s acceptable in the United States, to stand by and say, ‘Oh, sorry, we can’t give you that stent or that pacemaker, so it’s likely that you’ll have a stroke or heart attack and — that’s it.’ That’s what it means not to have enough Medicaid funding for the territories.”

“Full-court press” in Congress

The territories have been lobbying Congress, urging members to appropriate more funds for their Medicaid programs so health officials on the islands can avoid these hard choices — between, for instance, keeping a hospital going and paying for a patient’s cancer treatment.

Each territory has a nonvoting delegate in Congress. Puerto Rico also sent an additional delegation from the island last week to make the case to lawmakers that something must be done to stave off disaster.

“I would say that we’ve been doing a full-court press this entire calendar year,” says Jennifer Storipan, executive director of the Puerto Rico Federal Affairs Administration. “Gov. [Wanda] Vázquez has said that Medicaid funding is her highest priority for the island right now.”

A bill to temporarily increase funding to the territories’ Medicaid programs was passed by the House Energy and Commerce Committee in July but has yet to make it to the floor for a vote. It would greatly increase the federal match rate for Medicaid in all the territories and allocate a bonus $3 billion a year — but only for the next four years. There is no companion bill in the Senate.

“We’re in active negotiations with the Senate, but there is some opposition to our bill in the Senate,” says Rep. Darren Soto, D-Fla., who introduced the House legislation with Rep. Gus Bilirakis, R-Fla. Both represent districts in central Florida that have huge Puerto Rican populations, and Soto is of Puerto Rican descent. In the House, the bill has bipartisan support.

Opponents of the bill in the Senate say they worry that the billions of dollars that the territories are requesting could be misspent. Some senators have raised particular concerns about Puerto Rico. During a recent corruption probe, a Puerto Rican Medicaid official was arrested — that news emerged just a few days before a committee hearing on the territories’ Medicaid bill in July.

“So that didn’t help,” Soto says. Integrity provisions were added to the House bill, he says, specifically addressing concerns about Puerto Rico. “We do need to take it seriously and make sure that tax dollars are safeguarded,” he says, but adds, “There have been fraud instances in many states too, and we don’t take away their Medicaid funding.”

Some congressional Republicans note that the funding cliff was created by the Affordable Care Act, which gave extra funding to the territories for a limited time. In a letter to Secretary of Health and Human Services Alex Azar in July, several Republican members of the Senate Finance Committee raised concerns about Puerto Rico’s Medicaid spending.

“We are again confronting proposals for what amounts to another extension of boosted funding with no permanence or certainty and without any resolution of the Medicaid funding cliff constructed as part of the ACA,” they wrote.

“It is true: Giving these additional funds with a set expiration date, the legislation itself did create the cliff,” acknowledges the Kaiser Family Foundation’s Rudowitz. However, she says, Congress now should consider “the implications of letting that cliff happen and what that means to the health care systems in these territories.”

Planning for the worst

Medicaid program administrators from each of the territories gathered in an impromptu meeting outside the annual Medicaid directors conference last week. They have spent a lot of time together in Washington recently, testifying before congressional committees about the Medicaid funding crisis as it approaches.

“We were here in May. We were here in June,” Michal Rhymer-Browne, assistant commissioner with the Virgin Islands’ Department of Human Services, told NPR that day. “We pleaded. We shared ourselves — everything that we could.”

Despite their pleas, Congress has yet to act.

There are three options for managing a slashed budget for a program like Medicaid: reduce the size of payments to providers, cut the rolls or cover fewer services. All the territories say there’s no way to go lower on provider payments — Puerto Rico’s struggle with provider flight because of low pay is well known. So cutting the rolls and covered services is where the programs would need to find cuts, representatives of the territories say.

“Guam and [the Northern Mariana Islands] are about to topple over the cliff,” Rhymer-Browne says. “And for the Virgin Islands, we are nearing the cliff and seeing the bottom right now.”

Many of the territories would like to make improvements in the care they provide — invest in better facilities, recruit great health care providers, improve preventive care. All of that comes with upfront costs, they say, and they’ve had so much budget uncertainty that it has been impossible to move forward with those kinds of projects.

Right now, they’re just trying to keep the lights on.

“The urgency is here for us to let our congressional members know — even going to January is extremely dangerous,” Rhymer-Browne says. “It’s already catastrophic for our territories. We really need them to make a move.”

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