When Sgt. Anna Lange moved with her young family from Columbus, Ga., to the state’s more rural Houston County, her main priority was being able to stay near her son.

After five years of marriage — and many more years of internal turmoil — Lange had realized that despite being assigned male at birth, she’d felt female her entire life.

She had decided to undergo gender transition and knew it would eventually end her marriage. She also knew her soon-to-be ex-wife would want to move back home to Houston County, an hour and a half’s drive from Columbus.

“I wasn’t going to be that far from my son,” Lange said. “It wasn’t like I was thinking of, you know, the super-open community,” she said with more than a hint of sarcasm.

Although she’d loved working at the police department in Columbus, she took a job with a national insurance company in Houston County, hoping for a more accepting, less conservative environment than law enforcement.

She found the corporate structure so stifling, she didn’t even make it out of training. Within three months, she was once more wearing a badge and gun as a patrol officer at the Houston County Sheriff’s Office. She’s been there since 2006 and has been promoted twice.

That’s why it stung so much when she learned late last fall that the county’s employee health insurance plan wouldn’t cover any of her transition-related surgery. Although federal law prohibits health insurance plans from discriminating against transgender individuals, the plan adopted by Houston County specifically excludes trans-related health care from coverage.

The exclusion came as a shock. After Lange was told by Anthem Blue Cross and Blue Shield that her insurance would cover gender-confirmation surgery — and had her New York City-based surgeon confirm it — she traveled to Manhattan last November for a consultation. Shortly after she returned, she received a letter informing her that her employer’s plan would not, in fact, cover her procedure.

She then contacted Transcend Legal, a New York City-based nonprofit organization, and is now represented by Noah Lewis, the organization’s executive director. After the Houston County Board of Commissioners didn’t respond to a Jan. 16 letter from Lewis requesting that the board remove the exclusion, Lange and Lewis made their request in person during a meeting of the board on Feb. 19. Their request was denied; Lange now plans to sue Houston County in district court.

“The board is not considering any changes to the law at this time,” said Houston County Attorney Tom Hall in response to Lewis’ request, adding that he’d directed the commissioners themselves not to comment given the possibility of future litigation.

Lange’s is one of two Georgia cases challenging transgender exclusions in employee health plans. Skyler Jay, a trans man who appeared on an episode of the popular Netflix series Queer Eye, is currently suing his employer, the University of Georgia, in a lawsuit challenging its health plan’s similar exclusion. Jay is also represented by Lewis.

Within the past six months, transgender government employees in Wisconsin and Iowa have won similar cases and were awarded a total of $900,000 by juries. “It’s definitely going to be more expensive for them to defend it in court,” said Lewis of the Georgia state employee policy exclusion adopted by Houston County. “They can avoid that result by just voluntarily removing the exclusion.”

Gender dysphoria is the American Psychiatric Association’s name for the distress caused by discordance between one’s assigned gender at birth and the gender they identify as. Multiple major medical societies, including the American Medical Association, have endorsed the medical necessity of treating gender dysphoria with “gender-affirming care,” which may include hormones, surgeries or neither.

As the medical community has shifted from viewing gender-affirming care as cosmetic to understanding it as medically necessary, many insurers, including Medicare and many Medicaid programs, have likewise shifted to covering both surgical and nonsurgical trans-related health care.

Alongside them, the law has evolved to forbid discrimination against trans Americans. Section 1557 of the Affordable Care Act prohibits entities that receive federal funding for health coverage from denying coverage based on sex, gender identity and sex stereotyping. And the Americans with Disabilities Act and Title VII of the Civil Rights Act have also been broadly interpreted by courts to protect transgender individuals from discrimination.

Despite both medical and legal consensus, 30 states allow health insurance plans to exclude transgender-related health care from coverage. Most of these states are in the South, Midwest and Great Plains, and most have a relatively high proportion of rural residents.

Shortages in rural health care workforces, low rates of insurance coverage, and long distances from health care facilities have made it challenging for many Americans outside urban areas to find high-quality, affordable health care. Transgender people in rural areas often face particularly acute challenges when it comes to finding competent providers and obtaining health insurance.

Douglas Knutson, a psychologist who studies health and resiliency among LGBTQ populations at the University of Illinois in Carbondale, said rural trans populations often have high rates of anxiety, depression and suicidality.

That doesn’t mean they’re all eager to flee. Connections to home, land, language and heritage are powerful, said Knutson: “People have specific reasons for living in rural areas.”

Lange certainly does. Although she would love to be in a more welcoming environment, she remains in Houston County because of her son. “I’m a good parent,” she said. “I love him too much and I’m not going anywhere.”

She also has no intention of leaving law enforcement. If she did, she’d be leaving behind a retirement plan. Plus, she was recently promoted to sergeant in criminal investigations, and she finds it deeply satisfying to help people and solve crimes.

When trans people challenge employers’ policies in stereotypically conservative settings, they often encounter resistance, said Knutson. “There’s the feeling, ‘Why does the battleground have to be here?‘ ” he said.

Although it might seem easier to switch employers than fight an unwelcoming institution for equal treatment, he said, job searches are often expensive and require a financial cushion that many people – especially public servants — don’t have. Additionally, he said, for many, “there’s a commitment to vocation”; like Lange, many people simply like their jobs.

Studies assessing the financial implications of covering transgender-related health care have demonstrated that the cost of care to insurers, including hormones and surgical therapies, is relatively small. Hormone therapy, which around 75 percent of transgender people seek, starts at $20 to $80 a month and is usually taken for the duration of a person’s life after transition. Surgeries range widely in type and cost anywhere from $5,000 to $50,000 each, although many trans people don’t desire surgical treatment.

Perhaps of even greater significance is the finding that providing this coverage is cost-effective. Untreated gender dysphoria leads to high rates of adverse — and expensive – outcomes, including HIV infection, depression, suicidality and drug abuse. The cost of accepting these outcomes outweighs the cost of treating their cause.

Still, state and local governments have pursued costly court battles to maintain these exclusions. “Officials look at this as a political issue instead of as the medical and equal employment issue that it should be,” said Harper Jean Tobin, policy director of the National Center for Transgender Equality.

Although there is no consensus on transgender acceptance, according to the Pew Research Center, 39 percent of Americans surveyed in 2017 said society hasn’t gone far enough in accepting transgender people. Thirty-two percent said society has gone too far and 27 percent said society’s response has been about right.

Respondents were divided along partisan lines, with 60 percent of Democrats saying society hasn’t done enough compared with 12 percent of Republicans saying that.

Nevertheless, said Tobin, persistent transgender stigma in certain circles causes some lawmakers to assume that inclusive policies will be unpopular in their communities.

“Increasingly,” she said, “I think they’d be surprised.”

Keren Landman, a practicing physician and writer based in Atlanta, covers topics in medicine and public health.

Let’s block ads! (Why?)

The Trump Administration is weighing whether to require hospitals to publicly reveal the prices they charge insurance companies for medical procedures and services — prices that are currently negotiated in private and kept confidential.

The Department of Health and Human services says its aim is to boost competition and cut costs by letting consumers see how prices vary from place to place. But health economists say such “transparency” might not actually bring down costs for patients.

HHS tucked two questions about publicizing the negotiated prices into a separate, 187-page provisional rule released earlier this month that governs health care information technology. The Wall Street Journal reported on the idea last Friday.

“The availability of price information could help increase competition that is based on the quality and value of the services patients receive,” HHS argues in its proposed rule. “The Department is considering subsequent rule-making to expand access to price information for the public, prospective patients, plan sponsors and health care providers.”

Zack Cooper, a health economist at Yale University says he’s skeptical that this particular attempt at price transparency would reduce overall spending on health care.

“Most consumers don’t look at the price of health care services before they access care,” Cooper says. “So I think we need to understand that most folks are not going to, all of sudden, go Googling hospital prices and then make big changes as to where they [go for] care.”

Still, Cooper’s research suggests HHS is looking in the right direction. In a paper he published last month in Health Affairs, in which he analyzed the prices negotiated between hospitals and insurance companies, Cooper found that most health care inflation comes from rising prices for hospital care.

“By and large, physician prices haven’t gone up in the last 10 years,” he says. “In contrast, we’ve seen pretty remarkable growth — on the order of 5 percent per year — in hospital prices.”

Those high prices end up in insurance premiums, which have also been rising, Cooper says.

The American Hospital Association is opposed to making their negotiated prices public.

“This isn’t really what consumers need or want,” says Tom Nickels, the AHA’s executive vice president for government affairs. “What consumers need and want is ‘What are their out-of-pocket costs?’ “

Almost 60 percent of people with employer-sponsored health insurance carry plans with deductibles of more than $1,000. That means more people are exposed to high health care charges for hospital visits. In addition, patients complain frequently of surprise bills they receive after a hospital stay. Those surprise bills often arise when a patient is treated by out-of-network doctors who happen to be working in hospitals that do participate in the patient’s insurance network.

Congress is already considering bills to address such surprise billing practices.

Nickels, the representative of the hospital association, says consumers have no need to see the prices insurance companies pay hospitals, just as they don’t need to see what a grocery store pays for cases of Coca-Cola.

But a glance at the public comments posted on regulations.gov suggests members of public don’t agree with him.

The agency argues in this proposal that the complexity — and opaque pricing in health care system — make the system less efficient and hurts patients’ health.

“Enough with the secrecy and back room deals,” writes one commenter.

Another writes: “When we purchase groceries, cars, homes, airfare, hotel rooms, etc., we know the price before we buy. Shopping around of lower prices is easy. The glaring exception is health care.”

In contrast, Nickels argues that revealing the secretly negotiated deals would actually cut competition. And he questions whether it would be legal.

“We have a system that basically allows people to have private contracts between each other in an economy,” he says.

The hospital price proposal is the latest in a series of efforts by the Trump administration to boost price transparency in health care.

In the last few months, HHS Secretary Alex Azar has proposed several rules to make drug prices more transparent and to change the system for negotiating those prices.

The first would require drug companies to include the list prices of their medications in any television or magazine ads promoting their drugs. Another proposal would tie the price that Medicare pays for many cancer and arthritis drugs to the prices other countries pay for those medications.

And, finally, the agency wants to upend the entire system for pricing prescription drugs that people buy at their local pharmacy. Right now the prices of those medications are determined by negotiations between drug companies and middlemen known as pharmacy benefit managers who negotiate discounted prices on behalf of insurance companies.

But those discounts come in the form of secret rebates — and the PBMs keep a share of those rebates for themselves. Now HHS wants to make those rebates illegal and force the players to negotiate discounts upfront.

Sara Fisher Ellison, a health care economist at MIT, is pessimistic that these proposals will reduce costs in the prescription drug market.

“They’re trying to, around the edges, improve the function of the market,” she says. “But to be honest they probably missed the mark. That’s because the market for pharmaceuticals is not like a standard market.”

She says the problem is consumers don’t have the power to easily switch to a competitor product if the drug they’re taking has a high price.

“In pharmaceuticals, the end consumer — the patient — is not the only decision maker, and in fact is often not even the most important decision maker,” Ellison says.

In reality, she says, it’s the insurance companies and the doctors who decide what drugs a patient gets, and often what hospital a patient goes to. And those are the people who are already negotiating the price.

Let’s block ads! (Why?)

When Erin Gilmer filled her insulin prescription at a Denver-area Walgreens in January, she paid $8.50. U.S. taxpayers paid another $280.51.

She thinks the price of insulin is too high. “It eats at me to know that taxpayer money is being wasted,” says Gilmer, who was diagnosed with Type 1 diabetes while a sophomore at the University of Colorado in 2002.

The diagnosis meant that for the rest of her life she’d require daily insulin shots to stay alive. But the price of that insulin is skyrocketing.

Between 2009 and 2017 the wholesale price of a single vial of Humalog, the Eli Lilly and Company-manufactured insulin Gilmer uses, nearly tripled — rising from $92.70 to $274.70, according to data from IBM Watson Health.

Six years ago, Gilmer qualified for Social Security Disability Insurance — and thus, Medicare — because of a range of health issues. At the time, the insulin she needed cost $167.70 per vial, according to IBM Watson Health.

“When it’s taxpayer money paying for medication for someone like me, it makes it a national issue, not just a diabetic issue,” Gilmer says.

Stories about people with Type 1 diabetes dying when they couldn’t afford insulin have made headlines. Patient advocates like Gilmer have protested high prices outside Lilly’s headquarters in Indianapolis.

Don’t see the graphic above? Click here.

Last October in Minnesota, then state Attorney General Lori Swanson sued insulin manufacturers alleging price gouging. Pharmaceutical executives were grilled about high drug prices by the Senate Finance Committee on Feb. 26.

This is the backdrop for Lilly saying Monday that it is rolling out a half-priced, generic version of Humalog called “insulin lispro.” The list price: $137.35 per vial.

“Patients, doctors and policymakers are demanding lower list prices for medicines and lower patient costs at the pharmacy counter,” Eli Lilly CEO David Ricks wrote in a blog post about the move. “You might be surprised to hear that we agree – it’s time for change in our system and for consumer prices to come down.”

No panacea

When Lilly’s Humalog, the first short-acting insulin, came to market in 1996, the list price was about $21 per vial. The price didn’t reach $275 overnight, but yearly price increases added up.

In February 2009, for example, the wholesale price was $92.70, according to IBM Watson Health. It rose to $99.65 in December 2009, then to $107.60 in Sept. 2010, $115.70 in May 2011, and so on.

“There’s no justification for why prices should keep increasing at an average rate of 10 percent every year,” says Inmaculada Hernandez of the University of Pittsburgh School of Pharmacy who was lead author of a January report in Health Affairs attributing the skyrocketing cost of prescription drugs to accumulated yearly price hikes.

“The public perception that we have in general is that drugs are so expensive because we need to pay for research and development, and that’s true,” Hernandez says. “However, usually research and development is paid for in the first years of life of a drug”

At $137.35 per vial, Lilly’s generic insulin is priced at about the same level as Humalog was in 2012, 16 years after it came to market.

“We want to recognize that this is not a panacea,” says company spokesman Greg Kueterman. “This is an option that we hope can help people in the current system that we work with.”

It’s worth noting that Humalog is a rapid-acting insulin, but that’s only one of the two types of insulin most people with Type 1 diabetes use every day. The second kind is long-lasting. Lilly makes one called Basaglar. The most popular long-lasting insulin is Lantus, produced by Sanofi. Neither has a lower-cost alternative.

Still, Lilly’s move on Humalog could put pressure on the other two big makers of insulin to act.

Novo Nordisk called Lilly’s lower-priced generic insulin “an important development,” in an emailed statement.

“Bringing affordable insulin to the market requires ideas from all stakeholders,” Novo Nordisk’s Ken Inchausti said in an email, which also listed steps the company has taken, such as a patient assistance program. The statement didn’t say whether Novo Nordisk is considering offering a lower-priced version of its popular insulin Novolog, a rival of Humalog.

A statement from Sanofi, the third major insulin maker, also didn’t say whether the company would offer lower-priced version of its insulins.

“Sanofi supports any actions that increase access to insulins for patients living with diabetes at an affordable price,” spokesperson Ashleigh Koss said in the email, which also touted the company’s patient assistance program.

A different kind of generic

One twist in this story is that Lilly’s new insulin is just a repackaged version of Humalog, minus the brand name. It’s called an “authorized generic.”

“Whoever came up with the term, ‘authorized generic’ ?” Dr. Vincent Rajkumar says laughing. Rajkumar is a hematologist at the Mayo Clinic in Rochester, Minn.

“It’s the same exact drug” as the brand name, he continues.

Typically, Rajkumar says, authorized generics are introduced by brand-name drugmakers to compete with generic versions of their drugs made by rival companies.

But in the case of Humalog and other insulins, there are no generics made by competitors, as there are for, say, the cholesterol medicine Lipitor or even other diabetes drugs, such as metformin.

So when Lilly’s authorized generic comes to market, the company will have both Humalog insulin and the authorized generic version of that medicine on the market.

Rajkumar says it’s a public relations move.

“There’s outrage over the price of insulin that is being discussed in Congress and elsewhere. And so the company basically says, ‘Hey, we will make the identical product available at half price.’ On the surface that sounds great,” Rajkumar says.

“But you look at the problems and you think, ‘OK, how crazy is this that someone is actually going to be buying the brand-name drug?’ “

In fact, it’s possible that Lilly could make the same or even more profit off its authorized generic than it does from the name-brand Humalog, according to University of Pittsburgh’s Hernandez.

The profit margin would depend on the rebates paid by the company to insurers and pharmacy benefit managers. Rebates are getting a lot of attention these days as one factor in rising drug prices. They’re usually not disclosed and increase as a drug’s price increases providing an incentive to some

“Doing an authorized generic is nothing else than giving insurers two options,” Hernandez says: Pay the full list price for a brand-name drug and receive a higher rebate, or pay the lower price for the authorized generic and receive a presumably smaller rebate.

“What we really need to get insulin prices down is to get generics into the market, and we need more than one,” Hernandez says, adding that previous research has shown that prices begin to go down when two or three generics are competing in the marketplace.

Even so, Lillly’s Kueterman says the authorized generic insulin “is going to help hopefully move the system towards a more sustainable model.”

“I can guarantee you the reason that we’re doing this is to help people,” Kueterman says, noting the company’s Diabetes Solution Center has also helped “10,000 people each month pay significantly less for their insulin” since it opened in August 2018.

For Erin Gilmer, the news about an authorized generic insulin from Lilly has left her mildly encouraged.

“It sounds really good and it will help some people, which is great,” Gilmer says. “It’s Eli Lilly and pharma starting to understand that grassroots activism has to be taken seriously, and we are at a tipping point.”

This story is part of NPR’s reporting partnership with Kaiser Health News. Freelance journalist Bram Sable-Smith can be found on Twitter: @besables.

Let’s block ads! (Why?)

BrittLee Bowman had a huge decision to make as she lined up at an elite cyclocross race. Cyclocross is a sport that throws obstacles at you, from sand pits to staircases to knee high barriers. And this one, alongside the Hudson River in Queens, N.Y. was no different.

Bowman pedaled. People cheered. And if you saw her that day… you probably had no idea what she was wrestling with. That decision she had to make: Do I have both my breasts removed?

It all started with a tiny lump. “Sometime in October I just you know was touching my boob and felt a lump,” she says. “It was about the size of a pea.”

She immediately called her mom, Sara Bowman. Her mom says she was probably more concerned than her daughter, but she didn’t let on.

Bowman made an appointment with her doctor. And the doctor thought it was best to do an ultrasound. And the ultrasound showed another lump. Two total. And that led to a biopsy. And the biopsy led to waiting.

“I’m telling you,” she says. “In my mind, I did not have cancer.”

So Bowman went on with her life. She was out shopping when she got the call.

“You have breast cancer,” she says the doctor told her. “And I was like, ‘Wait. What!?'”

The doctor clarified her statement, telling Bowman the result came back positive. She had stage one multifocal invasive ductal carcinoma, ductal carcinoma in situ, and lobular carcinoma in situ all in her left breast. Her right was unaffected. She called her mom.

“I don’t even remember what I said,” Sara Bowman says. “I was just trembling.”

For BrittLee, the cancer diagnosis just didn’t make sense.

“You can exercise everyday of the week for an hour-and-a-half — except on Sundays, you need a rest day. Be pescatarian for six years. Eat lots of fruits and vegetables all the time. Drink green juice all the time. You know, you can be pretty healthy and live an active lifestyle and still get cancer,” she says. “It sucks.”

Bowman started researching her particular cancer: medical journals and anything she could get her hands on. Meanwhile, there were more tests. Her doctor gave her options: lumpectomy, single mastectomy, or double mastectomy.

“So basically, if I chose double mastectomy and then take care of everything right now then I hopefully will not have a recurrence of this cancer,” she says.

Thirty-four and single, she wanted the option to have kids. Some treatments impact fertility. Then there were a host of other concerns, including how it could impact her athletic career, and also, how she looked at her body.

“I’ve always been a very comfortable person with my body… And I know that a lot of women struggle with their bodies and don’t love them,” she says. “And so I had this fear that the surgery would change that about me. It wasn’t totally the fear of it changing my body, it’s like more about like the fear of it changing how I felt about my body.”

She continued to research and read. But sometimes journals feel impersonal.

So she looked up #doublemastectomy on Instagram. “And they’re posting everything. They’re showing: This is what it looks like right after surgery. This is what it looks like when you have a bad reconstruction that you’re sad about and that makes you want to get surgery again. This is what it looks like when you’re happy that your surgery went well. This is what it looks like when you have radiation. And so just finding that on Instagram was actually really helpful for me to see other women my general age going through this experience.”

She soon had her surgery date. But still hadn’t decided which surgery to get.

“It was the thing I thought about every moment.”

All that was going through her head when she entered that cyclocross race in Queens.

***

That day, Bowman powered through the course, battling for second place with rider Rachel Rubino. The two are competitors and also friends.

“Hey, I’ve been thinking about you so much all week, Rubino told her as they raced. “I love you so much.”

By the last lap, Rubino was in second and Bowman had third place wrapped up. They’d get to stand on the podium together. It meant a lot for Bowman. But it meant a lot for Rubino, too.

“A lot of people in my family have had cancer,” Rubino says. “My mom passed away of breast cancer when I was 22. So for me it hits this really deep place. You know? It’s like being a woman and being an athlete. This can happen to any of us.”

***

Days after the race, Bowman made her decision. She’d have surgery to remove both her breasts. On the day of the appointment she went to the hospital with family and a friend.

“It was just a long wait a long wait in there …” says Sarah Bowman.

Finally, it was time.

“So they they placed the I.V. in my arm while I was in the holding area with my family,” says Bowman. “And they walked me down a hallway. And there was an elevator. And I was with the nurse. And I had to say bye to my family. So I go into this elevator. The doors close. And I was like in the elevator with the nurse and I was just crying. … It’s just scary. You know you don’t want to have to do that, but you’re trying to fix the problem.”

She walked into the operating room in her gown, past a table of surgical tools. She climbed onto the table. And she stared into silver lamp lights.

***

Three weeks after her surgery, she was still healing and feeling hopeful about racing again.

“I got on my bike on a 28-degree day here in New York City. And I rode laps in Central Park,” she says.

Athletes are like that: Tough. But Bowman is quick point out that she only had stage one. She’s young. There’s a lot of women dealing with far worse. That said, there’s still radiation ahead, healing from reconstructive surgery, and five to 10 years of tamoxifen to ward off a recurrence.

“I’m like did I survive yet? I don’t know. Do I still have cancer? I’m a little unclear on that right now. Maybe I do still have cancer? Or maybe maybe it was all cut out of me? I’m not quite sure,” she says.

You can see the wear on Bowman’s face, but also the resolve. She’ll wake up. Roll out of bed. Do her treatment. Get on with her life.

Let’s block ads! (Why?)

A new report published by the Centers for Disease Control and Prevention details the harrowing story of a child in Oregon who contracted tetanus because he wasn’t vaccinated.

The boy was playing outside on a farm in 2017 when he cut his forehead. Six days later, he started having symptoms: a clenched jaw, muscle spasms and involuntary arching of his neck and back. When he started struggling to breathe, his parents realized he needed help and called for emergency medical services.

Doctors diagnosed the 6-year-old boy with tetanus and administered a dose of the vaccine, but it took 57 days in a hospital, including 47 days in intensive care, to restore his health.

“It was difficult to take care of him, to watch him suffer,” says Judith Guzman-Cottrill, a pediatric infectious-disease physician who co-authored the article in the CDC’s online journal Morbidity and Mortality Weekly Report.

At first, he asked for water but couldn’t open his mouth. The boy had to spend weeks in a dark room on a respirator. He was able to walk 20 feet, with help, after 50 days.

At a time when preventable outbreaks are making headlines in the United States, Guzman-Cottrill tells NPR that she has met many families who hesitate to give their children vaccines.

“These days, there are so many different places parents can go to for vaccine-related education and advice that many families struggle with knowing who to believe.”

The Internet and social media have made it harder for people to distinguish fact from fiction, she says.

The boy’s infection marked the first pediatric case of tetanus in the state of Oregon in more than 30 years, according to the researchers.

After allowing the first dose of vaccine, the parents refused a second dose for their son, despite doctors giving them information about the advantages of being immunized against tetanus. “I did provide education about the benefits of all pediatric vaccinations and that was also refused,” Guzman-Cottrill says.

The report of his illness comes after outbreaks of measles occurred this winter in the Pacific Northwest. Measles is also preventable with a vaccination.

The rise in measles cases, spurred by the anti-vaccination movement, is pushing authorities to address the issue.

On Tuesday, 18-year-old Ethan Lindenberger told lawmakers that his mother prevented him from getting immunizations because her Facebook feed turned her into an anti-vaxxer.

Facebook itself announced Thursday that it is using vaccine hoaxes identified by the World Health Organization, the CDC and other global organizations to address inaccurate information plaguing the site.

“As a parent myself, I understand that parents are trying to make the best decision for their child,” Guzman-Cottrill says.

“This illness could have been prevented with five doses of the tetanus vaccine, for $150,” she adds. Instead, the ordeal cost $811,929.

Let’s block ads! (Why?)

Oklahoma has been making progress in fighting the opioid epidemic. But there’s still a lot of work to be done.

While the death rate from prescription opioids is on the decline here, the number of opioid prescriptions written in the state continues to vastly outpace the national average. Also, deaths from heroin overdoses have been climbing — up by more than 50 percent between 2015 and 2016 — and that could be a byproduct of stricter state regulations that aim to curb opioid prescribing.

So in late February, I was one of about 60 people from across Oklahoma invited to brainstorm ideas during a one-day exercise to find solutions to the state’s opioid crisis. The Oklahoma Primary Healthcare Improvement Cooperative convened the meeting at the Tatanka Ranch in Stroud.

The cooperative was created in 2014 to help doctors and nurses across the state do their jobs better by implementing best practices as determined by medical research. It works like an agricultural extension service, with academic doctors and nurses acting like farm bureau experts and visiting local offices throughout the state to share their wisdom.

The conveners of the opioid meeting divided us into small groups and focused on two really tough questions:

• What if Oklahoma had zero overdose deaths?

• What would be expected of each of us to make that happen?

Academic physicians (like me) from the state’s two major research universities, were sprinkled among the groups, which also included community and rural physicians, some of whom specialize in medication-assisted treatment for substance use.

But what made the one-day summit unique in my eyes was the inclusion of professionals well beyond doctors, nurses and physician assistants. Pharmacists were there, as were officials from Oklahoma’s Medicaid agency and the state’s Bureau of Narcotics and Dangerous Drugs, which administers Oklahoma’s Prescription Monitoring Program.

Thirty-seven states now give health care providers access to online tools that let them see the prescriptions for controlled substances, such as opioids, that a patient has received. This information can help prevent “doctor shopping” by people seeking drugs and it can help clinicians be aware of potential overuse.

Given how disruptive opioid addiction can be for families, there were also child welfare and mental health professionals who reported on programs to help addicted mothers overcome opioids and find pathways to win back custody of their children.

The summit also included representatives from law enforcement and community-based support programs, such as a prison diversion initiative aimed at providing treatment and help instead of incarceration for nonviolent male offenders.

The strength of the meeting was that it brought together people who work on different aspects of the same broad problem, who may never have had the chance to meet one another in their day-to-day work and consider ideas from others’ perspectives.

“We’re all blindfolded people working on our own aspect of an elephant,” one person noted. “And this has allowed us to remove our blindfolds and see the whole elephant in the room.”

One set of conversations early in the day asked us to put ourselves on a complicated flow diagram of where, when and how opioid prescribing occurs.

Some people were involved in fielding patients’ complaints. Others worked in doctors’ offices or hospital emergency rooms, right on through to the dispensing of medicines in pharmacies. Still others were on the law enforcement, social service, and payer sides of such transactions.

By visualizing where each of us work along the opioid continuum, we could more easily imagine ways to improve things and implement new educational approaches to better inform the public about the risks and benefits of opioid use.

Suggestions for lessening the impact of opioid abuse included both “upstream” and “downstream” components.

Upstream refers to preventing opioid abuse and addiction before it starts. Ideas for that included more interdisciplinary and interagency cooperation, and pushing our state legislature to consider the health effects of all bills that are enacted into law.

Downstream suggestions included widening availability and accessibility of mental health and substance abuse treatment services, something Oklahoma sorely lacks. Other ideas included better data monitoring and sharing tools.

I left the meeting mulling over what we had really accomplished.

I don’t think we’ll ever realistically get to zero opioid deaths. But it’s certainly a worthy aspiration. In order for us to move in that direction, we have to treat addiction as a medical problem — not a character flaw — and place equal value on every human life.

Further, we have to accept the idea that we have excellent medical treatment for opioid addiction and be willing to provide it in all kinds of health care settings, including jails and prisons, without preconditions.

If we could achieve this mindset, people would have the chance to live longer, more productive lives. Family and childhood trauma could be greatly diminished, too.

The meeting prompted me to learn more about intranasal naloxone, an opioid antidote, and to carry it with me. If I can use it, certainly anyone can. I also plan to lobby to make medication-assisted treatment more widely available.

The attendees concluded it would be important for those of us in different sectors to keep in touch and sustain the dialogue. We also pledged to better educate each other, our lawmakers and the public.

But as inspiring as it was to be part of the meeting, it was abundantly clear that complex issues such as opioid use and abuse don’t lend themselves to one-day solutions.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa’s Medical Mondays and is on Twitter: @GlassHospital.

Let’s block ads! (Why?)

Cities and local governments in several states say they will continue to use a Canadian company to offer employees prescription drugs at a highly reduced price, even though officials from the U.S. Food and Drug Administration have raised safety concerns about the practice.

The municipalities use CanaRx, which connects their employees with brick-and-mortar pharmacies in Canada, Great Britain and Australia to fill prescriptions.

In a letter sent last week to CanaRx, the FDA said the company has sent “unapproved” and “misbranded” drugs to U.S. consumers, jeopardizing patient safety.

The FDA also urged consumers not to use any medicines from CanaRx, which works with about 500 cities, counties, school districts and private employers in the United States to arrange drug purchases. Some of these employers started using the service as far back as 2004.

Prices of drugs from overseas pharmacies can be as much as 70 percent lower than what people pay in the U.S. because the costs are regulated by the foreign governments.

FDA officials would not explain why they waited more than a decade to act. They acknowledged the agency had no reports of anyone harmed by drugs received through CanaRx.

The FDA made its warning as Congress and the Trump administration look into ways to lower drug prices. Last month, Florida Republican Gov. Ron DeSantis said he has President Donald Trump’s backing to start a program to begin importing drugs from Canada for state residents.

After DeSantis’ comments, White House officials stressed that any such plan must get state and federal approvals.

The FDA says that in most cases importing drugs for personal use is illegal, although it very rarely has tried to stop Americans from bringing drugs across the Canadian border. It has not stopped retail stores in Florida that have helped consumers buy drugs from Canada since 2003. Nine storefronts were raided by FDA officials in 2017, although the FDA has allowed them to continue operating.

Schenectady County in New York, which has worked with CanaRx since 2004, defended its relationship and has no immediate plans to end it, according to Chris Gardner, the county attorney. “We will wait to see how this plays out, but right now it’s status quo,” Gardner says.

He says CanaRx, which is headquartered in Windsor, Ontario, helped the county save $500,000 on drug costs in 2018. About 25 percent of the county’s 1,200 workers use the program and get their drugs with no out-of-pocket costs. If they use American pharmacies, they generally have a copayment.

“This is a good program, and on the merits it looks lawful, and they are not doing the terrible things that the FDA is suggesting,” Gardner says.

CanaRx officials deny they have been breaking any laws or putting Americans’ health at risk. They say they are not an online pharmacy but a broker between U.S. employees and brick-and-mortar pharmacies in Canada, Australia and Great Britain. People can buy drugs via CanaRx only with a prescription from their doctor.

The company says it has no plans to stop distributing drugs.

“The FDA’s characterizations of the CanaRx business model and operating protocols are completely wrong,” says Joseph Morris, a Chicago-based lawyer for the company. “It is not possible to place an order via any CanaRx website; the websites are informational only.”

Morris says the FDA notice has prompted calls from many municipalities; but so far all say they plan to stick with the company.

The FDA warning says online pharmacies that purport to sell drugs from Canada, Britain and Australia may actually get their drugs from other countries, which would increase the risk consumers are dealing with counterfeit drugs.

CanaRx says that “it contracts with government-licensed physicians, pharmacists and pharmacies in Canada, the United Kingdom, and Australia … to supply brand name medications, packaged and sealed by the original manufacturer, for direct delivery to all participants.”

Gabriel Levitt is president of pharmacychecker.com, an independent website for U.S. consumers that verifies international pharmacies offering drugs online. He notes that the FDA’s warning letter offered no evidence CanaRx has distributed any counterfeit drugs since it began business almost 20 years ago.

Columbia County, N.Y., has been using CanaRx for about a decade and says the savings allows it to offer employees drugs with no out-of-pocket costs, instead of requiring them to pay as much as a $40 copay in local pharmacies.

“This is bull,” Stephen Acciani, an insurance broker who works with the county, says of the FDA crackdown. “They are not selling unsafe medications.” His recommendation would be for the county, which has more than 600 employees on its health plan, to continue using CanaRx.

Acciani notes that employees receive the medicine through the mail in its original packaging from the manufacturer.

“It will give some clients pause,” says Kate Sharry, a benefits consultant to the city of Fall River, Mass., and more than 100 other municipalities in the state. “How can you not pay attention to this from the FDA?” But she expects the local governments to stay with CanaRx.

Federal health officials under both Republican and Democratic administrations have blocked efforts to legalize importing medication, saying it’s too risky.

“Sometimes a bargain is too expensive,” says Peter Pitts, a former FDA associate commissioner (from 2000 to 2004)who is now president of the Center for Medicine in the Public Interest, a New York-based nonprofit that receives some of its funding from drugmakers.

Pitts, who applauds the FDA action, says it’s difficult for consumers to know when their pills from foreign pharmacies don’t have the correct potency or ingredients. He says doctors may also not realize a patient’s problem stems from issues with the medicine. Instead, the physicians may just change the medication’s dosage. He says it is not safe for Americans to buy drugs that are imported through foreign pharmacies.

Levitt says CanaRx is one of the safest ways for Americans to get drugs from legitimate pharmacies in Canada and other industrialized counties.

The FDA is likely trying to intimidate CanaRx and its clients in local government, Levitt says.

“My biggest fear is they will scare consumers, [who then] won’t take their very safe and effective medications because they hear about this bogus warning,” says Levitt.

“The FDA’s action,” he says, “which appears to try and make those programs look unsafe and sinister, seems to have a political and public relations purpose — one that is perfectly allied with the lobbying agenda of drug companies.”

Levitt points to testimony FDA Commissioner Scott Gottlieb gave to a House subcommittee last week — just a day before the CanaRx warning, and ahead of his announcement that he will be leaving the FDA next month.

When asked about importing Canadian drugs, Gottlieb did not mention CanaRx, but did say that people going to a “brick and mortar” pharmacy in Canada “are getting a safe and effective drug. I have confidence in the Canadian drug regulatory system.” He added that his concerns are with online pharmacies.

The Pharmaceutical Research and Manufacturers of America, the industry trade and lobbying group, has cheered the FDA action but denies it had any role in it, says spokeswoman Nicole Longo.

“PhRMA supports the FDA’s efforts to crack down on organizations that are circumventing its robust safety and efficacy requirements,” Longo says. “Drug importation schemes expose Americans to potentially unsafe, counterfeit or adulterated medicines.”

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

Let’s block ads! (Why?)