Some Addiction Treatment Centers Turn Big Profits by Scaling Back Care

Private equity groups are cashing in on rising rates of alcohol and drug addiction in the U.S. But they aren’t necessarily investing in centers with the best treatment standards, and they often cut extra services.

Near the end of his scheduled three-month stay at a rehab center outside Austin, Texas, Daniel McKegney was forced to tell his father in North Carolina that he needed more time and more money, he recently recalled.

His father had already received bills from BRC Recovery totaling about $150,000 to cover McKegney’s treatment for addiction to the powerful opioid fentanyl, according to insurance statements shared with KHN. But McKegney, 20, said he found the program “suffocating” and wasn’t happy with his care.

He was advised against the long-term use of Suboxone, a medication often recommended to treat opioid addiction, because BRC does not consider it a form of abstinence. After an initial five-day detox period last April, McKegney’s care plan mostly included a weekly therapy session and 12-step group meetings, which are free around the country.

McKegney said a BRC staffer recommended he stay a fourth month and even sat in on the call to his dad.

“They used my life and [my] father’s love for me to pull another 20 grand out of him,” said McKegney, who told KHN he began using fentanyl again after the costly stay.

BRC did not respond to specific concerns raised by McKegney. But in an emailed statement, Mandy Baker, president and chief clinical officer of BRC Healthcare, said that many of the complaints patients and former employees shared with KHN are “no longer accurate” or were related to covid safety measures.

But addiction researchers and private equity watchdogs said models like the one used by BRC — charging high patient fees without guaranteeing access to evidence-based care — are common throughout the country’s addiction treatment industry.

The model and growing demand are why addiction treatment has become increasingly attractive to private equity firms looking for big returns. And they’re banking on forecasts that predict the market will grow by $10 billion — doubling in size — by the end of the decade as drug overdose and alcohol-induced death rates mount.

“There is a lot of money to be made,” said Eileen O’Grady, research and campaign director at the Private Equity Stakeholder Project, a watchdog nonprofit that tracks private equity investment in health care, housing, and other industries. “But it’s not necessarily dovetailing with high-quality treatment.”

In 2021, 127 mergers and acquisitions took place in the behavioral health sector, which includes treatment for substance use disorders, a rebound after several years of decline, according to investment banking firm Capstone Partners. Private equity investment drove much of the activity in an industry that is highly fragmented and rapidly growing, and has historically had few guardrails to ensure patients get appropriate care.

Roughly 14,000 treatment centers dot the country. They’ve proliferated as addiction rates rise and as health insurance plans are required to offer better coverage of drug and alcohol treatment. The treatment options vary widely and are not always consistent with those recommended by the federal Substance Abuse and Mental Health Services Administration. While efforts to standardize treatment advance, industry critics say private equity groups are investing in centers with unproven practices and cutting services that, while unprofitable, might support long-term recovery.

Baker said BRC treats people who have been unsuccessful in other facilities and does so with input from both clients and their families.

Private Equity Skimps on the Known Standards

Centers that discourage or prohibit the use of Food and Drug Administration-approved medications for the treatment of substance use disorder are plentiful, but in doing so they do not align with the American Society of Addiction Medicine’s guidelines on how to manage opioid use disorder over the long term.

Suboxone, for example, combines the pain reliever buprenorphine and the opioid-reversal medication naloxone. The drug blocks an overdose while also reducing a patient’s cravings and withdrawal symptoms.

“It is inconceivable to me that an addiction treatment provider purporting to address opioid use disorder would not offer medications,” said Robert Lubran, a former federal official and chairman of the board at the Danya Institute, a nonprofit that supports states and treatment providers.

Residential inpatient facilities, where patients stay for weeks or months, have a role in addiction treatment but are often overused, said Brendan Saloner, an associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

Many patients return to drug and alcohol use after staying in inpatient settings, but studies show that the use of medications can decrease the relapse rate for certain addictions. McKegney said he now regularly takes Suboxone.

“The last three years of my life were hell,” he said.

Along with access to medications, high-quality addiction treatment usually requires long-term care, according to Shatterproof, a nonprofit focused on improving addiction treatment. And, ideally, treatment is customized to the patient. While the “Twelve Steps” program developed by Alcoholics Anonymous may help some patients, others might need different behavioral health therapies.

But, when looking for investments, private equity groups focus on profit, not necessarily how well the program is designed, said Laura Katz Olson, a political science professor at Lehigh University who wrote a book about private equity’s investment in American health care.

With health care companies, investors often cut services and trim staff costs by using fewer and less-trained workers, she said. Commonly, private equity companies buy “a place that does really excellent work, and then cut it down to bare bones,” Olson said. During his stay, McKegney said, outings to movies or a lake abruptly stopped, food went from poke bowls and pork tenderloin to chili that tasted like “dish soap,” and staff turnover was high.

Nearly three years ago, BRC landed backing from NewSpring Capital and Veronis Suhler Stevenson, two private equity firms with broad portfolios. Their holdings include a payroll processor, a bridal wear designer, and a doughnut franchise. With the fresh funds, BRC started an expansion push and bought several Tennessee treatment facilities.

NewSpring Capital and Veronis Suhler Stevenson did not respond to emails and phone calls from KHN.

High Prices and Low Overhead = Big Business

Before the sale to BRC, Nashville Recovery Center co-founder Ryan Cain said, roughly 80% of the center’s offerings were free. Anyone could drop by for 12-step meetings, to meet a sponsor, or just to play pool. But the new owners focused on a new high-end sober living program that cost thousands of dollars per month and relied on staffers who were in recovery themselves.

In 2021, Nanci Milam, 48, emptied her 401(k) retirement fund to go through the sober living program and tackle her alcohol addiction. She had been sober for only six months when she was hired as a house manager, overseeing some of the same residents she had gone through the program with. She had to handle other residents’ medications, which she said she could have abused. Milam said she was fortunate to maintain sobriety.

“I think it served their need. And I was ambitious. But it should not have happened,” said Milam, adding that she left because the company hadn’t helped her start her certification as a drug counselor as promised.

A licensing violation reported to Tennessee regulators in late 2021 involved a staffer who was later fired for having sex with a resident in a storage area. And KHN obtained a copy of a 911 call placed in August 2022 — after a resident drank half a bottle of mouthwash — during which a staffer admitted there was no nurse on-site, which some other states require.

Removing the Burden from Consumers

The regulations of treatment providers largely focus on health and safety rather than clinical guidelines. Only a handful of states, including New York and Massachusetts, require that licensed addiction treatment centers offer medication for opioid use disorder and follow other best practices.

“We have a huge issue in the field where licensing standards don’t comport with what we know to be the most effective quality-of-care standards,” said Michael Botticelli, former director of the Office of National Drug Control Policy during the Obama administration and a member of a clinical advisory board for private equity-backed Behavioral Health Group. Some organizations, including Shatterproof, guide patients toward appropriate care. The federal and state governments largely direct public funds to centers that meet clinical quality-of-care standards.

But access to treatment is limited, and desperate patients and their families often don’t know where to turn. State or federal regulators aren’t policing claims from rehab facilities, like the “99% success rate” touted by BRC.

“We cannot put the burden on patients and their families” to navigate the system, said Johns Hopkins’ Saloner. “My heart really breaks for people who have thrown thousands of their dollars at programs that are bogus.”

When her niece was ready for inpatient rehab in summer 2020, Marina said, sending her to BRC was a “knee-jerk reaction.” Marina, a physician in Southern California, requested to be identified only by her middle name to protect the privacy of her niece, who suffers from alcohol addiction.

She had researched the facility three years earlier but didn’t investigate deeper because she was worried her niece would change her mind. BRC advertised success stories on the television show “Dr. Phil” and posted affirmations on social media.

Marina agreed to BRC’s upfront cost of $30,000 a month for a three-month stay in Texas, which she paid for out-of-pocket because her niece lacked insurance. She allowed KHN to review some of her niece’s pharmacy and treatment bills.

Marina said she paid for a fourth month, but said ultimately the program didn’t help her niece, who remains “horribly sick.” She said her niece felt constant guilt and shame at rehab. Marina thought there was inadequate medical oversight, and said the program “nickeled and dimed” her for additional services, like physicians’ visits, that she thought would be included.

“It almost doesn’t matter if you are educated and intelligent,” Marina said. “When it’s your loved one, you are just desperate.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

A $30 Million Gift to Build an Addiction Treatment Center. Then Staffers Had to Run It.

Howard Buffett, son of billionaire investor Warren Buffett and chairman of his own charitable foundation, gave $30 million to build an addiction treatment center in the central Illinois community where he farms. But the money was a one-time gift for infrastructure, so the clinic is on its own to keep it running.

DECATUR, Ill. — The question came out of the blue, or so it seemed to Crossing Healthcare CEO Tanya Andricks: If you had $30 million to design an addiction treatment facility, how would you do it?

The interim sheriff of Macon County, Illinois, posed the question in 2018 as he and Andricks discussed the community’s needs. When she responded that she’d have to do some research, she was told not to take too long because the offer wouldn’t be there forever.

“I thought: ‘Oh, my God, he’s serious,’” Andricks said.

That sheriff was Howard Buffett, the philanthropist son of billionaire investor Warren Buffett. The younger Buffett ended up giving Crossing about $30 million from his charitable foundation to build an addiction treatment center in Decatur, a city with a population of just over 69,000 in the heart of Macon County.

There was a caveat, though. The donation to Crossing was a one-time gift to pay only for the buildings. It was up to Andricks and her team to find money to run the programs. And that has proven difficult.

The covid-19 pandemic upended everything mere months after the facilities opened in October 2019. An audited financial statement said the inpatient recovery center had lost $2.5 million by June 2021, and management worried about its ability to continue operating. Even so, the center remained open while other addiction treatment facilities around the country shuttered.

Now communities nationwide are preparing for an unprecedented windfall of their own for addiction treatment from a nearly $26 billion national opioid settlement and a more than $300 million expansion of a federal pilot program for mental health. The experience at Crossing offers them a model but also a warning: It will take more than a single shot of money to build a treatment program that can last.

Drug addiction wasn’t on Howard Buffett’s radar, he told KHN, until he joined the Macon County sheriff’s office as an auxiliary deputy in 2012. While the county has had some treatment resources, like a behavioral health center, it has one of the state’s higher death rates from opioid overdoses.

Buffett moved to the area in 1992 to work for food-processing giant Archer Daniels Midland. He runs a farm nearby and his Decatur-based foundation donates hundreds of millions of dollars for initiatives ranging from helping people kidnapped by Joseph Kony’s Lord’s Resistance Army in central Africa to revitalizing the cacao industry in El Salvador.

Soon after Buffett was appointed interim sheriff in 2017, he toured Crossing to learn more about local social services. The health center offers primary care, including mental health, for all ages and sees roughly 17,500 patients a year. Most Crossing patients are on Medicaid, the public health insurance for people with low incomes.

“He was impressed with what we were able to provide patients,” Andricks recalled. “I don’t think he expected the scope and size of what we do.”

Addiction treatment, though, is notoriously difficult. Evidence supports treating addiction like a chronic illness, meaning even after difficult short-term behavior changes, it requires a lifetime of management. Research suggests relapse rates can be more than 85% in the first year of recovery. So any new treatment program is likely to face headwinds.

Buffett didn’t set Crossing up for failure. In fact, he has helped fund other aspects of the organization’s work. Part of the idea behind paying for the addiction treatment buildings but not the operations, Buffett said, is to keep his foundation “creative.” If it spends all its money on the same programming every year, that means less is available to fund other work around the globe. Buffett said it’s also about sustainability.

“If Tanya can show ‘with this investment I made this work,’” Buffett said, “then other people should be making that investment.”

Crossing’s inpatient recovery center holds eight beds for medication-assisted detox, 48 beds for rehabilitation, and a cafeteria where meals are cooked with input from dietitians working with patients. An outpatient treatment center also has classrooms for continuing education, a gym with a small bowling alley, and a movie theater. Buffett insisted on the last two amenities. (“People have to feel good about getting better,” he said.)

A separate building holds 64 beds of transitional housing, and just across the street are 20 rent-controlled apartments. Buffett spent an additional $25 million on buildings at that campus for other organizations focused on housing, workforce development, and education, among other things.

“There’s a lot to like in this program,” said Dr. Bradley Stein, director of Rand Corp.’s Opioid Policy and Tools Information Center.

As positives, Stein pointed specifically to the spectrum of care offered to patients as they progress in their recovery, the use of medication-assisted treatment to help stave off physical cravings for opioids, the connection to the health center, and even the involvement of law enforcement.

Laura Cogan, a 36-year-old mother who has struggled with addiction since she was 14, is one of the patients working their way through the system.

Cogan said she was the first patient in the doors when the recovery center opened. Less than 24 hours later, she was also the first patient to walk out.

The biggest challenge with Cogan’s previous attempts at recovery, she said, was never being sure about her next steps: What was she supposed to do after getting out of detox and residential treatment?

Crossing’s approach was designed to address that by providing transitional housing, easy access to outpatient services, and educational programming.

On her third attempt, Cogan got a round of applause after completing the first three days in detox. After six days, she joined residential treatment. After a month, she moved over to transitional housing, began outpatient treatment, and started offering peer support at Crossing. She tutored other patients, taught a writing class, and helped them get on computers and fill out job applications.

Then the pandemic hit.

Like other health centers around the nation, Crossing turned its attention to providing covid testing and vaccines. Meanwhile, just about every aspect of addiction treatment became more expensive. Crossing halved the number of residential treatment beds so each room would have only one patient and converted the rooms into negative pressure chambers to reduce the risk of covid transmission.

Staffing grew harder amid a nationwide nursing shortage. The number of patients in residential treatment dropped, Andricks said, because few people wanted to live inside a facility and wear masks. It was common to have as few as 10 beds occupied on a given day. The women’s unit was temporarily closed due to lack of demand and staffing constraints.

Cogan said several other transitional housing residents left once the $1,200 pandemic stimulus checks arrived, with some resuming treatment when that money dried up. But Cogan continued. Eventually she moved into Crossing’s rent-controlled apartments, where she has been one of just a few tenants.

Without the federal Paycheck Protection Program’s $1,375,200 forgivable loan in 2020, Andricks said, the outpatient treatment program might have had to close altogether.

But momentum at the recovery center started to change last spring as covid cases tapered off, Andricks said. Hiring became easier. More patients arrived. In October, the center received a grant to use the apartments for women with a history of substance misuse who are pregnant or who have given birth within the prior year. They’ve placed six women, in addition to Cogan, there already. The inpatient recovery center now averages about 27 occupied beds a day, within striking distance of the 30 that Andricks said the inpatient center needs to survive.

Rand’s Stein suggested another measurement of a treatment program’s success: whether people in the community get into treatment when they need it. National “secret shopper” reports have found significant barriers to service, such as long wait times.

Crossing’s program quadrupled the number of residential treatment beds in Macon County, according to Andricks. In the three years since the inpatient recovery center opened, it has had over 1,300 admissions. While most patients haven’t stayed in recovery, staffers have seen a pattern of success with those like Cogan who stay on campus and become involved with recovery offerings — although Andricks estimated that’s fewer than 10% of the patients.

Cogan said she hopes Crossing doesn’t get discouraged. People are going to mess up, she said, but she’s living proof of the impact the recovery center can have.

“I’m one of the lucky ones and I don’t know why,” Cogan said, sitting on a couch in the apartment on Crossing’s campus that she shares with her 12-year-old son since regaining custody of him. “I just know that today I am. And I hope that more people get the opportunity.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Readers and Tweeters Diagnose Greed and Chronic Pain Within US Health Care System

KHN gives readers a chance to comment on a recent batch of stories.

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

U.S. Health Care Is Harmful to One’s Health

Thank you for publishing this research (“Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?” Dec. 21). I am a psychotherapist and have written about this problem in my blog. The mercenary American health care system is hypocritical in the stressful financial demands and threats it imposes on so many patients. Stress due to health care-related bankruptcy, or the threat of bankruptcy, is harmful to one’s health. A health care system that is supposed to treat illness and restore health can, in fact, cause serious illness and/or exacerbate existing medical problems. The higher levels of stress and the threat of bankruptcy that all too frequently follow needed medical care can be harmful to individuals with cardiovascular issues such as high blood pressure and heart arrhythmia, and can trigger panic attacks in those who suffer from anxiety disorders. There may be digestive issues associated with higher levels of stress, and the patient’s sleep may be adversely affected. The individual may have to cut back on essentials such as food and medications because of unpaid medical bills, aggressive calls from collection agencies, and the threat of bankruptcy.

All of this in the name of “health care” delivered by professions and organizations that proclaim the importance of beneficence, justice, and malfeasance within their respective codes of ethics. Curative stress? Therapeutic bankruptcy? The hypocrisy is palpable.

American history is replete with examples of discrimination against certain groups, including racial discrimination, the disenfranchisement of women, child labor, and others. Eventually, political measures were enacted to correct these injustices. It’s only a matter of time until the American health care system, including the pharmaceutical industry, is forced to reform itself for the sake of the men, women, and children in need of essential health care. It’s not a question of if, but when.

— Fred Medinger, Parkton, Maryland

I find this infuriating! Especially the nonprofit organizations. Hundreds of US Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds | Kaiser Health News

— Jan Oldenburg ☮️ (@janoldenburg) December 21, 2022

— Jan Oldenburg, Richmond, Virginia

Thanks for the article about hospitals suing patients. I just switched health plans in New York state. Reasons: My previous insurer raised my premium over 90% last year, paid very little of my claims (leaving Medicare to pay most of the claims), and sent me to collections. This, even though I worked two full-time jobs for most of my 46 years of teaching. How do insurance companies and hospitals get away with this unethical and outrageous behavior?

— George Deshaies, Buffalo, New York

Great story by @KHNews' @NoamLevey, which found that at least 297 hospitals in MN, 56%, sue patients for unpaid medical bills. 90, or 17%, can deny patients nonemergency medical care if they have past-due bills.Mayo is one of those hospitals. See🧵

— Molly Work (@mollycastlework) December 21, 2022

— Molly Work, Rochester, Minnesota

Unhappy New Year of Deductibles and Copays

Listened to a conversation between Noam N. Levey and NPR’s Ari Shapiro, regarding Levey’s article on Germany’s lack of medical debt (“What Germany’s Coal Miners Can Teach America About Medical Debt,” Dec. 14). Levey passed along the tidbit that Affordable Care Act plans purchased through state exchanges would pay a maximum out-of-pocket amount of $9,000 a year. Likely Mr. Levey knows the actual details of the ACA at least as well as I, but I had well over $20,000 in out-of-pocket expenses for my own care last year (in addition to annual premiums of over $15,000). The deductible/copay aspect of health insurance is rigged against folks who actually use their insurance. The in-network and out-of-network provider scheme is likewise designed to benefit providers as opposed to patients.

I’ve had health insurance for about 40 years, since I graduated from college. Always a plan paid for by myself, never through an employer. I’ve had my first year of using a lot of heath care services (colon cancer surgery and chemo follow-up), and the bills are quite astronomical. Still awaiting the final negotiations between Stanford Hospital and Blue Shield of California for the $97,000 bill for services for the surgery and stay in the hospital. Though my surgery was in September, the two had not resolved the bill by year-end. Now all my copays and deductibles have reset, and I’ll be back at the starting gate, dollar-wise.

We need health care payment reform.

— George McCann, Half Moon Bay, California

Tx @NoamLevey for this important comparative piece on how Germany's private healthcare system does not create #medicaldebt. We need to do better. @RIPMedicalDebt

— Allison Sesso (@AllisonSesso) December 14, 2022

— Allison Sesso, president and CEO of RIP Medical Debt, Long Island City, New York

Greedy to the Bone?

In orthopedics, surgery is where the money is (“More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality,” Jan. 6). Just as a private equity-controlled ophthalmology group tried to persuade me to have unnecessary cataract surgery (three other eye doctors agreed it wasn’t necessary), too many orthopedic patients can expect to be pushed to unnecessary surgeries.

— Gloria Kohut, Grand Rapids, Michigan

As #private #equity firms acquire #physician practices, the issue of non-competes and #restrictive covenants become even more relevant in #healthcare @AAOS1 @AmerMedicalAssn @JHU_HBHI @linakhanFTC @KHNews

— Amit Jain, MD, MBA (@AmitJainSpine) January 8, 2023

— Dr. Amit Jain, Baltimore

The Painful Truth of the Opioid Epidemic

In a recent article, Aneri Pattani and Rae Ellen Bichell discussed disparities in the distribution of settlement funds from lawsuits against major pharmaceutical companies, especially in rural areas (“In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them,” Dec. 12).

We suggest that the merit of many of the lawsuits that led to these large settlements remains unproven. While Purdue Pharma clearly overstated the safety of prescription opioids in treating chronic pain, judges in two high-profile cases ruled in favor of the pharmaceutical companies stating that prosecutors falsely inflated the danger of opioids and noted that opioids used per FDA guidelines are safe and effective, remaining a vital means to treat chronic pain. Also, many cases involving Purdue Pharma, Johnson & Johnson, and others were settled based on expediency, rather than merit. This may have been due to the reasoning that continuing their defense against prosecutors having access to limitless public funds would lead to bankruptcy.

The primary cause of America’s overdose crisis is not physicians’ “overprescribing” opioids. Dr. Thomas Frieden, former head of the Centers for Disease Control and Prevention, noted that the rise in prescription opioids paralleled the increase in opioid deaths up to 2010, leading the CDC to create guidelines in 2016 limiting opioid use to treat chronic pain. However, cause-and-effect relationships between the legitimate use of prescription opioids and opioid deaths remain unclear. For example, the National Institute on Drug Abuse noted in 2015 that since 2000, misuse of prescription drugs preceded the use of heroin in most cases. But legitimate prescriptions by physicians to patients with chronic pain constituted only 20% of the cases leading to heroin addiction. Prescription drugs used by heroin addicts were from family members or friends in 80% of the cases leading to heroin use.

Since at least 2010, the volume of prescription opioids dropped by over 60% — yet overdose deaths have skyrocketed to over 100,000 cases in 2021. The opioid overdose death crisis is now driven mainly by illegally imported fentanyl and in part by a misguided crackdown of the Drug Enforcement Administration against physicians who legitimately prescribe opioids to chronic pain patients, forcing them to seek out street drugs.

Statistics from Michigan indicate that nearly 40% of primary care clinics will no longer see new patients for pain management. The CDC, in its 2022 updated guidelines, attempted to clarify misunderstandings, including inappropriate rapid tapering and individualizing care. However, the public health crisis of undertreated pain remains. Some states have passed intractable pain laws to restore access to opioids to chronic pain patients with a legitimate need, indicating the shortfalls of the CDC guidelines to treat pain.

— Richard A. Lawhern, Fort Mill, South Carolina, and Dr. Keith Shulman, Skokie, Illinois

Important reporting from @aneripattani and @raelnb in @KHNews: National settlements are being paid out by #opioids manufacturers, but #rural communities are often getting less funds to address the #OpioidCrisis than their urban and suburban counterparts.

— Joanne Conroy (@JoanneConroyMD) December 15, 2022

— Dr. Joanne Conroy, Lebanon, New Hampshire

We’re fighting to hold accountable the companies that helped create and fuel the opioid crisis so we can help people struggling with opioid use disorder across North Carolina and the country get resources for treatment and recovery. We need this money now to save lives.

To that end, I wanted to flag one concern about the article on rural counties and opioid funding. It looks as if the comparison and the maps about North Carolina funding by county and overdose deaths may not correlate. The reporting seems to reflect overdose deaths on a per capita basis, but funding is indicated by total dollars received.

This spreadsheet might be helpful. It ranks each North Carolina county by the amount of funds they will receive from the distributor and Johnson & Johnson settlements (as posted on per capita, using 2019 population figures. In per capita rankings, rural and/or less populous counties are typically receiving more funding per capita than larger counties. For example, the 10 counties receiving the most per capita funding are all rural and/or less populous counties (Wilkes, Cherokee, Burke, Columbus, Graham, Yancey, Mitchell, Clay, Swain, and Surry). Wake County, our most populous county, is ranked 80th.

It’s also important to note that the formula was developed by experts for counsel to local governments in the national opioid litigation, who represent and have duties of loyalty to both large urban and small rural local governments. It takes into account opioid use disorder in the county (the number of people with opioid use disorder divided by the total number of people nationwide with opioid use disorder), overdose deaths as a percentage of the nation’s opioid overdose deaths, and the number of opioids in the county. Click here for more information.

Indeed, one of the special masters appointed by U.S. District Judge Dan Polster in the national opioid litigation found that the national allocation model “reflects a serious effort on the part of the litigating entities that devised it to distribute the class’s recovery according to the driving force at the heart of the lawsuit — the devastation caused by this horrific epidemic.” (See Page 5 of this report of Special Master Yanni.)

You’re absolutely right that rural counties were often the earliest and hardest hit by the opioid epidemic, and it’s critical that they receive funds to help get residents the treatment and recovery resources they need. We’re hopeful that these funds, whose allocation was determined in partnership by local government counsel, will help deliver those resources.

— Nazneen Ahmed, North Carolina Attorney General’s Office, Raleigh, North Carolina

This article is a great example of equality ≠ equity regarding opioid settlement funds disbursement. Really thoughtful article by @aneripattani & @raelnb

— Kate Roberts, LCSW (@KateandOlive_) December 14, 2022

— Kate Roberts, Durham, North Carolina

A Holistic Approach to Strengthening the Nursing Workforce Pipeline

As we face the nation’s worst nursing shortage in decades, some regions are adopting creative solutions to fill in the gaps (“Rural Colorado Tries to Fill Health Worker Gaps With Apprenticeships,” Nov. 29). To truly solve the root of this crisis, we must look earlier in the workforce pipeline.

The entire nation currently sits in a dire situation when it comes to having an adequate number of nurses — especially rural communities. With the tripledemic of covid-19, influenza, and RSV tearing through hospitals, it’s never been more evident how vital nurses are to the functioning of our health care system. A recent McKinsey report found that we need to double the number of nurses entering the workforce every year for the next three years to meet anticipated demand. Without support from policymakers and health care leaders, we cannot meet that.

As a health care executive myself, I’ve seen firsthand how impactful apprenticeships can be because they help sustain the health care workforce pipeline. From high school students to working adults, these “earn while you learn” apprenticeships allow students to make a living while working toward their degree, and my system’s apprenticeship program has even reduced our turnover by up to 50%. It provides a framework to support a competency-based education rooted in real-life skills and hands-on training for key nursing support roles, all while team members earn an income.

Education is key to developing competent, practice-ready nurses. Not just through apprenticeships but early on in students’ educational journey, too. According to the newest data from the nation’s report card, students in most states and most demographic groups experienced the steepest declines in math and reading ever recorded. As we continue to see the devastating impact the pandemic had on young learners, it’s crucial we invest more in remediation and support, so students graduate from secondary school with a deep understanding of these core competencies and are ready to pursue nursing. A recent survey of nearly 4,000 prospective nursing students from ATI Nursing Education found that a lack of academic preparedness was the top reason for delaying or forgoing nursing school.

Without intervention now, our nursing workforce shortage will only worsen in the future. We need our leaders to face these challenges head-on and invest in a holistic approach to strengthen our nursing pipeline. There’s no time to waste.

— Natalie Jones, executive director of workforce development at WellStar Health System, Atlanta

1 solution to the staffing crisis: Apprenticeship programs put students directly into long-term care professions. Rural areas benefit the most since they have more residents who are 65 or older & fewer direct care workers to help people w/ disabilities.

— OK Health Action (@ok_action) November 30, 2022

— Oklahoma Health Action Network, Oklahoma City

Planning Major Surgery? Plan Ahead

I read Judith Graham’s good article “Weighing Risks of a Major Surgery: 7 Questions Older Americans Should Ask Their Surgeon” (Jan. 3) on CNN. Thought I should add some personal experience. At age 78, my mother had back surgery in 2016. When she was getting prepped, she was given multiple documents to sign. Once signed, she was immediately taken to surgery. There was not enough time to read any of them. In hindsight, we are certain the documents were mostly for release of liability if something goes wrong. After surgery, she had “drop foot” — total loss of use of her left foot. Never heard of it. She was told she would regain use in about six months. Never happened. She had to use a walker and still had numerous falls in which her head had hit the ground multiple times. She slowly slid into long-term “confusion” that was attributed to her falls and passed away at age 84.

My story is about my abdominal aorta aneurysm surgery in 2022 at age 62. I did not have an overnight recovery — tube taken out of my throat, catheter removed, and was immediately transferred to a room. An IV pump of saline was left on and my arm swelled up — I thought my arm was going to burst. Five days later, I was discharged. Everything seemed rushed. The only postsurgical “instructions” I received were to keep the incision clean and not to play golf, and I don’t even play golf. I recuperated at home, and after five months I still have abdominal pain that I’ll always have.

Both of our surgeries were done on a Friday. I’m certain our experiences were due to hospital staff wanting to leave early on Friday, and weekend staffers are mostly the “B” team. So, my advice is to suggest to the elderly not to have surgery scheduled on a Friday unless there is absolute urgency in choosing the date.

— Paul Lyon, Chesapeake, Virginia

Reality bites, doesn’t it.

— suzette sommer (@suzette_sommer) December 28, 2022

— Suzette Sommer, Seattle

I am writing to express my concerns over the significant misinformation in the article about what older Americans should ask their surgeon before major surgery.

Most abdominal aortic aneurysms are treated with endovascular methods. These minimally invasive procedures still require general anesthesia (with a breathing tube), but most patients have the tube removed before leaving the operating room, and many patients leave the hospital the next day with minimal functional limitations due to surgery being performed through half-inch incisions in each groin.

The “best case” surgical scenario described in your article describes open abdominal aortic aneurysm repair, which is recommended for fewer than 20% of patients requiring aortic aneurysm repairs.

In essence, you’re threatening everyone who comes in for a tuneup with an engine rebuild.

Abdominal aortic aneurysms are still undertreated in the U.S., with many patients not receiving screening recommended by Medicare since 2006. Your article misrepresents the “best case” scenario and may dissuade patients from receiving lifesaving care.

— Dr. David Nabi, Newport Beach, California

I read, with interest, Judith Graham’s article about older Americans preparing for major surgery. But you failed to mention the life-altering effects of anesthesia. My independent 82-year-old mother had a minor fall in July and broke her hip. After undergoing anesthesia, she is required to have 24/7 care as her short-term memory has been forever altered. Was there a choice not to have hip surgery? I didn’t hear one. Did anyone explain the issues that could (and often do) occur with an elderly brain due to anesthesia? No. And now we are dealing with this consequence. And what happens when you don’t have money (like most people in the U.S.) for 24/7 care? I hope you’ll consider writing about this.

— Nancy Simpson, Scottsdale, Arizona

Shouldn't more people wonder why MA plans are profitable while our own gov't MC is losing money. Only 5% of MA plans are audited yearly. Yet they are getting 8.5% increase in payment & docs (the folks taking care of the pts) are getting cut. via @khnews

— Madelaine Feldman (@MattieRheumMD) December 15, 2022

— Dr. Madelaine Feldman, New Orleans

The High Bar of Medicare Advantage Transparency

Unfortunately, KHN’s article “How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions” (Dec. 13) provided a misleading, incomplete depiction of Medicare Advantage payment.

This story focuses largely on audits that, in some cases, are more than a decade old. While KHN’s focus is on alleged “overpayment,” the same audits show that many plans were underpaid by as much as $773 per patient.

More recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars. For example, an October 2021 Milliman report concludes “the federal government pays less and gets more for its dollar in MA than in FFS,” while the Department of Health and Human Services’ fiscal year 2021 report shows that the net improper payment rate in Medicare Advantage was roughly half that of fee-for-service Medicare.

KHN’s article is right about one thing: Only a small fraction of Medicare Advantage plans are audited each year — denying policymakers and the public a fuller understanding of the program’s exceptional value to seniors and the health care system. That is why Better Medicare Alliance has called for regulators to conduct Risk Adjustment Data Validation (RADV) audits of every Medicare Advantage plan every year.

There are opportunities, as outlined in our recent policy recommendations, to further strengthen and improve Medicare Advantage’s high bar of transparency and accountability, but that effort is not well served by this misleading article.

— Mary Beth Donahue, president and CEO of the Better Medicare Alliance, Chevy Chase, Maryland

Targeting Gun Violence

I’m curious why KHN neglected to actually get into all the “meat and potatoes” regarding its report on Colorado’s red flag law (“Colorado Considers Changing Its Red Flag Law After Mass Shooting at Nightclub,” Dec. 23). Specifically, it failed to report that the suspect in this case used a “ghost gun” to execute the crime in Colorado Springs, and more importantly what impact any red flag law is going to have on a person who manufactures their own illegal firearm. Lastly, why is it the national conversation regarding the illegal use and possession of firearms curiously avoids any in-depth, substantive conversation of access to firearms by mentally ill people? Quite frankly, this is the underlying cause of illegal firearms use and no one wants to step up to the plate and address the issue at any in-depth level. It’s categorically embarrassing for American journalism.

— Steve Smith, Carbondale, Colorado

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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NY requiere que doctores receten naloxona a algunos pacientes que toman analgésicos opioides

Aunque los titulares son por las muertes por sobredosis de drogas ilícitas vendidas en la calle, el riesgo de sufrirlas también es real para los pacientes que toman opioides recetados por sus médicos.

Sin analgésicos opioides para aliviar el dolor de rodillas y otras articulaciones, Arnold Wilson no podría caminar media cuadra. El ex enfermero de la ciudad de Nueva York, de 63 años, tiene una artritis incapacitante y toma OxyContin dos veces al día, y oxicodona cuando necesita un alivio adicional.

En los últimos años, también ha tenido otro remedio a mano: naloxona, un medicamento para revertir una sobredosis, al que generalmente se menciona con el nombre de marca Narcan.

Aunque los titulares son por las muertes por sobredosis de drogas ilícitas vendidas en la calle, el riesgo de sufrirlas también es real para los pacientes que toman opioides recetados por sus médicos.

“Me da una sensación de alivio y seguridad”, dijo Wilson, quien tiene aerosol nasal Narcan en su auto y en su casa. Su médico en el Centro Médico Montefiore, en el Bronx, le recetó opioides en 2013, después que un episodio de meningitis exacerbara los problemas en las articulaciones que Wilson tenía como resultado de dos aneurismas cerebrales y varios accidentes cerebrovasculares. Su médico lo instó a comenzar a tener Narcan en 2017.

Generalmente otras personas administran la naloxona, que comienza a revertir una sobredosis en cuestión de minutos. Aunque nunca la ha necesitado, la hija de Wilson, de 18 años, sabe cómo usarla. “Le he dado instrucciones sobre cómo hacerlo, en caso de que esté letárgico”, dijo. Su novia y sus amigos también saben qué hacer.

Una ley recientemente promulgada en Nueva York tiene como objetivo garantizar que la naloxona esté disponible si la necesitan personas como Wilson que toman opioides recetados.

Según la ley, vigente desde el verano pasado, los médicos deben recetar naloxona junto con la primera receta de opioides cada año.

Los factores de riesgo que activarían el requisito incluyen tomar una dosis diaria alta de un opioide (al menos el equivalente a 90 miligramos de morfina, o MME); tomar ciertos medicamentos, como sedantes hipnóticos; o tener antecedentes de adicciones.

Al menos otros 10 estados tienen leyes similares, según una investigación de Network for Public Health Law.

“A veces, los pacientes, especialmente si han estado tomando opioides durante mucho tiempo, no entienden los riesgos”, dijo la doctora Laila Khalid, codirectora de la clínica de dolor crónico del Centro Médico Montefiore. La clínica proporciona naloxona gratis a los pacientes a través del programa de prevención de sobredosis de opioides del estado.

Por ejemplo, la persona puede haberse olvidado cuándo tomó la última dosis y, sin darse cuenta, tomar demasiado, o tomar algunos tragos adicionales en una fiesta, dijo Khalid. El alcohol y algunos medicamentos, como las benzodiazepinas, amplifican los efectos de los opioides.

“Las muertes por sobredosis de drogas continúan aumentando, como cada año durante más de dos décadas”, dijo Emily Einstein, jefa del área de Política Científica del Instituto Nacional sobre el Abuso de Drogas.

En 2021, apuntó Einstein, las muertes por sobredosis en Estados Unidos superaron las 100,000 estimadas por primera vez, según datos provisionales de los Centros para el Control y la Prevención de Enfermedades (CDC). Según estos datos, la gran mayoría de esas muertes, más de 80,000, involucraron a opioides, agregó. Si bien la mayoría de las muertes por sobredosis de opioides se atribuyeron al fentanilo ilegal, aproximadamente 17,000 muertes involucraron opioides recetados, incluida la metadona.

La naloxona, disponible como aerosol nasal o inyección, se considera segura y causa pocos efectos secundarios. No es adictiva. Los CDC recomiendan que las personas con riesgo de sobredosis la lleven consigo para que un familiar o transeúnte pueda administrarla si es necesario.

Los expertos en política de drogas señalan una estadística clave que leyes como la de Nueva York pretenden abordar: en casi el 40% de las muertes por sobredosis, otra persona está presente, según los CDC.

Si los transeúntes hubieran tenido la naloxona, “la mayoría de esas personas no habrían muerto”, dijo Corey Davis, director del Harm Reduction Legal Project en la Network for Public Health Law.

En todos los estados, incluido Nueva York, los farmacéuticos están autorizados a dispensar naloxona, a menudo bajo “órdenes permanentes” que permiten dispensarlo sin una receta, por lo general a personas que corren el riesgo de sufrir una sobredosis o están en condiciones de ayudar a alguien en riesgo.

Entonces, ¿por qué exigir que los médicos hagan recetas?

Obligar es más efectivo que recomendar, dicen expertos. Al requerir que los médicos receten el medicamento, más personas que podrían necesitar naloxona la tendrían a mano, si surten la receta. Pero no hay garantía de que lo hagan.

Una receta también puede ayudar a eliminar el estigma persistente de pedir una fármaco contra la sobredosis en el mostrador de una farmacia.

“Elimina los puntos de fricción”, dijo Davis. “Simplemente vas al mostrador y lo recoges”.

En un análisis de 2019, los farmacéuticos en los estados que requerían la receta conjunta de naloxona con opioides surtieron casi ocho veces más recetas de naloxona por cada 100,000 personas que los de los estados que no la requerían.

Missouri no tiene una ley de receta conjunta, pero el médico que ayuda a manejar el dolor a Danielle Muscato sugirió recientemente que llevara Narcan. La activista de derechos civiles de 38 años, que vive en Columbia, toma el opioide recetado tramadol y varios otros medicamentos para controlar su dolor lumbar severo y crónico. Está contenta de tener el aerosol nasal guardado en su bolso, por si acaso.

“Creo que es algo maravilloso” que la gente lo lleve y sepa cómo usarlo, dijo. “Ojalá esto fuera estándar en todas partes”.

Desde que entró en vigencia la ley de Nueva York, “definitivamente he visto un aumento de recetas que agregan naloxona a los opioides, especialmente si se trata de un pedido grande”, dijo Ambar Keluskar, gerente de farmacia de Rossi Pharmacy en Brooklyn.

Sin embargo, los pacientes no siempre entienden por qué lo obtienen, afirmó Toni Tompkins, farmacéutica supervisora de Phelps Hometown Pharmacy en la ciudad de Phelps, en el norte del estado de Nueva York.

Un caja de dos dosis de aerosol de naloxona generalmente cuesta alrededor de $150. El medicamento ahora está disponible en forma genérica, lo que puede reducir el costo de bolsillo. La mayoría de las aseguradoras lo cubren, aunque los pacientes suelen tener un copago.

Las personas sin seguro generalmente pueden obtener naloxona a través de programas estatales.

En Nueva York, las aseguradoras privadas están obligadas a cubrir la naloxona, y Medicaid también la cubre, dijo Monica Pomeroy, vocera del Departamento de Salud del estado. El Programa de asistencia de copago de naloxona (N-CAP) del estado cubre el costo de los copagos de hasta $40 para las personas con seguro, dijo Pomeroy.

Las personas sin seguro o aquellas que no han alcanzado su deducible pueden obtenerla gratis en uno de los sitios de prevención de sobredosis de opioides del estado.

En noviembre, la Administración de Alimentos y Drogas (FDA) anunció que está considerando que la naloxona esté disponible sin receta.

Aunque ofrecerla sin receta facilitaría la obtención del medicamento, a algunas personas les preocupa que el seguro no lo cubra. Además, “si un paciente simplemente lo recoge en algún lugar sin recibir orientación sobre cómo usarlo, eso podría ser un inconveniente”, dijo Anne Burns, vicepresidenta de asuntos profesionales de la Asociación Estadounidense de Farmacéuticos.

Algunos profesionales creen que se debe dispensar naloxona con cada receta de opioides, independientemente de los factores de riesgo. Así es en Rochester, Nueva York, y en los alrededores del condado de Monroe. En 2021, el ejecutivo del condado, Adam Bello, firmó la Ley de Maisie, que lleva el nombre de una niña local de 9 meses que murió después de tragarse una pastilla de metadona que encontró en el piso de la cocina de un vecino.

“Es horrible lo que pasó”, dijo Karl Williams, profesor de derecho farmacéutico y presidente de la junta de la Sociedad de Farmacéuticos del Estado de Nueva York. “Tal vez sea el próximo estándar que debería convertirse en ley”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

NY Docs Are Now Required to Prescribe Naloxone to Some Patients on Opioid Painkillers

This strategy — now in place in at least 10 states — is part of an effort to curb accidental opioid overdose deaths by patients who take these powerful medications.

Without opioid painkillers to dull the ache in his knees and other joints, Arnold Wilson wouldn’t be able to walk half a block. The 63-year-old former New York City nurse has crippling arthritis for which he takes OxyContin twice a day and oxycodone when he needs additional relief.

For the past several years, he’s kept another drug on hand as well: naloxone, an overdose reversal drug often referred to by the brand name Narcan.

Although overdose deaths from illicit drugs sold on the street make headlines, the risk of overdose is just as real for patients who take opioids prescribed by their doctors.

“It gives me a sense of relief and security,” said Wilson, who keeps Narcan nasal spray in his car and at home. His pain management doctor at Montefiore Medical Center in the Bronx prescribed the opioids in 2013, after a bout with meningitis exacerbated joint problems Wilson had as a result of two brain aneurysms and several strokes. His doctor urged him to start carrying Narcan in 2017.

Naloxone, which begins to reverse an overdose within minutes, is typically administered by others. Though he’s never needed it, Wilson’s 18-year-old daughter knows how to use it. “I’ve instructed her how to do it, in case I’m lethargic,” he said. His girlfriend and friends know what to do, too.

A recently enacted New York law aims to ensure that naloxone is available if needed by people like Wilson who take prescription opioids.

Under the law, which took effect this summer, doctors must co-prescribe naloxone to certain patients who are at risk of an overdose when writing the patients’ first opioid prescription each year. Risk factors that would trigger the requirement include taking a high daily dose of an opioid (at least 90 morphine milligram equivalents, or MME); taking certain other drugs, like sedative hypnotics; or having a history of substance use disorder.

At least 10 other states have similar laws, according to research by the Network for Public Health Law.

“Sometimes patients, especially if they’ve been taking opioids for a long time, don’t understand the risks,” said Dr. Laila Khalid, co-director of the chronic pain clinic at Montefiore Medical Center. The clinic provides free naloxone to patients through the state’s opioid overdose prevention program.

Someone may forget the timing of their last dose and inadvertently take too much, for example, or have a few extra drinks at a party, Khalid said. Alcohol and some medications, like benzodiazepines, amplify opioids’ effects.

“Drug overdose deaths continue to climb, as they have nearly every year for more than two decades,” said Emily Einstein, chief of the Science Policy Branch at the National Institute on Drug Abuse. In 2021, Einstein noted, overdose deaths in the United States topped an estimated 100,000 for the first time, according to provisional data from the Centers for Disease Control and Prevention. According to this provisional data, Einstein said, the vast majority of those deaths — over 80,000 — involved opioids. While most opioid overdose deaths were attributable to illicit fentanyl, approximately 17,000 deaths involved prescription opioids, including methadone.

Naloxone, available as either a nasal spray or injection, is considered safe and causes few side effects. It’s not addictive. The CDC recommends that people at risk of overdose carry it with them so that a family member or bystander can administer it if necessary.

Experts in drug policy point to a key statistic that laws like the one in New York aim to address: In nearly 40% of overdose deaths, another person is present, according to the CDC.

If bystanders had had naloxone, “most of those people wouldn’t have died,” said Corey Davis, director of the Harm Reduction Legal Project at the Network for Public Health Law.

In every state, including New York, pharmacists are authorized to dispense naloxone, often under “standing orders” that allow dispensing without a prescription, typically to people who are at risk of overdose or are in a position to help someone at risk.

So then why require physicians to write scripts?

Mandating is more effective than recommending, experts said. By requiring physicians to prescribe the drug, more people who might need naloxone would have it on hand — if they fill the prescription. But there’s no guarantee they will.

A prescription can also help remove the lingering stigma of asking for an overdose drug at the pharmacy counter.

“It removes friction points,” said Davis. “You just drive through the window and pick it up.”

In a 2019 analysis, pharmacists in states that required co-prescribing naloxone with opioids filled nearly eight times as many naloxone prescriptions per 100,000 people as those in states that didn’t require it.

Missouri doesn’t have a co-prescribing law, but Danielle Muscato’s pain management doctor recently suggested she carry Narcan. The 38-year-old civil rights activist, who lives in Columbia, takes the prescription opioid tramadol and several other drugs to keep her chronic severe lower back pain in check. She’s glad to have the nasal spray tucked in her purse, just in case.

“I think it’s a wonderful thing” that people carry it and know how to use it, she said. “I wish this was standard everywhere.”

Since the New York law went into effect, “I have definitely seen an uptick of prescribers adding naloxone to opioids, especially if it’s a large order,” said Ambar Keluskar, pharmacy manager at Rossi Pharmacy in Brooklyn.

Patients don’t always understand why they’re getting it, though, said Toni Tompkins, supervising pharmacist at Phelps Hometown Pharmacy in the upstate New York town of Phelps.

A two-dose package of naloxone spray typically costs about $150. The medication is now available in generic form, which may reduce the out-of-pocket cost. Most insurers cover it, although patients typically owe a copayment. The uninsured can generally get naloxone through state programs.

In New York, private insurers are required to cover naloxone, and Medicaid also covers it, said Monica Pomeroy, a spokesperson for the state health department. The state’s Naloxone Co-Payment Assistance Program (N-CAP) covers the cost of copays up to $40 for those with insurance, Pomeroy said. Uninsured people or those with unmet deductibles can get it free at one of the state’s opioid overdose prevention sites.

In November, the FDA announced it is considering making naloxone available without a prescription.

Although offering it over the counter would make the drug easier to get, some people are concerned that insurance might not cover it. Further, “if a patient is just picking it up somewhere without getting any guidance on how to use it, that could be a downside,” said Anne Burns, vice president of professional affairs at the American Pharmacists Association.

Some professionals believe naloxone should be dispensed with every opioid prescription, regardless of risk factors. In Rochester, New York, and surrounding Monroe County, that’s what happens. In 2021, the county executive, Adam Bello, signed Maisie’s Law, named after a local 9-month-old girl who died after swallowing a methadone pill she found on a neighbor’s kitchen floor.

“It’s horrible what happened,” said Karl Williams, a pharmacy law professor and chair of the board of the Pharmacists Society of the State of New York. “Maybe it’s a next-level standard that should become law.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).