Addiction Treatment Proponents Urge Rural Clinicians to Pitch In by Prescribing Medication

The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years, and treatment advocates hope to see that trend continue.

MARSHALLTOWN, Iowa — Andrea Storjohann is glad to see that she’s becoming less of a rarity in rural America.

The nurse practitioner prescribes medication to dozens of patients trying to recover from addiction to heroin or opioid painkillers.

The general-practice clinic where she works, housed in a repurposed supermarket building, has no signs designating it as a place for people to seek treatment for drug addiction, which is how Storjohann wants it.

“You could be coming here for OB-GYN care. You could be coming here for a sore throat. You could be coming here for any number of reasons,” and no one in the waiting room would know the difference, she said.

Privacy is an important part of the treatment. And so is the medication Storjohann prescribes: buprenorphine, which staves off cravings and prevents withdrawal symptoms for people who have stopped misusing opioid drugs. The central Iowa clinic, owned by the nonprofit agency Primary Health Care, has offered buprenorphine since 2016. “We were kind of a unicorn in this part of the state,” Storjohann said, but that’s changing.

Unlike methadone, the traditional medication to wean people off heroin or other opioids, buprenorphine can be prescribed at primary care clinics and dispensed at neighborhood pharmacies. Federal and state authorities have encouraged more front-line health care professionals to prescribe Suboxone and other medications containing buprenorphine for patients trying to overcome opioid addiction. Federal regulators have made it easier for doctors, nurse practitioners, and physician assistants to become certified to offer the service.

The opioid crisis has deepened in the past decade with the illicit distribution of fentanyl, a powerful, extremely addictive opioid. Its prevalence has complicated the use of medication to treat opioid addiction. Patients who have been misusing fentanyl can suffer severe withdrawal symptoms when they begin taking buprenorphine, so health practitioners must be careful when starting the treatment.

In Iowa, officials designated $3.8 million from the state’s initial share of opioid lawsuit settlement money for a University of Iowa program that helps health care providers understand how to use the medications.

Federal agencies are spending millions to expand access to medication to treat addictions, including in rural areas. The Health Resources and Services Administration, which aims to improve health care for underserved people, offers many of these grants.

Carole Johnson, the agency’s top administrator, said she hopes increased training on treating opioid addiction encourages health care providers to learn the latest ways to treat other kinds of addiction, including methamphetamine dependence and alcoholism, which plague many rural states. “We’re sensitizing people to substance use disorder writ large,” she told KHN.

In 2016, just 40% of rural counties nationwide had at least one health care provider certified to prescribe buprenorphine, according to a University of Washington study. That figure climbed to 63% by 2020, the study found.

The study credited the rise to changes in federal rules that allow nurse practitioners, physician assistants, and other midlevel health care providers to prescribe buprenorphine. In the past, only physicians could do so, and many rural counties lacked doctors.

Buprenorphine is an opioid that pharmacies most often sell as a tablet or a film that both dissolve under the tongue. It does not cause the same kind of high as other opioid drugs do, but it can prevent the debilitating withdrawal effects experienced with those drugs. Without that help, many people relapse into risky drug use.

The idea of opioid “maintenance treatment” has been around for more than 50 years, mainly in the form of methadone. That drug is also an opioid that can reduce the chance of relapse into misusing heroin or painkillers. But the use of methadone for addiction treatment is tightly regulated, due to concerns that it can be abused.

Only specialized clinics offer methadone maintenance treatment, and most of them are in cities. Many patients starting methadone treatment are required to travel daily to the clinics, where staffers watch them swallow their medicine.

Federal regulators approved Suboxone in 2002, opening an avenue for addiction treatment in towns without methadone clinics.

Storjohann said buprenorphine offers a practical alternative for Marshalltown, a town of 27,000 people surrounded by rural areas.

The nurse practitioner spends about half her time working with patients who are taking medications to prevent relapse into drug abuse. The other half of her practice is mental health care. A recent appointment with patient Bonnie Purk included a bit of both.

Purk, 43, sat in a small exam room with the nurse practitioner, who asked about her life. Purk described family struggles and other stressors she faces while trying to abstain from abusing painkillers.

Storjohann asked whether Purk felt hopeless. “Or are you just frustrated?”

Purk thought for a moment. “I went through a week where I was just crying,” she said, wiping her eyes with a tissue. But she said she hasn’t been seriously tempted to relapse.

Storjohann praised her persistence. “You’re riding a roller coaster,” she said. “I think you need to give yourself some grace.”

Purk knows Suboxone is not a miracle cure. She has taken the medication for years, and twice relapsed into misusing pain pills. But she has avoided a relapse since spring, and she said the medication helps.

In an interview after her monthly appointment with Storjohann, Purk said the medicine dulls cravings and blocks withdrawal symptoms. She recalled terrible night sweats, insomnia, diarrhea, and jitters she suffered when trying to stop abusing pills without taking Suboxone.

“You focus on nothing but that next fix. ‘Where am I going to get it? How am I going to take it?’” she said. “You just feel like a train wreck — like you’ll die without it.”

Purk said mental health counseling and frequent drug tests have also helped her remain sober.

Patients can stay on buprenorphine for months or even years. Some skeptics contend it’s swapping one drug dependence for another, and that it should not be seen as a substitute for abstinence. But proponents say such skepticism is easing as more families see how the treatment can help people regain control over their lives.

Dr. Alison Lynch, a University of Iowa addiction medicine specialist, warned about the risks of fentanyl and buprenorphine in a recent lecture to health professionals in training.

Lynch explained that fentanyl remains in the body longer than other opioids, such as heroin. When someone with fentanyl in their system takes buprenorphine, it can cause a particularly harsh round of nausea, muscle pain, and other symptoms, she said. “It’s not dangerous. It’s just miserable,” she said, and it can discourage patients from continuing the medication.

Lynch noted drug dealers are lacing fentanyl into other drugs, so people don’t always realize they’ve taken it. “I just make the assumption that if people are using any drugs they bought on the street, it’s probably got fentanyl,” she said. Because of that, she said, she has been using smaller initial doses of buprenorphine and increasing the dosage more gradually than she used to.

Nationwide, the number of health professionals certified to prescribe buprenorphine has more than doubled in the past four years, to more than 134,000, according to the federal Substance Abuse and Mental Health Services Administration. Efforts to expand access to the treatment come as drug overdose deaths have more than doubled in the U.S. since 2015, led by overdoses of fentanyl and other opioids.

Storjohann would like to see more general clinicians seek training and certification to prescribe buprenorphine at least occasionally. For example, she said, emergency room doctors could prescribe a few days’ worth of the medication for a patient who comes to them in crisis, then refer the patient to a specialist like her. Or a patient’s primary doctor could take over the buprenorphine treatment after an addiction treatment specialist stabilizes a patient.

Dr. Neeraj Gandotra, chief medical officer of the Substance Abuse and Mental Health Services Administration, said he sees potential in expanding such arrangements, known as a “hub and spoke” model of care. Family practice providers who agree to participate would be assured that they could always send a patient back to an addiction treatment specialist if problems arose, he said.

Gandotra said he hopes more primary care providers will seek certification to prescribe buprenorphine.

Johnson, the Health Resources and Services Administration administrator, said states can also increase access to medication-assisted treatment by expanding their Medicaid programs, to offer health insurance coverage to more low-income adults. The federal government pays most of the cost of Medicaid expansion, but 11 states have declined to do so. That leaves more people uninsured, which means clinics are less likely to be reimbursed for treating them, she said.

Health care providers no longer are required to take special classes to obtain federal certification — called a “waiver” — to treat up to 30 patients with buprenorphine. But Lynch said even veteran health care providers could benefit from training on how to properly manage the treatment. “It’s a little daunting to start prescribing a medication that we didn’t get a lot of training about in medical school or PA school or in nursing school,” she said.

Federal officials have set up a public database of health care providers certified to offer buprenorphine treatment for addiction, but the registry lists only providers who agree to include their names. Many do not do so. In Iowa, only about a third of providers with the certification have agreed to be listed on the public registry, according to the Iowa Department of Health and Human Services.

Lynch speculated that some health care professionals want to use the medication to help current patients who need addiction treatment, but they aren’t looking to make it a major part of their practice.

Storjohann said some health care professionals believe addiction treatment would lead to frustration, because patients can repeatedly relapse. She doesn’t see it that way. “This is a field where people really want to get better,” she said. “It’s really rewarding.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Los mentores trabajan, sin límites, en la recuperación de adicciones

Los especialistas en apoyo a pares están ellos mismos en recuperación y se los contrata para ayudar a otros. Pueden vincularse con los pacientes de una manera distinta que los profesionales de salud.

CENTENNIAL, Colorado.— Sarah Wright visita a su mentora varias veces al día, en la habitación de hotel transformada en oficina en este suburbio de Denver.

Pero su visita de un miércoles por la mañana a mediados de octubre fue una de las primeras con dientes.

La especialista en ayuda a pares, Donna Norton, había impulsado a Wright a ir al dentista años después de que la falta de vivienda y la adicción afectaran su salud, literalmente hasta la mandíbula.

Wright todavía se estaba acostumbrando a su dentadura postiza. “No he tenido dientes en 12, 13 años”, dijo, y agregó que la hacían sentir como un caballo.

Una nueva sonrisa fue el hito más reciente de Wright mientras trabaja para reconstruir su vida, y Norton ha estado allí en cada paso: al abrir una cuenta bancaria, conseguir un trabajo, desarrollar un sentido de autoestima.

La voz de Wright comenzó a temblar cuando habló sobre el papel de Norton en su vida durante los últimos meses. Norton envolvió a Wright en sus brazos, adornados con tatuajes de llamas, telarañas y un zombi Johnny Cash.

“Oh, muffin”, le dijo. “Estoy tan orgullosa de ti”.

Norton, de 54 años, es una abuela que maneja una Harley, ama a los bulldogs, lleva ocho años sobria y, profesionalmente, “es una persona que anima a los que se ven mal en papel”.

La gente la quiere. “Si me buscaras en un papel, no estarías en esta habitación conmigo”, dijo Norton. “No me dejarías acercarme a tu casa”.

Si fuera terapeuta o trabajadora social, abrazar y compartir sus experiencias con las drogas y la ley podría considerarse cruzar la línea de los límites profesionales. Pero como especialista en apoyo de pares, a menudo eso es parte del trabajo.

“No tengo límites”, dijo Norton. “A la m…”, dijo, “aquí es un término cariñoso”.

Norton trabaja para la Fundación Hornbuckle, que brinda apoyo entre pares a los participantes en la SAFER Opportunities Initiative, que ofrece refugio a corto plazo en el hotel para personas del condado de Arapahoe que no tienen hogar y tienen trastornos de salud mental o adicciones.

Los especialistas en apoyo a pares están ellos mismos en recuperación y se los contrata para ayudar a otros. A medida que se distribuyen miles de millones de dólares en fondos para acuerdos por opioides a los estados y localidades, los líderes locales deciden qué hacer con el dinero.

Entre las opciones están apoyar y capacitar a estos especialistas, cuyos requisitos de certificación varían según el estado.

Los estados, condados, municipios y naciones indígenas presentaron miles de demandas contra las compañías farmacéuticas y los mayoristas acusados ​​de alimentar la crisis de los opioides. Muchos de esos casos se convirtieron en grandes demandas colectivas.

Este año, cuatro empresas llegaron a un acuerdo extrajudicial y acordaron pagar $26,000 millones durante 18 años. Los estados participantes deben seguir las pautas sobre cómo se puede gastar el dinero.

En Colorado, cientos de millones de dólares de ese acuerdo (y algunos otros) se destinarán a gobiernos locales y grupos regionales, varios de los cuales presentaron planes para utilizar parte del dinero en servicios de apoyo a pares.

David Eddie, psicólogo clínico y científico investigador del Recovery Research Institute del Hospital General de Massachusetts, dijo que los servicios de apoyo de recuperación entre pares han “ganado mucha fuerza en los últimos años”.

De acuerdo con la Administración de Servicios de Salud Mental y Abuso de Sustancias, la “evidencia creciente” muestra que trabajar con un par especialista puede generar mejores resultados de recuperación, desde una mayor estabilidad en la vivienda hasta tasas más bajas de recaídas y hospitalizaciones.

Un informe de la Oficina de Responsabilidad del Gobierno de EE.UU. identificó los servicios de apoyo entre pares como una práctica prometedora en el tratamiento de adultos con adicciones. En muchos estados, estos especialistas reciben un reembolso a través de Medicaid.

“Pueden llenar un vacío realmente importante”, dijo Eddie. “Pueden hacer cosas que nosotros, como médicos, no podemos hacer”.

Pueden, por ejemplo, ayudar a navegar la burocracia del sistema de servicios de protección infantil, sobre el cual los médicos pueden tener poco conocimiento, o invitar a alguien a tomar un café para construir una relación. Si una persona deja de asistir a la terapia, dijo Eddie, un especialista en apoyo de pares “puede ir físicamente a buscar a alguien y traerlo de vuelta al tratamiento, ayudarlo a volver a participar, reducir su vergüenza, eliminar el estigma de la adicción”.

Norton, por ejemplo, recogió a un cliente que la llamó desde un callejón después de ser dado de alta de un hospital por una sobredosis.

“Algunas personas te dirán: ‘Decidí que me iba a recuperar y nunca más iba a beber, drogarme o consumir’. Esa no es mi experiencia. Me tomó 20 años lograr mi primer año limpia y sobria. Y significó intentarlo todos los días”, dijo Norton desde su oficina. En una canasta debajo de su escritorio tiene tres kits de reversión de sobredosis de opioides surtidos con Narcan.

Su oficina, tibia por la luz del sol que entra por una ventana orientada al sur y la rotación casi constante de personas que se dejan caer en el sofá, tiene un estante con artículos esenciales. Hay tampones, para quien los necesite —Norton “nunca olvidará” la vez que recibió una multa por robar tampones en una tienda de comestibles mientras no tenía hogar— y kits de análisis de orina, para determinar si alguien está drogado o experimentando psicosis.

Norton enseña a “parar, tirarse al piso y rodar” como un mecanismo de afrontamiento cuando las personas se sienten perdidas y piensan en volver a consumir. “Si estás en crisis, ¿qué haces?”, dijo Norton. “Te detienes de inmediato, te recuestas en el suelo, ruedas y sales. Así que digo ‘Vete a la cama. Solo ve a dormir’. La gente dice: ‘Esa no es una herramienta de bienestar’”.

“Lo es”, intervino Audrey Salazar. Una vez, cuando Salazar estaba a punto de recaer, se quedó con Norton un fin de semana. “Literalmente me dormí”, dijo Salazar. Las dos descansaron y comieron Cocoa Puffs y Cheez-Its de la caja.

“Fue tan malo”, dijo Norton sobre el atracón de comida chatarra. Pero el fin de semana volvió a encarrilar a Salazar. Trabajar con un especialista en apoyo de pares que ha “recorrido el mismo camino”, dijo Salazar, “te vuelve responsable de una manera muy amorosa”.

Ese día de octubre, Norton pasó de regañar a una persona para que hiciera una cita con el médico, a conseguir que otra persona creara una despensa de alimentos, a descubrir cómo responder al banco que le dijo a un tercer cliente que no se podía abrir una cuenta sin una dirección residencial. También trabajó en bajar las defensas de un recién llegado, un hombre elegantemente vestido que parecía escéptico del programa.

Algunas personas llegan a Norton después de haber sido liberadas de la cárcel del condado, otras por el boca en boca. Y Norton ha reclutado gente en los parques y en la calle. El recién llegado aplicó después de enterarse del programa en un refugio para personas sin hogar.

Norton decidió que compartir un poco sobre ella misma era el camino a seguir con él.

“‘Mi experiencia son las cárceles, los hospitales y las instituciones. Tengo un número antiguo, es decir, un número de convicto. ‘Y tengo ocho años sin drogas’”, recordó haberle dicho. “‘Mi oficina está al final del pasillo. Hagamos algunos trámites. Hagámoslo'”.

Norton es uno de los siete pares en el personal de la Fundación Hornbuckle, que estima que cuesta alrededor de $24,000 por mes para brindar servicios de pares a este grupo de residentes, y los especialistas que trabajan a tiempo completo ganan alrededor de $3,000 por mes más $25 por hora por cliente.

La oficina de Norton es el centro de actividad de un piso en un hotel donde viven unas 25 personas que participan en la Iniciativa SAFER mientras se recuperan de los trastornos adicciones hasta que se “gradúan” en otro hotel, ubicado al lado. A partir de ahí, se mudarán a su propia vivienda, que los empleados a menudo les ayudan a encontrar.

Mientras están en el programa, los residentes se reúnen al menos una vez a la semana con un administrador de casos, un terapeuta y un especialista en apoyo de pares, además de asistir a reuniones grupales, que se llevan a cabo todos los días excepto los domingos y están dirigidas por compañeros.

Kyle Brewer, con sede en Arkansas, es el administrador del programa de especialistas en pares de NAADAC, la Asociación de Profesionales en Adicción (anteriormente, la Asociación Nacional de Consejeros sobre Alcoholismo y Abuso de Drogas). Brewer, quien dijo que su vida se descarriló después de que comenzó a usar opioides recetados para controlar el dolor de la extracción de una muela de juicio, dijo que los fondos de acuerdos por opioides presentan una oportunidad para apoyar a las personas que trabajan con las personas necesitadas.

“Cuando estamos trabajando y hablando y resolviendo problemas de diferentes enfoques para resolver la crisis de los opioides, deberíamos tener a las personas que se han visto directamente afectadas por esos problemas en la sala, guiando esas conversaciones”, dijo.

Hacia el final del día, Norton volvió a encontrarse con el muchacho nuevo en el pasillo, esta vez cuando regresaba de la máquina de hielo.

“Ocho años limpio. Me quito el sombrero ante ti”, dijo.

“Empecé con un día”, dijo Norton.

“Bueno, comenzaré con una hora”, dijo el muchacho.

Dijo que necesitaba limpiar su auto, donde había estado viviendo. Dijo que tiene problemas para ponerse los jeans por la mañana después de perder un pulgar por haber estado expuesto a temperaturas congelantes. Quería encontrar un trabajo de medio tiempo. Tiene que resolver un trauma con terapia. Su madre murió hace aproximadamente un año y medio.

“El viernes por la noche, iremos al cine”, dijo Norton.

“Oh, genial”, dijo. “Quiero ver la nueva de Top Gun”.

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.

USE OUR CONTENT

This story can be republished for free (details).

The Player-Coaches of Addiction Recovery Work Without Boundaries

States, tribes, and local governments are figuring out how best to spend billions of dollars from an opioid lawsuit settlement. One option they’re considering is funding peer support specialists, who guide people recovering from addiction as they do it themselves.

CENTENNIAL, Colo. — Sarah Wright stops by her peer support specialist’s hotel room-turned-office in this Denver suburb several times a day.

But her visit on a Wednesday morning in mid-October was one of her first with teeth.

The specialist, Donna Norton, had pushed Wright to go to the dentist years after homelessness and addiction had taken a toll on her health, down to the jawbone.

Wright was still getting used to her dentures. “I haven’t had teeth in 12½, 13 years,” she said, adding that they made her feel like a horse.

A new smile was Wright’s latest milestone as she works to rebuild her life, and Norton has been there for each step: opening a bank account, getting a job, developing a sense of her own worth.

Wright’s voice started to waver when she talked about Norton’s role in her life during the past few months. Norton wrapped her arms, adorned with tattoos of flames, spiderwebs, and a zombie Johnny Cash, around Wright.

“Oh, muffin,” she said. “I’m so proud of you.”

Norton, 54, is a Harley-riding, bulldog-loving, eight-years-sober grandmother and, professionally, “a cheerleader for the people that look bad on paper.”

People like her. “If you were to look me up on paper, you wouldn’t be in this room with me,” Norton said. “You would not let me near your house.”

If she were a therapist or social worker, hugging and sharing her experiences with drugs and the law might be considered a breach of professional boundaries. But as a peer support specialist, that’s often part of the job.

“I have no boundaries,” Norton said. “F— off,” she said, “is a term of endearment here.”

Norton works for the Hornbuckle Foundation, which provides peer support to participants in the SAFER Opportunities Initiative. SAFER provides short-term shelter in the hotel for people in Arapahoe County who are homeless and have mental health or substance use disorders.

Peer support specialists are themselves in recovery and are employed to help others. As billions of dollars in opioid settlement funds roll out to states and localities, local leaders are deciding what to do with the money. Supporting and training peer specialists, whose certification requirements vary by state, are among the options.

States, counties, municipalities, and tribes filed thousands of lawsuits against drug companies and wholesalers that are accused of fueling the opioid crisis. Many of those cases were lumped together into one mega-lawsuit. This year, four companies settled out of court, agreeing to pay $26 billion over 18 years. Participating states must follow guidelines for how the money can be spent.

In Colorado, hundreds of millions of dollars from that settlement (and a few others) will go to local governments and regional groups, several of which submitted plans to use some of the money for peer support services.

David Eddie, a clinical psychologist and a research scientist at the Recovery Research Institute at Massachusetts General Hospital, said peer recovery support services have “been gaining a lot of traction in recent years.”

According to the Substance Abuse and Mental Health Services Administration, “mounting evidence” shows that working with a peer specialist can result in better recovery outcomes, from greater housing stability to reduced rates of relapse and hospitalization. A report by the U.S. Government Accountability Office identified peer support services as a promising practice in treating adults with substance use disorders. In many states, peer specialists are reimbursed through Medicaid.

“They can plug a really important gap,” Eddie said. “They can do things that we as clinicians can’t do.”

They can, for example, help navigate the bureaucracy of the child protective services system, about which clinicians might have little knowledge, or take someone out to coffee to build a relationship. If a person stops showing up to therapy, Eddie said, a peer support specialist “can physically go and look for somebody and bring them back to treatment — help them reengage, reduce their shame, destigmatize addiction.”

Norton has, for instance, picked up a client who called her from an alley after being discharged from a hospital stay for an overdose.

“Some people will tell you, ‘I decided I was going to get in recovery, and I never had to drink, drug, or use again.’ That’s not my experience. It took me 20 years to get my first year clean and sober. And that was trying every day,” said Norton from her office, her Vans planted just inches from a basket that lives under her desk: It contains three opioid overdose reversal kits stocked with Narcan.

Her office, warmed by the sunlight coming through a south-facing window and the nearly constant rotation of people plopping onto the couch, contains a shelf of essential items. There are tampons, for whoever needs them — Norton will “never forget” the time she got a ticket for stealing tampons from a grocery store while she was homeless — and urine analysis kits, for determining whether someone is high versus experiencing psychosis.

She teaches “stop, drop, and roll” as a coping mechanism for when people are feeling lost and thinking about using substances again. “If you’re on fire, what do you do?” Norton said. “You stop immediately, you lay on the ground, you roll and get yourself out. So I’m like, ‘Go to bed. Just go to sleep.’ People are like, ‘That’s not a wellness tool.’”

“It is,” Audrey Salazar chimed in. Once, when Salazar was close to relapsing, she stayed with Norton for a weekend. “I literally just slept,” Salazar said. The two rested and ate Cocoa Puffs and Cheez-Its by the box.

“It was so bad,” Norton said of the junk food binge. But the weekend got Salazar back on track. Working with a peer support specialist who has “walked the same walk,” Salazar said, “holds you accountable in a very loving way.”

That October day, Norton pivoted from nagging one person to make a doctor’s appointment, to getting someone else set up with a food pantry, to figuring out how to respond to the bank that told a third client that an account couldn’t be opened without a residential address. She also worked on lowering the defenses of a newcomer, a sharply dressed man who seemed skeptical of the program.

Some people come to Norton after being released from the county jail, others by word of mouth. And Norton has recruited people in parks and the street. The newcomer applied after hearing about the program in a homeless shelter.

Norton decided that sharing a little about herself was the way to go with him.

“‘My experience is jails and hospitals and institutions. I’ve got an old number,’ meaning a convict number. ‘And I have eight years drug-free,’” she recalled telling him. “‘My office is down the hall. Let’s get some paperwork done. Let’s do this.’”

Norton is one of seven peers on staff with the Hornbuckle Foundation, which estimates that it costs about $24,000 a month to provide peer services to this group of residents, with peer specialists working full time make about $3,000 a month plus $25 an hour per client. Norton’s office is the hub of activity for a floor in one hotel where about 25 people participating in the SAFER Opportunities Initiative live while recovering from substance use disorders until they “graduate” to another hotel, located next door. From there, they’ll move on to their own housing, which staffers often help them find.

While in the program, residents meet at least once a week with a case manager, a therapist, and a peer support specialist, in addition to attending group meetings, which take place every day except Sundays and are all run by peers.

Kyle Brewer, based in Arkansas, is the peer specialist program manager for NAADAC, the Association for Addiction Professionals (formerly the National Association for Alcoholism and Drug Abuse Counselors). Brewer, who said his life derailed after he started using prescription opioids to manage the pain from a wisdom tooth removal, said opioid settlement funds present an opportunity to support the people who work on the ground.

“When we’re working and talking and troubleshooting different approaches to solve the opioid crisis, we should have the people that have been directly affected by those issues in the room, guiding those conversations,” he said.

Toward the end of the day, Norton ran into the new guy in the hallway again, this time on his way back from the ice machine.

“Eight years clean. My hat goes off to you,” he said.

“I started with one day,” said Norton.

“Well, I’ll start with one hour,” said the new guy.

He said he needed to clean out his car, where he’d been living. He said he has trouble putting his jeans on in the morning after losing a thumb to frostbite. He wanted to find a part-time job. He has trauma to work through in therapy. His mother died about a year and a half ago.

“Friday night, we’re going to the movies,” said Norton.

“Oh, cool,” he said. “I want to see ‘Top Gun,’ the new one.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Hospitals Have Been Slow to Bring On Addiction Specialists

Hospitals have specialists ready to offer consult and care for concerns from cancer to childbirth but often no one with expertise in addiction medicine. Patients with a history of substance use — who are discharged without care — are at risk for overdose.

In December, Marie, who lives in coastal Swampscott, Massachusetts, began having trouble breathing. Three days after Christmas, she woke up gasping for air and dialed 911.

“I was so scared,” Marie said later, her hand clutched to her chest.

Marie, 63, was admitted to Salem Hospital, north of Boston. The staff treated her chronic obstructive pulmonary disease, a lung condition. A doctor checked on Marie the next day, said her oxygen levels looked good, and told her she was ready for discharge.

We are not using Marie’s last name because she, like 1 in 9 hospitalized patients, has a history of addiction to drugs or alcohol. Disclosing a diagnosis like that can make it hard to find housing, a job, and even medical care in hospitals, where patients with an addiction might be shunned.

But talking to the doctor that morning, Marie felt she had to reveal her other medical problem.

“‘I got to tell you something,’” Marie recalled saying. “‘I’m a heroin addict. And I’m, like, starting to be in heavy withdrawal. I can’t — literally — move. Please don’t make me go.’”

At many hospitals in Massachusetts and across the country, Marie would likely have been discharged anyway, still in the pain of withdrawal, perhaps with a list of local detox programs that might provide help.

Discharging a patient without specialized addiction care can mean losing a crucial opportunity to intervene and treat someone at the hospital. Most hospitals don’t have specialists who know how to treat addiction, and other clinicians might not know what to do.

Hospitals typically employ all sorts of providers who specialize in the heart, lungs, and kidneys. But for patients with an addiction or a condition related to drug or alcohol use, few hospitals have a clinician — whether that be a physician, nurse, therapist, or social worker — who specializes in addiction medicine.

That absence is striking at a time when overdose deaths in the U.S. have reached record highs, and research shows patients face an increased risk of fatal overdose in the days or weeks after being discharged from a hospital.

“They’re left on their own to figure it out, which unfortunately usually means resuming [drug] use because that’s the only way to feel better,” said Liz Tadie, a nurse practitioner certified in addiction care.

In fall 2020, Tadie was hired to launch a new approach at Salem Hospital using $320,000 from a federal grant. Tadie put together what’s known as an “addiction consult service.” The team included Tadie, a patient case manager, and three recovery coaches, who drew on their experiences with addiction to advocate for patients and help them navigate treatment options.

After Marie asked her doctor to let her stay in the hospital, he called Tadie for a bedside consultation.

Tadie started by prescribing methadone, a medication to treat opioid addiction. Although many patients do well on that drug, it didn’t help Marie, so Tadie switched her to buprenorphine, with better results. After a few more days, Marie was discharged and continued taking buprenorphine.

Marie also continued seeing Tadie for outpatient treatment and turned to her for support and reassurance: “Like, that I wasn’t going to be left alone,” Marie said. “That I wasn’t going to have to call a dealer ever again, that I could delete the number. I want to get back to my life. I just feel grateful.”

Tadie helped spread the word among Salem’s clinical staff members about the expertise she offered and how it could help patients. Success stories like Marie’s helped make the case for addiction medicine — and helped unravel decades of misinformation, discrimination, and ignorance about patients with an addiction and their treatment options.

The small amount of training that doctors and nurses get is often unhelpful.

“A lot of the facts are outdated,” Tadie said. “And people are trained to use stigmatizing language, words like ‘addict’ and substance ‘abuse.’”

Tadie gently corrected doctors at Salem Hospital, who, for example, thought they weren’t allowed to start patients on methadone in the hospital.

“Sometimes I would recommend a dose and somebody would give pushback,” Tadie said. But “we got to know the hospital doctors, and they, over time, were like, ‘OK, we can trust you. We’ll follow your recommendations.’”

Other members of Tadie’s team have wrestled with finding their place in the hospital hierarchy.

David Cave, one of Salem’s recovery coaches, is often the first person to speak to patients who come to the emergency room in withdrawal. He tries to help the doctors and nurses understand what the patients are going through and to help the patients navigate their care. “I’m probably punching above my weight every time I try to talk to a clinician or doctor,” Cave said. “They don’t see letters after my name. It can be kind of tough.”

Naming addiction as a specialty, and hiring people with specific training, is shifting the culture of Salem Hospital, said social worker Jean Monahan-Doherty. “There was finally some recognition across the entire institution that this was a complex medical disease that needed the attention of a specialist,” Monahan-Doherty said. “People are dying. This is a terminal illness unless it’s treated.”

This approach to treating addiction is winning over some Salem Hospital employees — but not all.

“Sometimes you hear an attitude of, ‘Why are you putting all this effort into this patient? They’re not going to get better.’ Well, how do we know?” Monahan Doherty said. “If a patient comes in with diabetes, we don’t say, ‘OK, they’ve been taught once and it didn’t work, so we’re not going to offer them support again.’”

Despite lingering reservations among some Salem clinicians, the demand for addiction services is high. Many days, Tadie and her team have been overwhelmed with referrals.

Four other Massachusetts hospitals added addiction specialists in the past three years using federal funding from the HEALing Communities Study. The project is paying for a wide range of strategies across several states to help determine the most effective ways to reduce drug overdose deaths. They include mobile treatment clinics; street outreach teams; distribution of naloxone, a medicine that can reverse an opioid overdose; rides to treatment sites; and multilingual public awareness campaigns.

It’s a new field, so finding staff members with the right certifications may be a challenge. Some hospital leaders say they’re worried about the costs of addiction treatment and fear they’ll lose money on the efforts. Some doctors report not wanting to initiate a medication treatment while patients are in the hospital because they don’t know where to refer patients after they’ve been discharged, whether that be to outpatient follow-up care or a residential program. To address follow-up care, Salem Hospital started what’s known as a “bridge clinic,” which offers outpatient care.

Dr. Honora Englander, a national leader in addiction specialty programs, said the federal government could support the creation of more addiction consult services by offering financial incentives — or penalties for hospitals that don’t embrace them.

At Salem Hospital, some staffers worry about the program’s future. Tadie is starting a new job at another hospital, and the federal grant ended June 30. But Salem Hospital leaders say they are committed to continuing the program and the service will continue.

This story is part of a partnership that includes WBURNPR and KHN.

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.

USE OUR CONTENT

This story can be republished for free (details).

Médicos se apresuran a usar fallo de la Corte Suprema para liberarse de cargos por opioides

En una decisión de junio, el tribunal dijo que los fiscales no solo deben probar que una receta no estaba médicamente justificada sino también que el que la escribió sabía del riesgo de recetar opioides.

El doctor Nelson Onaro admitió el verano pasado que había escrito recetas ilegales, aunque dijo que solo pensaba en sus pacientes. Desde una pequeña clínica en Oklahoma, repartió cientos de pastillas de opioides y docenas de parches de fentanilo sin un propósito médico legítimo.

“Esos medicamentos fueron recetados para ayudar a mis pacientes, desde mi propio punto de vista”, dijo Onaro en la corte, mientras, a regañadientes, se declaraba culpable de seis cargos de tráfico de drogas. Al confesar, podría haber recibido una sentencia reducida de tres años o menos en prisión.

Pero Onaro cambió de opinión en julio. En los días previos a su sentencia, le pidió a un juez federal que desestimara su acuerdo de culpabilidad, enviando su caso a juicio. Para tener la oportunidad de ser exonerado, enfrentaría cuatro veces más cargos y la posibilidad de una sentencia más severa.

¿Por qué correr el riesgo? Un fallo de la Corte Suprema ha elevado el umbral para condenar en casos como el de Onaro. En una decisión de junio, el tribunal dijo que los fiscales no solo deben probar que una receta no estaba médicamente justificada sino también que el que la escribió sabía del riesgo.

De repente, el estado mental de Onaro tiene más peso en la corte. Los fiscales no se han opuesto a que el médico retire su declaración de culpabilidad de la mayoría de los cargos, admitiendo en una presentación judicial que enfrenta “un cálculo legal diferente” después de la decisión de la Corte Suprema.

El fallo unánime de la Corte complica los esfuerzos continuos del Departamento de Justicia para responsabilizar penalmente a los que recetan de manera irresponsable por alimentar la crisis de opioides.

Antes, los tribunales inferiores no habían considerado la intención del que recetaba. Hasta ahora, los médicos enjuiciados en gran medida no podían defenderse argumentando que estaban actuando de buena fe cuando emitían recetas incorrectas. Ahora pueden, aunque no es necesariamente una garantía para salir de la cárcel, dicen los abogados.

“Esencialmente, a los médicos se los esposaba”, dijo Zach Enlow, abogado de Onaro. “Ahora pueden quitarse las esposas. Pero eso no significa que van a ganar la pelea”.

La decisión de la Corte Suprema en Ruan vs. Estados Unidos, emitida el 27 de junio, fue eclipsada por la controversia nacional tres días antes, cuando el tribunal anuló los derechos federales del aborto.

Pero el fallo, menos conocido ahora, se está filtrando en silencio a través de los tribunales federales, fortaleciendo a los acusados ​​en los casos de abuso de recetas y puede tener un efecto escalofriante en futuros juicios a médicos bajo el Controlled Substance Act.

En los tres meses desde que se emitió, la decisión de Ruan se ha invocado en al menos 15 juicios en curso en 10 estados, según una revisión de KHN de los registros de la corte federal.

Los médicos citaron la decisión en las apelaciones posteriores a la condena, las mociones para absoluciones, nuevos juicios, reversiones de culpabilidad y un intento fallido de excluir el testimonio de un experto en prescripciones, argumentando que su opinión ahora era irrelevante. Otros acusados ​​han solicitado con éxito retrasar sus casos para que la decisión de Ruan pueda verse utilizarse en sus argumentos en los próximos juicios o audiencias de sentencia.

David Rivera, ex fiscal estadounidense de la era Obama, quien lideró juicios sobre abuso de prescripciones en Tennessee, dijo que cree que los médicos tienen una “gran oportunidad” de anular las condenas si se les prohibió discutir una defensa de buena fe o se instruyó a un jurado que ignorara este argumento.

Rivera dijo que los acusados ​​que movilizaban cientos de miles de pastillas aún serían condenados, incluso si finalmente se requiriera un segundo juicio. Pero la Corte Suprema ha extendido un “salvavidas” a un grupo pequeño de acusados ​​que “dispensaron con su corazón, no con su mente”, dijo.

“Lo que la Corte Suprema está tratando de hacer es dividir entre un médico malo y una persona que podría tener una licencia para practicar la medicina pero que no actúa como médico y es un traficante de drogas”, dijo Rivera. “Un médico que actúa bajo una creencia sinceramente sostenida de que está haciendo lo correcto, incluso si puede ser horrible en su trabajo y no se le deben confiar vidas, incluso eso no es criminal”.

La decisión de Ruan fue el resultado de las apelaciones de dos médicos, Xiulu Ruan y Shakeel Kahn, quienes fueron condenados por separado por recetar píldoras en Alabama y Wyoming, respectivamente, y sentenciados a 21 y 25 años de prisión. En ambos casos, los fiscales se basaron en una táctica común para mostrar que las recetas eran un delito: los testigos expertos revisaron las recetas de los acusados ​​y testificaron que estaban fuera de lugar con lo que un médico razonable haría.

Pero al escribir la opinión de la Corte Suprema, el entonces juez Stephen Breyer insistió en que la carga de la prueba no debería ser tan simple de superar, devolviendo ambas condenas a los tribunales inferiores para su reconsideración.

Debido a que a los médicos se les permite, y se espera, que distribuyan drogas, escribió Breyer, los fiscales no solo deben demostrar que escribieron recetas sin propósito médico, sino que también lo hicieron “a sabiendas o intencionalmente”. De lo contrario, los tribunales corren el riesgo de castigar “conductas que se encuentran cerca, pero en el lado permitido de la línea criminal”, escribió Breyer.

Para los abogados defensores, el fallo unánime envió un mensaje inequívoco.

“Este es un tiempo hiperpolarizado en Estados Unidos, y particularmente en la corte”, dijo Enlow. “Sin embargo, este fue un fallo de 9-0 que decía que el mens rea, o el estado mental del médico, es importante”.

Tal vez en ninguna parte la decisión de Ruan fue más apremiante que en el caso del doctor David Jankowski, un médico de Michigan que estaba en juicio.

Jankowski fue condenado por crímenes federales de drogas y fraude y enfrenta 20 años de prisión. En un anuncio del veredicto, el Departamento de Justicia dijo que el médico y su clínica suministraron a las personas “sin necesidad de drogas”, que se “vendían en las calles para alimentar las adicciones de los adictos a los opioides”.

La abogada defensora Anjali Prasad dijo que el fallo de Ruan llegٕó antes de las deliberaciones del jurado en el caso, pero después de que los fiscales pasaran semanas presentando el argumento de que el comportamiento de Jankowski no fue el de alguien que prescribe de manera razonable, un estándar legal que ya no es suficiente para convencer.

Prasad citó la decisión de Ruan en una moción para un nuevo juicio, que fue denegada, y dijo que tiene la intención de utilizar la decisión como base para una próxima apelación. La abogada también dijo que está discutiendo con otros dos clientes sobre apelar sus condenas en base a Ruan.

“Espero que los abogados de defensa penal como yo estén más fortalecidos para llevar sus casos a juicio y que sus clientes estén 100% listos para luchar contra los federales, lo cual no es una tarea fácil”, dijo Prasad.

Algunos acusados ​​lo están intentando. Hasta ahora, algunos han obtenido pequeñas victorias. Y al menos uno sufrió una derrota aplastante.

En Tennessee, la enfermera practicante Jeffrey Young, acusada de intercambiar opioides por sexo y notoriedad para ser parte de un piloto de un reality show, retrasó con éxito su juicio de mayo a noviembre para dar cuenta de la decisión de Ruan, argumentando que “alteraría drásticamente el paisaje de la guerra del gobierno contra los que hacen recetas”.

También en Tennessee, Samson Orusa, un médico y pastor que el año pasado fue condenado por entregar recetas de opioides sin examinar a los pacientes, presentó una moción para un nuevo juicio basado en la decisión de Ruan, luego persuadió a un juez reacio a retrasar su sentencia durante seis meses. para considerarlo.

Y en Ohio, el doctor Martin Escobar citó el fallo de Ruan en un argumento de 11 horas para evitar la prisión.

En enero, Escobar se declaró culpable de 54 cargos de distribución de sustancias controladas, incluidas las recetas que causaron la muerte de dos pacientes. Después de la decisión de Ruan, Escobar intentó retirar su petición, diciendo que habría ido a juicio si hubiera sabido que los fiscales tenían que demostrar intencionalidad.

Una semana después, el día en que Escobar fue sentenciado, un juez federal negó la moción.

Su declaración de culpabilidad permaneció.

Escobar fue condenado a 25 años.

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.

USE OUR CONTENT

This story can be republished for free (details).

Doctors Rush to Use Supreme Court Ruling to Escape Opioid Charges

After a unanimous ruling from the high court, doctors who are accused of writing irresponsible prescriptions can go to trial with a new defense: It wasn’t on purpose.

Dr. Nelson Onaro conceded last summer that he’d written illegal prescriptions, although he said he was thinking only of his patients. From a tiny, brick clinic in Oklahoma, he doled out hundreds of opioid pills and dozens of fentanyl patches with no legitimate medical purpose.

“Those medications were prescribed to help my patients, from my own point of view,” Onaro said in court, as he reluctantly pleaded guilty to six counts of drug dealing. Because he confessed, the doctor was likely to get a reduced sentence of three years or less in prison.

But Onaro changed his mind in July. In the days before his sentencing, he asked a federal judge to throw out his plea deal, sending his case toward a trial. For a chance at exoneration, he’d face four times the charges and the possibility of a harsher sentence.

Why take the risk? A Supreme Court ruling has raised the bar to convict in a case like Onaro’s. In a June decision, the court said prosecutors must not only prove a prescription was not medically justified ― possibly because it was too large or dangerous, or simply unnecessary ― but also that the prescriber knew as much.

Suddenly, Onaro’s state of mind carries more weight in court. Prosecutors have not opposed the doctor withdrawing his plea to most of his charges, conceding in a court filing that he faces “a different legal calculus” after the Supreme Court decision.

The court’s unanimous ruling complicates the Department of Justice’s ongoing efforts to hold irresponsible prescribers criminally liable for fueling the opioid crisis. Previously, lower courts had not considered a prescriber’s intention. Until now, doctors on trial largely could not defend themselves by arguing they were acting in good faith when they wrote bad prescriptions. Now they can, attorneys say, although it is not necessarily a get-out-of-jail-free card.

“Essentially, the doctors were handcuffed,” said Zach Enlow, Onaro’s attorney. “Now they can take off their handcuffs. But it doesn’t mean they are going to win the fight.”

The Supreme Court’s decision in Ruan v. United States, issued June 27, was overshadowed by the nation-shaking controversy ignited three days earlier, when the court erased federal abortion rights. But the lesser-known ruling is now quietly percolating through federal courthouses, where it has emboldened defendants in overprescribing cases and may have a chilling effect on future prosecutions of doctors under the Controlled Substances Act.

In the three months since it was issued, the Ruan decision has been invoked in at least 15 ongoing prosecutions across 10 states, according to a KHN review of federal court records. Doctors cited the decision in post-conviction appeals, motions for acquittals, new trials, plea reversals, and a failed attempt to exclude the testimony of a prescribing expert, arguing their opinion was now irrelevant. Other defendants have successfully petitioned to delay their cases so the Ruan decision could be folded into their arguments at upcoming trials or sentencing hearings.

David Rivera, a former Obama-era U.S. attorney who once led overprescribing prosecutions in Middle Tennessee, said he believes doctors have a “great chance” of overturning convictions if they were prohibited from arguing a good faith defense or a jury was instructed to ignore one.

Rivera said defendants who ran true pill mills would still be convicted, even if a second trial was ultimately required. But the Supreme Court has extended a “lifeline” to a narrow group of defendants who “dispensed with their heart, not their mind,” he said.

“What the Supreme Court is trying to do is divide between a bad doctor and a person who might have a license to practice medicine but is not acting as a doctor at all and is a drug dealer,” Rivera said. “A doctor who is acting under a sincerely held belief that he is doing the right thing, even if he may be horrible at his job and should not be trusted with human lives ― that’s still not criminal.”

The Ruan decision resulted from the appeals of two doctors, Xiulu Ruan and Shakeel Kahn, who were separately convicted of running pill mills in Alabama and Wyoming, respectively, then sentenced to 21 and 25 years in prison. In both cases, prosecutors relied on a common tactic to show the prescriptions were a crime: Expert witnesses reviewed the defendants’ prescriptions and testified that they were far out of line with what a reasonable doctor would do.

But in writing the opinion of the Supreme Court, then-Justice Stephen Breyer insisted the burden of proof should not be so simple to overcome, remanding both convictions back to the lower courts for reconsideration.

Because doctors are allowed and expected to distribute drugs, Breyer wrote, prosecutors must not only prove they wrote prescriptions with no medical purpose but also that they did so “knowingly or intentionally.” Otherwise, the courts risk punishing “conduct that lies close to, but on the permissible side of, the criminal line,” Breyer wrote.

To defense attorneys, the unanimous ruling sent an unambiguous message.

“This is a hyperpolarized time in America, and particularly on the court,” Enlow said. “And yet this was a 9-0 ruling saying that the mens rea ― or the mental state of the doctor ― it matters.”

Maybe nowhere was the Ruan decision more pressing than in the case of Dr. David Jankowski, a Michigan physician who was on trial when the burden of proof shifted beneath his feet.

Jankowski was convicted of federal drug and fraud crimes and faces 20 years in prison. In an announcement of the verdict, the DOJ said the doctor and his clinic supplied people with “no need for the drugs,” which were “sold on the streets to feed the addictions of opioid addicts.”

Defense attorney Anjali Prasad said the Ruan ruling dropped before jury deliberations in the case but after prosecutors spent weeks presenting the argument that Jankowski’s behavior was not that of a reasonable prescriber — a legal standard that on its own is no longer enough to convict.

Prasad cited the Ruan decision in a motion for a new trial, which was denied, and said she intends to use the decision as a basis for a forthcoming appeal. The attorney also said she is in discussion with two other clients about appealing their convictions with Ruan.

“My hope is that criminal defense attorneys like myself are more emboldened to take their cases to trial and that their clients are 100% ready to fight the feds, which is no easy task,” Prasad said. “We just duke it out in the courtroom. We can prevail that way.”

Some defendants are trying. So far, a few have scored small wins. And at least one suffered a crushing defeat.

In Tennessee, nurse practitioner Jeffrey Young, accused of trading opioids for sex and notoriety for a reality show pilot, successfully delayed his trial from May to November to account for the Ruan decision, arguing it would “drastically alter the landscape of the Government’s war on prescribers.”

Also in Tennessee, Samson Orusa, a doctor and pastor who last year was convicted of handing out opioid prescriptions without examining patients, filed a motion for a new trial based on the Ruan decision, then persuaded a reluctant judge to delay his sentencing for six months to consider it.

And in Ohio, Dr. Martin Escobar cited the Ruan ruling in an eleventh-hour effort to avoid prison.

Escobar in January pleaded guilty to 54 counts of distributing a controlled substance, including prescriptions that caused the deaths of two patients. After the Ruan decision, Escobar tried to withdraw his plea, saying he’d have gone to trial if he’d known prosecutors had to prove his intent.

One week later, on the day Escobar was set to be sentenced, a federal judge denied the motion.

His guilty plea remained.

Escobar got 25 years.

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.

USE OUR CONTENT

This story can be republished for free (details).

Never-Ending Costs: When Resolved Medical Bills Keep Popping Up

A bill one family considered paid wrongfully resurfaced, resurrecting painful memories. It’s a scenario that’s not uncommon but grievously unsettling.

Every now and then, Suzanne Rybak and her husband, Jim, receive pieces of mail addressed to their deceased son, Jameson. Typically, it’s junk mail that requires little thought, Suzanne said.

But on March 5, an envelope for Jameson came from McLeod Health.

Jim saw it first. He turned to his wife and asked, “Have you taken your blood pressure medication today?”

He knew showing her the envelope would resurface the pain and anger their family had experienced since taking Jameson to McLeod Regional Medical Center two years ago.

As KHN previously reported, Jameson was experiencing withdrawal symptoms from quitting opioids. Suzanne feared for her son’s life and took him to the emergency room near their home in Florence, South Carolina, on March 11, 2020.

There, they encountered a paucity of addiction treatment and the potential for high medical costs — two problems that plague many families affected by the opioid crisis and often lead to missed opportunities to save lives.

Jameson was not offered medications to treat opioid use disorder in the ER, nor was he given referrals to other treatment facilities, Suzanne said. The hospital wanted to admit him, but, being uninsured, Jameson feared a high bill. The hospital didn’t inform him of its financial assistance policy, Suzanne said. And he decided to leave.

Three months later, Jameson, 30, died of an overdose in his childhood bedroom.

In the following months, the Rybaks received bills from the McLeod Health system addressed to Jameson. He owed $4,928, it said. Suzanne called and wrote to hospital administrators until September 2020, when the bill was resolved under the system’s financial assistance program.

That was the last they had heard from McLeod Health until the new envelope arrived March 5 — one week before the two-year anniversary of his ER visit. That visit was what Suzanne calls “the beginning of the end for my son.”

When the Rybaks opened the envelope, they found a strikingly familiar bill for $4,928.

“I can’t even describe my anger and sadness,” Suzanne said. “It’s always present, but when we received that statement, we were just stunned.”

There’s no national data to indicate how often patients or their families receive medical bills that were previously paid or forgiven, but hospital billing experts say they frequently see it happen. Patients receive bills for claims their insurers already paid. A reminder statement arrives even after a patient submitted payment.

Unlike “surprise bills,” which often result from policy gaps when a provider is out of network, these are bills that were resolved but continue to pop up anyway. They can carry financial consequences — patients wind up paying for something they don’t truly owe or bills get passed on to debt collection agencies, triggering more phones calls and red tape. But often it’s the emotional toll that wears on patients most, spending hours on the phone with customer service each time the bill resurfaces or reliving the situations that led to the bill in the first place. For families like the Rybaks, the cost can feel never-ending.

Suzanne Rybak refused to engage with the McLeod hospital again but told KHN about the new bill.

In response to questions from KHN, McLeod Health determined the bill the Rybaks received was a mistake.

“Unfortunately our software system regenerated this statement due to a technical issue,” wrote spokesperson Jumana Swindler. “We are checking to ensure that it has not happened to any other patients and we are sorry this family was impacted by the error.”

A week after KHN’s inquiry, the Rybaks received a letter from the hospital explaining and apologizing for the error.

Many medical billing cases like this “boil down to human error,” said Michael Corbett, director of health care consulting for LBMC, a Tennessee-based firm that consults with health systems nationally on issues like billing and revenue. “Facilities don’t have a lack of tools [to avoid this]. It’s a breakdown in their processes.”

A billing agent may forget to mark the account as paid, he said. Or the hospital might contract its billing to an outside company and fail to inform them that this bill was covered under the hospital’s financial assistance program.

As hospitals and medical practices increasingly consolidate under large health systems, the chances for errors increase. Even hospitals and clinics within the same system may have different backend software, and within each hospital there can be separate programs for billing and electronic health records, Corbett explained.

Larger health systems may also have more people processing any given bill. If responsibilities are not clearly defined, multiple employees could unknowingly act on the same patient account.

The covid-19 pandemic has exacerbated potential errors, Corbett said. New medical billing employees may have received quick, virtual training and are working remotely with little interaction with team members or oversight. Some billing departments are understaffed, leading to delays in patients receiving bills or follow-up notices, he added.

To curb mistakes, Corbett said, hospitals need to invest in more comprehensive training and supervision for billing employees; enact consistent processes for anything from how patients’ financial information is collected at registration to when they’re sent bills; and, perhaps most important, track whether those processes are being followed.

For patients who find themselves in a situation like the Rybak family’s, Corbett advises calling the hospital billing department and asking to speak with a senior leader in its revenue cycle division. Unlike an account representative, this person could make decisions, Corbett said.

At the end of the conversation, ask to get the explanation in writing, he added.

“You’d anticipate and hope those notes are being recorded,” Corbett said, but that may not be the case. Or notes might get recorded in a section of hospital files that are excluded from a patient’s legal medical record, making it difficult for patients to access later.

For Suzanne Rybak, the idea of calling McLeod Health to straighten out yet another bill was too much. Instead, she added the statement to a binder of paperwork, in which she’s documented all her billing struggles with McLeod Health over the past two years.

Still, out of sight hardly means out of mind. The binder sits in her craft room, where she remembers Jameson encouraging her as she made beach bags and other items. He’d say to use “fruity colors,” Suzanne recalled — his way of describing tropical colors. Now she makes candles in that room, focusing on tropical fragrances she knows Jameson would have loved.

“I want hospitals to realize that you’re not just sending this bill to an address,” Suzanne said. “There are people who live in that house, who are going to open that mail and have feelings. … It’s a disaster to bring all that up again.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Money Flows Into Addiction Tech, But Will It Curb Soaring Opioid Overdose Deaths?

Experts are concerned that flashy Silicon Valley technology won’t reach those most in need of treatment for substance use disorders.

David Sarabia had already sold two startups by age 26 and was sitting on enough money to never have to work another day in his life. He moved from Southern California to New York City and began to indulge in all the luxuries his newly minted millionaire status conveyed. Then it all went sideways, and his life quickly unraveled.

“I became a massive cocaine addict,” Sarabia said. “It started off just casual partying, but that escalated to pretty much anything I could get my hands on.”

At one particularly low point, Sarabia was homeless for three months, sleeping on public transportation to stay warm. Even with plenty of money in the bank, Sarabia said, he’d lost the will to live. “I’d given up,” he said.

He got back on his feet, sort of, and for the next three years lived as a “functional cocaine addict” until his best friend, Jay Greenwald, died after a night of partying. Finally, Sarabia checked himself into a rehab in Southern California — ostensibly a luxurious one, although Sarabia didn’t find it to be so.

Still, the place saved his life. The clinicians really cared, he recalled, although their efforts were hampered by clunky technology and poor management. He had the feeling that the owners were more interested in profits than in helping people recover.

Just days off cocaine, the tech entrepreneur was scribbling designs for his next startup idea: a digital platform that would make clinician paperwork easier, combined with a mobile app to guide patients through recovery. After he left treatment in 2017, Sarabia tapped his remaining wealth — about $400,000 — to fund an addiction tech company he named inRecovery.

With the nation’s opioid overdose epidemic hitting a record high of more than 100,000 deaths in 2021, effective ways to fight addiction and expand treatment access are desperately needed. Sarabia and other entrepreneurs in the realm they call addiction tech see a $42 billion U.S. market for their products and an addiction treatment field that is, in techspeak, ripe for disruption.

It has long been torn by opposing ideologies and approaches: medication-assisted treatment versus cold-turkey detox; residential treatment versus outpatient; abstinence versus harm reduction; peer support versus professional help. And most people who report struggling with substance use never manage to access treatment at all.

Tech is already offering help to some. Those who can pay out-of-pocket, or have treatment covered by an employer or insurer, can access one of a dozen addiction telemedicine startups that allow them to consult with a physician and have a medication like buprenorphine mailed directly to their home. Some of the virtual rehabs provide digital cognitive behavior treatment, with connected devices and even mail-in urine tests to monitor compliance with sobriety.

Plentiful apps offer peer support and coaching, and entrepreneurs are developing software for treatment centers that handle patient records, personalize the client’s time in rehab, and connect them to a network of peers.

But while the founders of for-profit companies may want to end suffering, said Fred Muench, clinical psychologist and president of the nonprofit Partnership to End Addiction, it all comes down to revenue.

Startup experts and clinicians working on the front lines of the drug and overdose epidemic doubt the flashy Silicon Valley technology will ever reach people in the throes of addiction who are unstably housed, financially challenged, and on the wrong side of the digital divide.

“The people who are really struggling, who really need access to substance use treatment, don’t have 5G and a smartphone,” said Dr. Aimee Moulin, a professor and behavioral health director for the Emergency Medicine Department at UC Davis Health. “I just worry that as we start to rely on these tech-heavy therapy options, we’re just creating a structure where we really leave behind the people who actually need the most help.”

The investors willing to feed millions of dollars on startups generally aren’t investing in efforts to expand treatment to the less privileged, Moulin said.

Besides, making money in the addiction tech business is tough, because addiction is a stubborn beast.

Conducting clinical trials to validate digital treatments is challenging because of users’ frequent lapses in medication adherence and follow-up, said Richard Hanbury, founder and CEO of Sana Health, a startup that uses audiovisual stimulation to relax the mind as an alternative to opioids.

There are thousands of private, nonprofit, and government-run programs and drug rehabilitation centers across the country. With so many bit players and disparate programs, startups face an uphill battle to land enough customers to generate significant revenue, he added.

After conducting a small study to ease anxiety for people detoxing off opioids, Hanbury postponed the next step, a larger study. To sell his product to the country’s sprawling array of addiction treatment providers, Hanbury decided, he would need to hire a much larger sales team than his budding company could afford.

Still, the immense need is feeding enthusiasm for addiction tech.

In San Francisco alone, more than twice as many people died from drug overdoses as from covid over the past two years. Employers, insurers, providers, families, and those suffering addiction themselves are all demanding better and affordable access to treatment, said Unity Stoakes, president and managing partner of StartUp Health.

The investment firm has launched a portfolio of seed-stage startups that aim to use technology to end addiction and the opioid epidemic. Stoakes hopes the wave of new treatment options will reduce the stigma of addiction and increase awareness and education. The emerging tools aren’t trying to remove human care for addiction, but rather “supercharge the doctor or the clinician,” he said.

While acknowledging that underserved populations are hard to reach, Stoakes said tech can expand access and enhance targeted efforts to help them. With enough startups experimenting with different types of treatment and delivery methods, hopefully one or more will succeed, he said.

Addiction telehealth startups have gained the most traction. Quit Genius, a virtual addiction treatment provider for alcohol, opioid, and nicotine dependence, raised $64 million from investors last summer, and in October, $118 million went to Workit Health, a virtual prescriber of medication-assisted treatment. Several other startups — Boulder Care, Groups Recover Together, Ophelia, Bicycle Health, and Wayspring, most of which have nearly identical telehealth and prescribing models — have landed sizable funding since the pandemic started.

Some of the startups already sell to self-insured employers, providers, and payers. Some market directly to consumers, while others are conducting clinical trials to get FDA approval they hope to parlay into steadier reimbursement. But that route involves a lot of competition, regulatory hurdles, and the need to convince payers that adding another treatment will drive down costs.

Sarabia’s inRecovery plans to use its software to help treatment centers run more efficiently and improve their patient outcomes. The startup is piloting an aftercare program, aimed at keeping patients connected to prevent relapse after treatment, with Caron Treatment Centers, a high-end nonprofit treatment provider based in Pennsylvania.

His long-term goal is to drive down costs enough to offer his service to county-run treatment centers in hopes of expanding care to the neediest. But for now, implementing the tech doesn’t come cheap, with treatment providers paying anywhere from $50,000 to $100,000 a year to license the software.

“Bottom line, for the treatment centers that don’t have consistent revenue, those on the lower end, they will probably not be able to afford something like this,” he said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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.

USE OUR CONTENT

This story can be republished for free (details).

Money Flows Into Addiction Tech, But Will It Curb Soaring Opioid Overdose Deaths?

Experts are concerned that flashy Silicon Valley technology won’t reach those most in need of treatment for substance use disorders.

David Sarabia had already sold two startups by age 26 and was sitting on enough money to never have to work another day in his life. He moved from Southern California to New York City and began to indulge in all the luxuries his newly minted millionaire status conveyed. Then it all went sideways, and his life quickly unraveled.

“I became a massive cocaine addict,” Sarabia said. “It started off just casual partying, but that escalated to pretty much anything I could get my hands on.”

At one particularly low point, Sarabia was homeless for three months, sleeping on public transportation to stay warm. Even with plenty of money in the bank, Sarabia said, he’d lost the will to live. “I’d given up,” he said.

He got back on his feet, sort of, and for the next three years lived as a “functional cocaine addict” until his best friend, Jay Greenwald, died after a night of partying. Finally, Sarabia checked himself into a rehab in Southern California — ostensibly a luxurious one, although Sarabia didn’t find it to be so.

Still, the place saved his life. The clinicians really cared, he recalled, although their efforts were hampered by clunky technology and poor management. He had the feeling that the owners were more interested in profits than in helping people recover.

Just days off cocaine, the tech entrepreneur was scribbling designs for his next startup idea: a digital platform that would make clinician paperwork easier, combined with a mobile app to guide patients through recovery. After he left treatment in 2017, Sarabia tapped his remaining wealth — about $400,000 — to fund an addiction tech company he named inRecovery.

With the nation’s opioid overdose epidemic hitting a record high of more than 100,000 deaths in 2021, effective ways to fight addiction and expand treatment access are desperately needed. Sarabia and other entrepreneurs in the realm they call addiction tech see a $42 billion U.S. market for their products and an addiction treatment field that is, in techspeak, ripe for disruption.

It has long been torn by opposing ideologies and approaches: medication-assisted treatment versus cold-turkey detox; residential treatment versus outpatient; abstinence versus harm reduction; peer support versus professional help. And most people who report struggling with substance use never manage to access treatment at all.

Tech is already offering help to some. Those who can pay out-of-pocket, or have treatment covered by an employer or insurer, can access one of a dozen addiction telemedicine startups that allow them to consult with a physician and have a medication like buprenorphine mailed directly to their home. Some of the virtual rehabs provide digital cognitive behavior treatment, with connected devices and even mail-in urine tests to monitor compliance with sobriety.

Plentiful apps offer peer support and coaching, and entrepreneurs are developing software for treatment centers that handle patient records, personalize the client’s time in rehab, and connect them to a network of peers.

But while the founders of for-profit companies may want to end suffering, said Fred Muench, clinical psychologist and president of the nonprofit Partnership to End Addiction, it all comes down to revenue.

Startup experts and clinicians working on the front lines of the drug and overdose epidemic doubt the flashy Silicon Valley technology will ever reach people in the throes of addiction who are unstably housed, financially challenged, and on the wrong side of the digital divide.

“The people who are really struggling, who really need access to substance use treatment, don’t have 5G and a smartphone,” said Dr. Aimee Moulin, a professor and behavioral health director for the Emergency Medicine Department at UC Davis Health. “I just worry that as we start to rely on these tech-heavy therapy options, we’re just creating a structure where we really leave behind the people who actually need the most help.”

The investors willing to feed millions of dollars on startups generally aren’t investing in efforts to expand treatment to the less privileged, Moulin said.

Besides, making money in the addiction tech business is tough, because addiction is a stubborn beast.

Conducting clinical trials to validate digital treatments is challenging because of users’ frequent lapses in medication adherence and follow-up, said Richard Hanbury, founder and CEO of Sana Health, a startup that uses audiovisual stimulation to relax the mind as an alternative to opioids.

There are thousands of private, nonprofit, and government-run programs and drug rehabilitation centers across the country. With so many bit players and disparate programs, startups face an uphill battle to land enough customers to generate significant revenue, he added.

After conducting a small study to ease anxiety for people detoxing off opioids, Hanbury postponed the next step, a larger study. To sell his product to the country’s sprawling array of addiction treatment providers, Hanbury decided, he would need to hire a much larger sales team than his budding company could afford.

Still, the immense need is feeding enthusiasm for addiction tech.

In San Francisco alone, more than twice as many people died from drug overdoses as from covid over the past two years. Employers, insurers, providers, families, and those suffering addiction themselves are all demanding better and affordable access to treatment, said Unity Stoakes, president and managing partner of StartUp Health.

The investment firm has launched a portfolio of seed-stage startups that aim to use technology to end addiction and the opioid epidemic. Stoakes hopes the wave of new treatment options will reduce the stigma of addiction and increase awareness and education. The emerging tools aren’t trying to remove human care for addiction, but rather “supercharge the doctor or the clinician,” he said.

While acknowledging that underserved populations are hard to reach, Stoakes said tech can expand access and enhance targeted efforts to help them. With enough startups experimenting with different types of treatment and delivery methods, hopefully one or more will succeed, he said.

Addiction telehealth startups have gained the most traction. Quit Genius, a virtual addiction treatment provider for alcohol, opioid, and nicotine dependence, raised $64 million from investors last summer, and in October, $118 million went to Workit Health, a virtual prescriber of medication-assisted treatment. Several other startups — Boulder Care, Groups Recover Together, Ophelia, Bicycle Health, and Wayspring, most of which have nearly identical telehealth and prescribing models — have landed sizable funding since the pandemic started.

Some of the startups already sell to self-insured employers, providers, and payers. Some market directly to consumers, while others are conducting clinical trials to get FDA approval they hope to parlay into steadier reimbursement. But that route involves a lot of competition, regulatory hurdles, and the need to convince payers that adding another treatment will drive down costs.

Sarabia’s inRecovery plans to use its software to help treatment centers run more efficiently and improve their patient outcomes. The startup is piloting an aftercare program, aimed at keeping patients connected to prevent relapse after treatment, with Caron Treatment Centers, a high-end nonprofit treatment provider based in Pennsylvania.

His long-term goal is to drive down costs enough to offer his service to county-run treatment centers in hopes of expanding care to the neediest. But for now, implementing the tech doesn’t come cheap, with treatment providers paying anywhere from $50,000 to $100,000 a year to license the software.

“Bottom line, for the treatment centers that don’t have consistent revenue, those on the lower end, they will probably not be able to afford something like this,” he said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: Why Health Care Is So Expensive, Chapter $22K

Congress is making slow progress toward completing its ambitious social spending bill, although its Thanksgiving deadline looks optimistic. Meanwhile, a new survey finds the average cost of an employer-provided family plan has risen to more than $22,000. That’s about the cost of a new Toyota Corolla. Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews Rebecca Love, a nurse academic and entrepreneur, about the impending crisis in nursing.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Congress appears to be making progress on its huge social spending bill, but even if it passes the House as planned the week of Nov. 15, it’s unlikely it can get through the Senate before the Thanksgiving deadline that Democrats set for themselves.

Meanwhile, the cost of employer-provided health insurance continues to rise, even with so many people forgoing care during the pandemic. The annual KFF survey of employers reported that the average cost of a job-based family plan has risen to more than $22,000. To provide what their workers most need, however, this year many employers added additional coverage of mental health care and telehealth.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s episode:

  • Moderate Democrats who were worried about the price tag of the social spending bill said during negotiations last week that they wanted to see the full analysis of spending and costs from the Congressional Budget Office. But members of the House probably won’t get that score before voting on the bill. CBO instead is releasing its assessments piecemeal as analysts go through specific sections of the huge bill.
  • If the House passes the bill next week, which leadership is pledging, the legislation could still undergo major revisions in the Senate. Some provisions will be subject to the Byrd Rule, which says items in this type of bill must be related to the budget. Republicans are expected to challenge parts of the bill, and the parliamentarian will have to rule on whether their objections are valid.
  • Among the provisions that some moderate Democratic senators might object to are the paid family leave and the mechanism for lowering Medicare drug prices.
  • Congress is looking at a very busy end of the year, which could complicate passage of the social spending bill. Leaders already postponed a bill to raise the debt ceiling and the annual federal spending bills until early December.
  • A federal judge has blocked Texas Republican Gov. Greg Abbott’s order prohibiting mask mandates in schools. But a final resolution is likely some time away as the case is appealed. Disability rights groups, which had sued to stop the governor’s order, argued that the ban was keeping children with health problems who are at high risk from covid from coming to school.
  • Despite opposition from conservative leaders to vaccine mandates, the vast majority of workers have had their shots, either because they wanted them or their employer mandated it. Lawsuits brought against those workplace requirements may not signal a broad opposition among the population.
  • In its survey of employers’ health plans, KFF found that premiums are still increasing faster than wages as health costs continue to rise. Leaders of both political parties say they would like to reduce the cost of care, but no magic pill appears likely. Instead, lawmakers generally are more inclined to have the government pick up a bigger portion of the country’s health care costs when not finding a way to cut that spending.
  • One key challenge in addressing rising health care spending in Congress is the power of the health care industry. With the close political party margins on Capitol Hill, it is fairly easy for the industries to use their contributions to pick off a couple of members and keep major reform from passing.
  • The KFF survey also documented the wide expansion of telehealth coverage during the pandemic. Although employers and the government have been concerned that telehealth adds to spending because it duplicates services or allows doctors to charge for services they once performed over the phone without billing, it will be hard to put this genie back in the bottle. Consumers like the convenience. And some services, such as mental health therapy or medical consultations for rural residents, are much easier.

Also this week, Rovner interviews Rebecca Love, a nurse, academic and entrepreneur who has thought a lot about the future of the nursing profession and where it fits into the U.S. health care system

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Washington Monthly’s “The Doctor Will Not See You Now,” by Merrill Goozner.

Alice Miranda Ollstein: NPR’s “Despite Calls to Improve, Air Travel Is Still a Nightmare for Many With Disabilities,” by Joseph Shapiro and Allison Mollenkamp.

Rebecca Adams: KHN’s “Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out,” by Christina Jewett.

Anna Edney: Bloomberg News’ “All Those 23andMe Spit Tests Were Part of a Bigger Plan,” by Kristen V Brown.

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

Watch: Going Beyond the Script of ‘Dopesick’ and America’s Real-Life Opioid Crisis

KHN teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.”

KHN and policy colleagues at our parent organization KFF teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.”

The discussion explored how the series’ writers worked with journalist Beth Macy, author of the book “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” and showrunner Danny Strong to create and fact-check scripts and develop characters. It quickly moved on to a deeper discussion of how the fictionalized version of the opioid epidemic portrayed in the Hulu series dovetailed with the broader reality KFF’s journalists and analysts have been documenting in their work for the past few years.

Providing perspective on the role of public health and treatment were KHN correspondent Aneri Pattani, who has reported extensively on opioid policy, substance use and mental health, and KFF senior policy analyst Nirmita Panchal, whose analytical work focuses on mental health and substance use.

The forum was moderated by Chaseedaw Giles, audience engagement editor and digital strategist at KHN who has written about hip-hop music’s relationship with opioid abuse. It was filmed in KFF’s Washington, D.C., conference center to an audience of no one (courtesy of covid-19).

You can read a transcript of the forum by clicking here.

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: The Politics of Vaccine Mandates

Like almost everything else associated with the covid-19 pandemic, partisans are taking sides over whether vaccines should be mandated. Meanwhile, Democrats on Capitol Hill are still struggling to find compromise in their effort to expand health insurance and other social programs. Alice Miranda Ollstein of Politico, Jen Haberkorn of the Los Angeles Times and Mary Ellen McIntire of CQ Roll Call join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews best-selling author Beth Macy about her book “Dopesick,” and the new Hulu miniseries based on it.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Should covid vaccines be mandated? The answer to that question has become predictably partisan, as with almost everything else associated with the pandemic. Even as the federal government prepares to issue rules requiring large employers to ensure their workers are vaccinated, GOP governors are trying to ban such mandates, leaving employers caught in the middle.

Meanwhile, on Capitol Hill, Democrats are still working to reach a consensus on a package of social-spending improvements, the size of which will depend largely on how much they can cut prices for prescription drugs.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Jen Haberkorn of the Los Angeles Times and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s episode:

  • Congressional Democrats’ struggle to find a compromise on a $3.5 trillion spending package for health and other social programs looks likely to push them past their self-imposed deadline of the end of October to pass a bill. Leaders are wrestling with what to cut as they meet demands from moderates in the party to bring the spending down.
  • Everything in that package appears vulnerable at this stage in the negotiations. Party leaders are considering a variety of strategies, including throwing out some proposals or setting up the new benefits over a shorter time frame to test whether they work and the public appreciates them.
  • It appears that Democrats’ priorities will include proposals to enhance benefits for children. But the health programs at stake — new benefits for Medicare, providing insurance to low-income residents of states that have not expanded their Medicaid programs, and extending the enhanced premium subsidies for the Affordable Care Act — each have strong constituencies and will be hard for leaders to settle on.
  • The proposal to add billions of dollars to long-term care programs may draw the short straw. However, it does have some strong allies in Congress, including Sens. Ron Wyden (D-Ore.) and Bob Casey (D-Pa.).
  • Democratic leaders hope to fund some of the initiatives in this package by cutting Medicare’s drug spending. A poll by KFF this week showed that is a very popular notion, even among Republicans. But drugmakers are fighting that strategy with major ad campaigns and political donations. They need to pick off only a couple of vulnerable lawmakers to thwart the effort since Democrats have razor-thin majorities in both the House and Senate. House Speaker Nancy Pelosi, however, appears determined to get some sort of provision on drug price negotiations in the bill, even without the full effect of her original plan.
  • The Department of Labor reportedly has sent a proposed rule requiring large employers to have their workforce vaccinated to the Office of Management and Budget for review. That means the rule could be coming soon. But it is bound to run headlong into opposition in conservative states, like Texas, where Republican Gov. Greg Abbott has banned mandates. The issue will likely end up in federal court.
  • The fight over vaccine mandates highlights a divide in the Republican Party between the business-oriented faction that wants to move past the pandemic and the more libertarian wing of the party. Some of the most conservative political leaders lean toward that libertarian wing and see the vaccine mandate as a way to excite the base. The experience of some major companies, however, suggests that businesses and many workers don’t object to mandates. One example is United Airlines, where 99% of workers have been vaccinated.
  • As the federal courts bat the Texas abortion law back and forth, it appears headed for a review by the Supreme Court. Some analysts suggest that the urgency of the issue could push the court to take on the Texas issue before they hear a case in December about a different law seeking to limit abortion in Mississippi. But the Supreme Court generally likes to have cases fully debated in lower courts before coming to the justices, so a decision on the Texas law may have to wait.
  • The issue of abortion is getting a good bit of advertising time in the Virginia gubernatorial race. Democratic candidate Terry McAuliffe is telling voters he will work to keep abortions legal in the state and suggesting his opponent, Glenn Youngkin, will not. It’s a strategy that California Gov. Gavin Newsom used as he successfully fought a recall in an election last month.

Also this week, Rovner interviews Beth Macy, author of the best-selling “Dopesick: Dealers, Doctors and the Drug Company That Addicted America” and an executive producer of a miniseries of the same name now streaming on Hulu.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “6 Months to Live or Die: How Long Should an Alcoholic Liver Disease Patient Wait for a Transplant,” by Aneri Pattani

Jen Haberkorn: The Washington Post’s “Covid and Cancer: A Dangerous Combination, Especially for People of Color,” by Laurie McGinley

Mary Ellen McIntire: NPR’s “Judging ‘Sincerely Held’ Religious Belief Is Tricky for Employers Mandating Vaccines,” by Laurel Wamsley

Alice Miranda Ollstein: The 19th’s “Kansas Has Become a Beacon for Abortion Access. Next Year, That Could Disappear,” by Shefali Luthra

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: Delta Changes the Covid Conversation

With covid cases on the upswing again around the country, partisan division remains over how to address the pandemic. Meanwhile, the Biden administration proposes bigger penalties for hospitals that fail to make their prices public as required. Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Tami Luhby of CNN join KHN’s Julie Rovner to discuss these issues and more. Also, for “extra credit,” the panelists suggest their favorite stories of the week they think you should read, too.

Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

The resurgence of covid cases in the U.S. — largely attributable to the much more contagious delta variant — has given policymakers the jitters. The Biden administration is redoubling efforts to get people vaccinated, and even some Republicans who had been silent or skeptical of the vaccines are encouraging the unvaccinated to change their status.

Meanwhile, it’s not just covid that’s shortening U.S. life expectancy. Nearly 100,000 people died of drug overdoses in 2020, according to the Centers for Disease Control and Prevention. This week a multibillion-dollar settlement among states, drugmakers and distributors could funnel funding to fight the opioid scourge.

This week’s panelists are Julie Rovner of KHN, Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Tami Luhby of CNN.

Among the takeaways from this week’s episode:

  • If lawmakers fail to craft a bipartisan deal on Capitol Hill on traditional infrastructure spending, Democrats’ plans for a second bill that incorporates significant health care programs may need to be scaled back. That’s because the Democrats have pledged to fund major improvements in infrastructure and they would need to add that to the second bill, which is being moved through a special procedure that keeps it from being stalled in the Senate by a Republican filibuster. Some Democrats are nervous about making that second bill too broad.
  • The momentum toward vaccinating the public has stalled abruptly in the past month or so, and reports of rising cases is causing concern among conservatives. Some high-profile Republicans — including Senate Minority Leader Mitch McConnell, Rep. Steve Scalise (La.) and Florida Gov. Ron DeSantis — have been out during the past week touting the vaccines’ successes.
  • The agreement reached this week between state officials and companies that made or distributed opioids will send billions of dollars to the states to fund prevention and treatment programs for people with addiction problems. Some advocates worry, however, that the funding — much like the landmark tobacco settlement of past years — will instead be absorbed by cash-strapped states for other uses.
  • The Biden administration proposed significantly increasing the fines for hospitals that do not make their prices easily seen online and understood for patients. Despite the widespread eagerness to establish transparency, there is little indication consumers are using such tools.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: NPR’s “The Life Cycle of a COVID-19 Vaccine Lie,” by Geoff Brumfiel

Stephanie Armour: The Washington Post’s “Biden Administration, Workers Grapple With Health Threats Posed by Climate Change and Heat,” by Eli Rosenberg and Abha Bhattarai

Tami Luhby: The Los Angeles Times’ “Same Hospitals but Worse Outcomes for Black Patients Than White Ones,” by Emily Alpert Reyes

Alice Miranda Ollstein: The 19th’s “Courts Block Laws Targeting Transgender Children in Arkansas and West Virginia,” by Orion Rummler

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

Coronavirus Crisis Opens Access To Online Opioid Addiction Treatment

Under the national emergency, the government has waived a law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Now they can get those prescriptions via a phone call or videoconference with a doctor. That may give video addiction therapy a kick-start.

[UPDATED on April 28]

Opioid addiction isn’t taking a break during the coronavirus pandemic.

But the U.S. response to the viral crisis is making addiction treatment easier to get.

Under the national emergency declared by the Trump administration in March, the government has suspended a federal law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Patients can now get those prescriptions via a phone call or videoconference with a doctor.

Addiction experts have been calling for that change for years to help expand access for patients in many parts of country that have shortages of physicians eligible to prescribe these medication-assisted treatments. A federal report in January found that 40% of U.S. counties don’t have a single health care provider approved to prescribe buprenorphine, an active ingredient in Suboxone.

A 2018 law called for the new policy, but regulations were never finalized.

“I wish there was another way to get this done besides a pandemic,” said Dr. David Kan, chief medical officer of Bright Heart Health, a Walnut Creek, California, company. It has recently started working with insurers and health providers to help addicted patients get therapy and medications without having to leave their homes. He said he hopes the administration will make the changes permanent after the national emergency ends.

For years before the emergency regulations, Bright Heart — along with several other telemedicine counseling providers — began offering opioid addiction treatment and counseling via telemedicine, even if they couldn’t prescribe initial medication for addiction. Patients can renew prescriptions for drugs to deal with withdrawal symptoms, get drug-tested and meet with counselors for therapy.

When Nathan Post needed help overcoming a decade-long drug addiction, he went online in 2018 and used Bright Heart Health to connect to a doctor and weekly individual and group counseling sessions. He said the convenience is a big benefit.

“As an addict, it was easy to have excuses not to do stuff, but this was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he said.

Post, 38, a tattoo artist who recently moved from New Mexico to Iowa City, Iowa, was addicted to Suboxone, the drug he was prescribed in 2009 to deal with an addiction to opioid pills.

Officials with the insurer Anthem said using Bright Heart’s telemedicine option has helped increase medication-assisted treatment for members with opioid drug abuse issues from California and nine other states from 16% to more than 30%. While fewer than 5% of Anthem patients seeking addiction treatment use telemedicine, the company expects the option to become more common.

Bright Heart Health officials say one barometer of the effectiveness of the care is that 90% of patients are still in treatment after 30 days and 65% after 90 days — far higher than with traditional treatment.

Several insurers — including Aetna, and Blue Cross and Blue Shield companies like Anthem across the country — have begun covering the telemedicine addiction service.

Dr. Miriam Komaromy, medical director of Boston Medical Center’s Grayken Center for Addiction, said there are some downsides to virtual care.

“I think therapists and providers do worry whether it provides the same level of engagement with the patient and whether it’s possible to gauge someone’s sincerity and level of motivation as easily over a camera as in person,” she said.

But she predicted telemedicine service will grow because of the tremendous need to broaden access to mental health and addiction counseling. “Too often the default is no counseling for patients,” she said. “This gives us another set of tools.”

Patients can also have trouble finding a doctor who is eligible to prescribe medication to help treat addiction. Physicians are required to get a federal license to prescribe Suboxone and other controlled substances that help patients with opioid addictions and can write only limited numbers of prescriptions each month. Many doctors hesitate to seek that qualification.

A few small studies have found that patients are as likely to stay with telemedicine treatment as with in-person care for drug addiction. But no studies have determined whether one type of therapy is more effective.

Telemedicine does have its limits — and is not right for everyone, particularly patients who require more intensive inpatient care or who lack easy internet access, Komaromy said.

Premera Blue Cross and Blue Shield officials said they are partnering with Boulder Care, a digital recovery program based in Portland, Oregon, to help customers in rural Alaska. “Telemedicine is a unique way for someone to go through treatment in a discreet manner,” said Rick Abbott, a Premera vice president.

Nathan Post, a tattoo artist living in Iowa City, Iowa, used a telemedicine service to help overcome his addiction to Suboxone. “This was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he says. (Courtesy of Nathan Post)

While telemedicine has been growing in popularity for physical medicine, some people may still be reluctant to use it for drug addiction.

There are also concerns that allowing providers to prescribe controlled substances without meeting patients in person could increase the risks of fraud.

“There is a fear around this that there may be some rogue providers who make a lot of money off addiction and will do it stealthily on the internet,” said Dr. Alyson Smith, an addiction medical specialist with Boulder Care. “While that is a small risk, we have to compare it to the huge benefit of expanding treatment that will save lives.”

Smith said she doesn’t notice a big difference in treating patients for drug addiction in her office compared with on a video screen. She can still see patients’ pupils to make sure they are dilated and ask them about how they are feeling — which can determine whether it’s appropriate to prescribe certain drugs. Dilated pupils are a sign of patients suffering from withdrawal from heroin and other drugs.

Dr. Dawn Abriel, who treated Post and previously directed a methadone clinic in Albuquerque, New Mexico, said she can diagnose patients over video without issue.

“I can pick up an awful lot on the video,” particularly a patient’s body language, she said. “I think people open up to me more because they are sitting in their homes and in their place of comfort.”

In West Virginia, one of the states hardest hit by the opioid addiction epidemic, Highmark, a Blue Cross and Blue Shield company, started offering telehealth addiction coverage with Bright Heart Health in January. Highmark officials say a lack of providers, particularly in rural parts of the state, meant that many of the insurer’s members had difficulty finding the help they need.

Dr. Caesar DeLeo, vice president and executive medical director of strategic initiatives for Highmark, said the insurer was having problems getting customers into care. Only about a third of members with addiction issues were receiving treatment, he said.

“We needed to address the crisis with a new approach,” DeLeo said. “This will give people more options and give primary care doctors who do not want to prescribe Suboxone another place to refer patients.”

DeLeo said patients will also be referred to Bright Heart in hospital emergency rooms.

Dr. Paul Leonard, an emergency doctor and medical director for Workit Health, an Ann Arbor, Michigan, company offering telemedicine treatment and counseling programs, said many patients who turn to ERs for addiction treatment get little help finding counseling. With online therapy, patients can sign up while still in the ER.

“We’ve built a better mousetrap,” Leonard said.

Telemedicine addiction providers said they and their patients are getting more accustomed to virtual care.

“There are always times you wish you could reach out and hold someone’s hand, and you can’t do that,” said Boulder’s Smith. “But we feel like we are more skilled at a virtual hand-holding and really connect with people and they feel well supported in return.”

Readers And Tweeters Dive Into Debate Over ‘Medicare For All’

Kaiser Health News 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.


Savings For All?

Your criticism about former Vice President Joe Biden’s “Medicare for All” cost estimates is spot-on but leaves out important savings (“KHN & PolitiFact HealthCheck: Would ‘Medicare For All’ Cost More Than U.S. Budget? Biden Says So. Math Says No,” Feb. 14). Under Biden’s plan, private insurance stays intact, meaning there are premiums and point-of-service costs that do not appear as taxes but are added to the nation’s health care expense. Medicare for All, on the other hand, is zero at the point of service, meaning Americans would have no financial qualms seeking comprehensive care. Public options add bureaucratic costs, are subject to personal income fluctuations and have deductibles and copays. We depend on organizations like yours to present the full picture. Here’s hoping you will, in the public’s interest.

― Dr. Donald Green, Pennington, New Jersey


— Manuel Freire, Fort Lauderdale, Florida


For Alzheimer’s Patients Like Me, Knowing Is Half The Battle

I want to thank Judith Graham for her piece discussing the uncertainty and fear patients feel when faced with the potential onset of Alzheimer’s disease or dementia (“Stalked By The Fear That Dementia Is Stalking You,” Feb. 21).

As an Alzheimer’s patient with a confirmed diagnosis, I know all too well how unsettling it can be to suffer from cognitive decline without knowing the nature of your condition. For me, it started with little things like forgetting a name or misplacing a set of house keys. Still, it wasn’t until I applied to participate in an Alzheimer’s clinical trial and received a PET scan identifying amyloid protein buildup in my brain did I definitively know I had the disease.

Like many of the patients discussed in the article, dealing with these early warning signs can be an enormous source of anxiety — especially when it’s unclear whether or not the cause is Alzheimer’s or another cognitive issue. That’s why getting a precise diagnosis was such a critical step for myself and my husband, Jim.

As mentioned in the article, amyloid PET scans are not fully covered by Medicare, a critically important detail, which I believe must be remedied. As the prevalence of Alzheimer’s continues to grow as our population ages, expanding access to diagnostic tools that can identify this disease will become ever more critical. I remain optimistic that our representatives in Washington can come together and address this issue ― so more patients like me don’t have to live under a cloud of uncertainty.

— Geri Taylor, New York City


An Infusion Of Debt

Glad you are pointing this out (“Patients Stuck With Bills After Insurers Don’t Pay As Promised,” Feb. 7). It’s happening again, post-Affordable Care Act. For us, it’s my husband’s battle with multiple sclerosis, but more the battle with his insurer. It approved his treatment cost for a new drug, sent a letter saying everything was covered. Then, lo and behold, we get a bill for $4,000 that it said we had to pay. No reason or rationale given. So now we are on a payment plan with the hospital that gave him his infusion. Not sure why we even bother with paying our premiums in the first place, considering the out-of-pocket expense and worthlessness of preapprovals; it doesn’t really matter. Please keep writing these articles ― it helps.

― Margaret Paez, Los Angeles


When Choice Of Hospitals Is A Life-Or-Death Choice

Thanks so much for your coverage of death-with-dignity situations (“Terminally Ill, He Wanted Aid-In-Dying. His Catholic Hospital Said No,” Jan. 29). We all need to know as much as possible about the institutions and structures that may prevent patients from choosing a dignified death. Please consider linking to the Catholic ethics rules so readers can read them for themselves. Please make us a map of Colorado showing the hospitals that are abiding by these rules. Please explain that emergency services in rural areas may have no choice but to take patients to the nearest (possibly non-law-abiding) hospital. Rewired has written about Eastern hospitals where serious pregnancy issues were poorly treated by Catholic hospitals.

Many of us do not understand that hospital choice may become a life choice and doctor choice may also become a life choice. And, please, also feature regularly and loudly all the practitioners and organizations being formed to protect patients’ legal right to die. Thanks so much for the good work that you do.

― Diane Curlette, Boulder, Colorado


Taking Pains Over Statistics

In stories about the opioid crisis (“No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy,” Feb. 13), I always see total death statistics but never a breakdown of how many of the fatalities represent responsible legal users vs. illegal users.

A lot of us elderly folks have a very hard time getting our pain meds nowadays. Thirty used to last me five to seven months, and I took them only when I couldn’t get to sleep due to pain throughout my body. We have discussed it on our seniors’ webpage in our rural area and many of us used to get them. Overdoses and addiction aren’t the norm and aren’t even in the realm of our experiences. Why do we have to pay for others’ mistakes? They don’t outlaw cars even though many people die from wrecks caused by bad drivers!

― William Scriven, Valley Springs, California


— Nicolas Terry, Indianapolis


Collateral Damage From Insurers’ Dispute

When I read Brian Krans’ article about the Dignity-Cigna dispute (“Patients Caught In Crossfire Between Giant Hospital Chain, Large Insurer,” Feb. 6), I was reminded of my own situation: In California, Oscar dropped coverage for all UCLA care facilities in its Covered California (Affordable Care Act) plans, as of this year. I don’t know how many people use Oscar, but the UCLA system is a major health care provider here in West L.A. There’s no indication that there’s a dispute — this is represented as a final decision. UCLA is gone!

I figured I could get similar care from the Providence network, but my first choice for a primary care physician proved a bit odd: On our first visit, he presented at least four ideas that seem outside the medical mainstream. With some embarrassment, I asked for a different PCP. That physician ordered lab work but said no one in the building was authorized by Oscar to do blood draws, so I was sent to a facility in another city … which turned out to be out of business. I was finally referred to a third facility, which turned out to be more convenient than the last ― but the inconvenient run-around for something as simple as a blood draw and the penny-pinching by my insurance company do not bode well for the future of American medicine.

This is the second disruption I’ve had in insurance providers since the ACA began, and another indication that our current health care system is still very broken.

— Gary Davis, Los Angeles


— Scott Gordon, Fennimore, Wisconsin


Raising A Red Flag On Animal Rights Group

As a registered dietitian, I do not promote the keto diet. Mentioned in the article “As VA Tests Keto Diet To Help Diabetic Patients, Skeptics Raise Red Flags” (Feb. 3) is the group Physicians for Responsible Medicine, which is an extreme animal rights group with ties to PETA. About 3% of its members are physicians. Attending a seminar on nutrition for cardiovascular disease, I was dismayed to see the speaker had ties to Physicians for Responsible Medicine. After hearing about all the terrible effects of eating animal products, when the speaker could no longer contain himself and shouted out, “You don’t eat dead animals, do you?” I walked out and called my professional association to complain. Please do not give credibility to this organization.

― Mary Lucius, Beavercreek, Ohio


— Nancy Coney, South Bend, Indiana


Price-Gouging At Its Core

I read your most recent story on surprise medical billing (“When Your Doctor Is Also A Lobbyist: Inside The War Over Surprise Medical Bills,” Feb. 12) and found it to be largely one-sided against physicians and, somewhat, hospitals. Although private equity certainly is an influence in the conversation, very little to any time was spent discussing the efforts of insurance companies to continually drive down reimbursements. Furthermore, when we look at Medicare rates, which insurance companies rates are based on, the actual reimbursement has not significantly increased over the past few decades when you account for inflation or the consumer price index. So to paint the picture that physicians are trying to gouge patients does not seem very fair. While there are always a few bad apples and opportunists, the majority of physicians simply want to be paid fairly. Remember: Over the past few years, insurance companies have reported record profits — billions per fiscal quarter. Why are we not talking about why more of our premiums are not going to the provision of health care and instead to shareholders? I think the article fails to paint the entire picture for a lay audience. Nowhere does it report the amount of money spent on lobbying by the insurance industry.

― Dr. Shamie Das, Atlanta


— Gene Christian, Memphis, Tennessee


Health Care’s High-Cost Formula Goes Beyond Drug Prices

What patients care about more than drug prices is how much they have to pay out-of-pocket for their critical medications (“Watch: Let’s Talk About Trump’s Health Care Policies,” Feb. 4). Because of high-deductible health plans and tiered formularies, what patients pay at the pharmacy counter often has less to do with the list price of the drugs they need and more to do with the design of their health benefits. It is especially troubling that high-value drugs for chronic conditions like diabetes are often subject to unaffordable cost sharing that hits disproportionately at the beginning of the benefit year. Employers and health plans need to exempt these drugs from high deductibles as now permitted by the IRS. The same goes for Medicare Part D, which hugely penalizes seriously ill patients at the start of each year when they have yet to reach the catastrophic threshold.

Clearly, the problem of high drug prices needs to be addressed, but this will require a systematic and comprehensive approach that is certain to be resisted by one vested interest or another. In the meantime, patients need immediate relief from unaffordable out-of-pocket costs. Some steps that should be taken immediately include exempting high-value care from plan deductibles and capping and smoothing out-of-pocket costs in Medicare Part D. Much, if not all, of the cost associated with these measures can be offset by not paying for low- and no-value care that costs billions per year.

― Daniel Klein, president & CEO of the Patient Access Network (PAN) Foundation, Washington, D.C.


Cause For Investigation

The example you give presents an illegal activity by the home health agency (“Why Home Health Care Is Suddenly Harder To Come By For Medicare Patients,” Feb. 3). At a minimum, that agency should have a complaint registered against them, if not investigated by the Office of the Inspector General. The agency lied about Medicare not covering the patient’s needs. And they should have had the patient sign an ABN/NOMNC (Advance Beneficiary Notice/Notice of Medicare Non-Coverage) and explained it to the patient as required, so he could choose to appeal with the Quality Improvement Organization (QIO) for coverage of medically necessary care.

Kaiser Health News needs to provide education for the elderly and families to make sure they don’t fall prey to this type of behavior. If the agency simply says “I don’t have the staff to cover you,” they are responsible to assist the patient in finding another agency. But they cannot elect to just stop providing a medically necessary service, just as they cannot keep seeing someone when it is not medically necessary. Key here is to get people to know their rights as a Medicare beneficiary.

― Edward Dieringer, Salt Lake City


— Tom Cassels, Arlington, Virginia


— Peg Graham, Washington, D.C.


Privacy Concern: I Lack Seamless Access To My Own Records

I work in a medical center and have taken HIPAA training repeatedly over the years. I have also noted the staggering amount of money spent on medical electronic records. Yet in four attempts over a 20-year period, I have yet to get my medical records sent from one doctor or practice to another. I could not get records of my husband’s hospital stay sent to his primary physician, dental records sent from one dentist to another and, this fall, the pertinent records when my rheumatologist changed practices. My insurance paid for blood tests four times a year and X-rays over a five-year period. I have contacted the facilities and submitted a complaint to HHS Office for Civil Rights, which appears to be the correct office.

I find it unacceptable that, with all the talk about how expensive medical care is, tests over time are not easily available to patients when requested. I read Kaiser Health News regularly and at least I feel informed about what can go wrong. Thank you.

— Susan Klimley, New York City


— Dr. Sarah Nguyen, Los Angeles

Listen: Missouri Efforts Show How Hard It Is To Treat Pain Without Opioids

KHN Midwest correspondent Lauren Weber was interviewed by KBIA’s Sebastián Martínez Valdivia to discuss the challenges Missouri faces in managing patients’ pain amid the opioid epidemic.

KHN Midwest correspondent Lauren Weber speaks with KBIA’s Sebastián Martínez Valdivia about the challenges Missouri faces in trying to treat chronic pain without opioids. Weber had reported that only about 500 of Missouri’s roughly 330,000 adult Medicaid beneficiaries used a new, alternative pain management plan to stem opioid overprescribing in the program’s first nine months. Meanwhile, 109,610 Missouri Medicaid patients received opioid prescriptions last year.

You can listen to the conversation on the KBIA website.