When most people think of the victims of the nation’s opioid abuse epidemic, they seldom picture members of the Medicare set.
But a research letter published Wednesday in JAMA Psychiatry found Medicare beneficiaries had the highest and most rapidly growing rate of “opioid use disorder.” Six of every 1,000 recipients struggle with the condition, compared with one out of every 1,000 patients covered through commercial insurance plans.
The letter also concluded that Medicare beneficiaries may face a treatment gap. In 2013, doctors prescribed a high number of opioid prescription painkillers for this population — which put patients at risk for addiction — but far fewer prescriptions for buprenorphine-naloxone, the only effective drug therapy for opioid use disorder covered by Medicare Part D.
“The take home message is we have very effective treatments,” said Anna Lembke, one of the research letter’s authors and assistant professor at the Stanford University School of Medicine. “But they’re not widely accessible.”
Researchers analyzed 2013 Medicare Part D claims to count the number of prescriptions for Schedule II opioids and buprenorphine-naloxone. The latter drug curbs addiction by partially stimulating the same brain receptors as a stronger opioid, but with a lower risk of overdose.Use Our Content This KHN story can be republished for free (details).
The data showed the number of doctors who prescribed buprenorphine-naloxone equaled less than 2 percent of the 381,575 prescribers responsible for 56,516,854 Schedule II opioid claims. For instance, the researchers found that for every 40 family physicians prescribing pain killers, only one family physician prescribed the addiction management drug.
The letter also found states in the northeast, including Maine, Massachusetts and Vermont, had the highest ratio of buprenorphine-naloxone claims in the country, more than 300 times the national average.
In the last decade, the incidence of opioid addiction in the United States has reached crisis levels. According to the latest data from the Centers for Disease Control and Prevention, more than 19,000 Americans died from prescription opioid overdoses in 2014.
More than 300,000 Medicare recipients battle with opioid use disorder, according to the study. Among beneficiaries, hospitalizations due to complications caused by opioid abuse or misuse increased 10 percent every year from 1993 to 2012.
Lembke said part of the reason doctors do not prescribe more addiction management medications is because they view the problem as one of medicine’s lost causes.
“Doctors feel helpless and hopeless when it comes to addiction,” she said. “They feel that nothing can be done for them.”
And Medicare patients face additional obstacles when it comes to addiction treatment. First, Part D, Medicare’s prescription drug program, only covers buprenorphine-naloxone. Other effective treatments such as methodone are not covered, posing a barrier to access, said Lembke.
Buprenorphine-naloxone also usually requires prior authorization before a patient can receive the treatment. In addition, in order to prescribe it, physicians must take an 8-hour class, apply for a waiver and receive a special Drug Enforcement Administration number in addition to his or her regular DEA registration number. It becomes a hassle many medical professionals do not feel is worth the time, said Dr. Jonathan Chen, co-author of the study and instructor at Stanford.
“Why is it hard to [prescribe buprenorphine-naxolone], yet so easy for me to hand out things that get people dependent in the first place?” he said.
A different JAMA study found only 2 percent of doctors nationwide had obtained the authorization needed to prescribe the medication in 2014. And over half of the nation’s counties did not have a health provider with the ability to prescribe the medication.
But the letter’s authors note that physicians who prescribe opioid painkillers have in place a relationship with their patients that makes them well-positioned — with some additional training — to take steps to intervene when opioids are being misused.
“The bottom line is it’s a heck of a lot more work to get patients off of opioids than to get them on opioids,” said Lembke.
KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.
Dr. Thomas Gallagher has been through many tough conversations with patients. He remembers once standing in front of a patient and the patient’s family, preparing to tell them about a mistake that had occurred.
“This is a topic I think about all the time and it was still very nerve-racking and embarrassing,” said Gallagher, an internist and a professor at the University of Washington’s medical school specializing in quality and patient safety issues. The patient had been sent to another clinic an hour away to get an MRI, but because of a miscommunication, the MRI was done in the wrong area of the body and would have to be repeated.
“The patient was disgusted,” Gallagher recalled about the event that occurred before he came to Washington. “His family was furious … that after all the patient had gone through to get this test … we still couldn’t even figure out something this basic.”Use Our Content This KHN story can be republished for free (details).
Medical mistakes often happen. National guidelines call for doctors to provide full disclosure about adverse events, and studies have shown that those discussions benefit patients. But new research finds that the act of disclosure, combined with stress from the procedure gone wrong, can be an anxious experience for some doctors — and more training is needed to help them engage in these difficult conversations.
The study, published in JAMA Surgery Wednesday, examines what surgeons tell patients and what effect those discussion can have on the doctor.
“For a long time in the field, people thought that the primary reason that physicians have trouble reporting adverse events is that they were worried about being sued, but there are other barriers that are more important,” said Gallagher, one of the authors of the study. “This paper helps highlight how embarrassing and upsetting these events are for clinicians … (and) makes it difficult for the physician to admit to the patient, ‘Here is exactly what happened.’”
The researchers used surveys of surgeons who reported adverse events at three Veterans Affairs medical centers. They found that about 90 percent of the surveys showed that doctors said they had disclosed the event to patients or their families within 24 hours, expressed concern for the patient’s welfare, explained why the event happened, expressed regret and discussed with patients steps to treat subsequent problems.
But only about half showed the doctors discussed whether the event was preventable and a third reported they talked about how it could be avoided in the future. Just over half apologized to the patient.
The study also reported that those surgeons who find an event very or extremely serious and who had difficulty discussing that event are more likely to suffer anxiety over the experience. That was also true of surgeons who feared negative reaction from patients, an impact on their reputations, bad publicity or a malpractice suit.
“These surgeons who have volunteered to participate probably feel very comfortable talking to patients compared to those who didn’t participate, and even among these surgeons there was a lot of anxiety,” said A. Rani Elwy, an associate professor at Boston University and an investigator and researcher at the VA Boston Healthcare System who was the lead author of the study. “I can only imagine it is much more accentuated among the bigger population.”
Initial questionnaires were administered to 67 surgeons between January 2011 and December 2013. Of those doctors, 35 contacted the researchers during the study period to report adverse events and filled out 62 individual surveys on those events. Surgeons could complete up to three surveys for the study.
Elwy said that the VA surgeons who participated in the study had not been taught how to deal with patients on these situations and the study called for more training to create a “culture of professionalism” that will help surgeons better handle patients’ needs and allow for “self-care following disclosures [that] may also increase surgeons’ well-being.”
“Lots of clinicians don’t feel comfortable about these conversations, and doctors say they don’t know what to say, they don’t know how to say it,” Gallagher said. “I’ve had no training on having these conversations in medical school or residency.”
That’s also a concern of Dr. Marjorie Stiegler, an associate professor of anesthesiology at University of North Carolina at Chapel Hill who was not associated with the study.
“Every physician, perhaps every clinician, at some point will have some kind of adverse event,” she said, adding, “It’s never easy to break bad news to a family member of a loved one.”
She wrote an article in JAMA in 2015 arguing for more awareness of physicians’ well-being when faced with clinical adverse events. She noted a study that found physicians were twice as likely to commit suicide than the general population and a survey documenting post-traumatic stress disorder symptoms among anesthesiologists involved in surgical deaths.
Gallagher said that in the case of the botched MRI he apologized to the patient and tried to help the family figure out the next steps.
“At the end of the conversation, while they were unhappy, they felt like they were getting care at an organization that would tell them if there was a problem,” he said.
Twenty years after Temporary Assistance for Needy Families’ (TANF) inception, few poor families actually receive cash assistance under it and, for those who do, state benefit levels are low and are losing value. Our new series of maps illustrates the decline of this cash assistance safety net.
Today’s interview is with Ashley Breymaier, a remote metadata intern for the Digital Resources Division.
Describe your background
I am a military brat who grew up traveling all over the world. I left Maryland when I was seven years old and moved to Harrogate, England. When I was eleven, we moved to Bad Abiling, Germany and I lived there until I was eighteen. I attended boarding school in Edinburgh, Scotland for my first two years of high school. I love to travel and have visited 16 countries thus far. I have always loved libraries and books, so when I travel I always find at least one library to visit. In middle school, I read one book a night and now I re-read my favorites every year: Little Women, Wuthering Heights, and Jane Eyre. No one was surprised when I decided to become a librarian!
I earned my Bachelor of Science degree in professional writing from Old Dominion University while working full-time as a technical writer/project manager for a large government contractor in Washington, D.C. As a graduation present to myself, I went backpacking through Europe for three weeks and visited all of the libraries and museums I could find. When I returned home, I decided I wanted to be a librarian and applied to graduate school. I completed my Master of Library and Information Science degree from Syracuse University while simultaneously working full-time, completing internships at both the Smithsonian Natural History Museum and the Law Library of Congress, working with George Mason’s Special Collections Library, and volunteering at Arlington Library’s reference desk. There was never a dull moment during those three years!
How would you describe your job to other people?
I am an intern for the Law Library of Congress. I produce and assign metadata and descriptive keywords for the Statutes at Large to make them searchable online. I learn something new about America’s history every time I open the statute I’m working on!
Why did you want to work at the Library of Congress?
When I was in middle school my mother bought me a pocket constitution, that I used to take it everywhere. Now, it sits proudly on one of my bookshelves at home. At a young age, I realized the importance of knowing and understanding our rights as Americans and making that information accessible to the public. The Library of Congress makes that happen in an unbiased fashion. Plus, the Library of Congress has over 800 miles of bookshelves–who wouldn’t want to be a part of that?!
What is the most interesting fact you’ve learned about the Law Library of Congress?
I am truly impressed with how international and worldly the Law Library is. It contains legal information for almost all jurisdictions in the world. That’s pretty impressive!
What’s something most of your co-workers do not know about you?
I can debark a tree, create bricks out of mud, and I have a rather diverse collection of hobbies. I enjoying reading, going on long motorcycle rides, hiking, shooting at the range, arts and crafts projects, and watching bad/cheesy scary movies. And I once shared a leg press with Brett Michaels at the gym.
Shane Peebles has a ticking time bomb in his mouth.
He has multiple cavities, including one that has been infected and formed a pocket of painful pus. He also has a disease that causes swollen, bleeding gums, making it painful to chew.
He finally visited a health clinic two months ago when the pain became unbearable — and learned that it would cost $300 for surgery to treat the infection.
But Peebles is homeless and he cannot afford that. He got a free checkup, cleanings and antibiotics to reduce the swelling in his face and jaw from the Venice Family Clinic, a health center in Los Angeles that serves more than 22,000 low-income, uninsured and homeless individuals. Last year, the clinic had more than 5,000 dental visits, overseen by two full-time dentists and one volunteer. They offer procedures like tooth examinations, cleanings, fillings, extractions and basic gum treatment — but not the surgery that Peebles needs.This KHN story also ran in USA Today. It can be republished for free (details).
Last month, the Department of Health & Human Services awarded $156 million to 420 health centers around the country — including the Venice Family Clinic — to help address an overwhelming demand for affordable dental coverage. According to the department, 108 million Americans have no dental insurance and access to care can be difficult even for those who are covered.
“It’s the first time the grants are targeting oral health services,” said Martin Kramer, head of the communications office at the Health Resources and Services Administration, a part of HHS.
Dental care has become a luxury item for many middle- and low-income families, especially for adults. Cost is the primary barrier. Twenty percent of low-income adults say their mouth and teeth are in poor condition, according to the American Dental Association.
While dental benefits are guaranteed for lower income children under Medicaid and CHIP, dental coverage for adults in Medicaid is not compulsory and varies from state to state.
But even if Medicaid offers coverage, many patients have trouble getting appointments because often dentists say reimbursement rates are too low.
For these people, health centers are the go-to for dental care. Yet health centers, which generally rely heavily on federal funding, say they have trouble supporting the level of dental services needed by patients.
The Lingering Toothache For Adults
Marko Vujicic, chief economist of the Health Policy Institute in the American Dental Association, found that as the number of children getting dental care has been rising, adults have been increasingly staying away from their dentists.
Visits to private dental offices fell by 9 percent from 2006 to 2012 – but adults have been seeking more care at health centers and emergency departments, where dental appointments have increased 74 percent and 20 respectively.
“What’s driving that? Coverage is a huge issue,” he said. “We see adults increasingly reporting financial barriers to dental care because we haven’t had any sort of coverage expansion.”
A study by the Kaiser Family Foundation found that in 2013, 49 percent of adults with private coverage had a dental visit in the last year, while only 20 percent of adults insured by Medicaid or CHIP and 17 percent of uninsured adults saw a dentist. (Kaiser Health News is an editorially independent project of the Kaiser Family Foundation.)
Even for those with dental insurance, Vujicic said coverage and cost is still a problem.
“Dental insurance is not really health insurance. Health insurance is to help you smooth out the risk, it protects people from catastrophic costs,” he said, referring to the maximum out-of-pocket cost health insurance plans offer. “Dental insurance is structured completely the opposite. There is a cap on how much the plan will pay and beyond that, it’s fully out of pocket.”
In California, A “Broken” Dental Care System
Peebles has dental coverage under California’s state dental insurance, Denti-Cal. But Denti-Cal has a history of funding problems, and it has limits on care.
In 2009 the state legislature removed adult dental services from Denti-Cal coverage because of budget constraints. The health department was sued over the cuts, and the coverage was reinstated in 2010.
A state auditor report in 2014 condemned Denti-Cal for limiting access, and last April the independent Little Hoover Commission found that fewer than half of those eligible for dental benefits use the services because of the paucity of dentists who will accept Denti-Cal patients. At least five counties have no Denti-Cal providers, and many counties have no dental providers who would accept new Denti-Cal patients.
The reason, according to the commission, was that California has one of the country’s lowest reimbursement rates for dentists.
In 2013, only 29 percent of California dentists participated in Denti-Cal compared to the national average of 42 percent. Nonprofit dental providers testified at the commission’s hearings that they are overwhelmed with Denti-Cal patients, putting some on three-month waitlists.
“It’s getting harder to find dental care,” said Maria Chandler, a pediatrician and the chief medical officer at the Children’s Clinic: “Serving Children and Their Families” in Long Beach, Calif. “Patients line out every day to get care, it’s so highly overwhelmed that most of our adults cannot get care.”
Her clinic is one of the health centers awarded dental funding last month in the federal grant. The clinic plans to hire dentists and assistants with the $349,999 it received.
The clinic never had in-house dentists in the past and relied on pediatricians or medical assistants. Patients receive basic dental services, such as screening and cleaning, while more complex procedures are referred to dentists elsewhere.
“It’s hard to provide dental care without some sort of grant support because the revenue from the care will not cover the cost,” she said. “And I think this grant and the services that we are going to provide is still only a fraction of what is needed.”
Peebles might agree to that. He just found a new job as a bouncer at a local bar, and he is somewhat resigned to the fact that part of his paycheck will be spent on the oral surgery.
His caseworker from the clinic is trying to help him find an affordable option for treatment.
“The toothache is probably my biggest issue right now,” he says. “I’m going to have to get it done as soon as possible. I’m tired of going through the pain.”
Delegates at the Republican convention in Cleveland have approved the strongest anti-abortion platform in the party’s history. But groups that oppose abortion — and that lobbied for the strong language — are far from unified.
In fact, in the wake of last month’s Supreme Court decision reaffirming a woman’s right to abortion, leaders of a movement known for speaking largely with one voice are showing some surprising disagreement.
For the past several years, anti-abortion groups have pushed an agenda aimed at imposing much stricter regulation on abortion facilities. The groups said it was to promote the health and safety of women; abortion-rights supporters said it was an effort to regulate the clinics out of existence.
At least for now, the Supreme Court is siding with abortion-rights backers. Neither of the portions of Texas’ omnibus abortion law that were up for review “offers medical benefits sufficient to justify the burdens upon access that each imposes,” wrote Justice Stephen Breyer in the majority opinion.
The provisions that were struck down required abortion clinics in the state to meet the much higher safety standards for facilities that do much more advanced surgical procedures and required doctors who perform abortions to have admitting privileges at a hospital within 30 miles of the clinic.This KHN story also ran on NPR. It can be republished for free (details).
In hindsight, “maybe it was a mistake for us to champion safeguards for women,” said Marjorie Dannenfelser, president of the Susan B. Anthony List, whose goal is to elect more anti-abortion candidates to public office. “Maybe we shouldn’t have done that.”
At a media briefing, Dannenfelser said her group will instead rally around legislation that has passed in more than a dozen states to ban abortion at roughly 20 weeks of pregnancy. Similar legislation passed the U.S. House but not the Senate.
The 20-week ban is “our top priority,” she said.
But Clarke Forsythe, acting president and senior counsel for Americans United for Life, said his group plans no fundamental change in strategy.
“It is more important than ever to focus on the risks to women and negative consequences,” he said in an interview. “The justices can’t sweep away the public health vacuum that they created with a few pen strokes.”
Forsythe said that while the court’s ruling has “put some roadblocks in the way, and we will have to take those into consideration,” there are still plenty of opportunities to regulate abortion providers that could pass constitutional muster, particularly if they are more narrowly targeted than the Texas law was.
The nation’s oldest anti-abortion group, the National Right to Life Committee, has never embraced the push for health and safety regulations aimed at women.
“Our focus has always been on the humanity of the unborn,” said its president, Carol Tobias, rather than potential risks to women seeking abortions.
Her group has instead been pushing state and federal bills to ban abortions after 20 weeks and ban “dilation and evacuation” abortions, which are the most common procedure performed after the first trimester of pregnancy.
“I don’t think the Texas decision is necessarily going to impact those types of legislation, and I know it’s not going to affect us,” she said.
But there is one thing they all seem to agree on: The future makeup of the Supreme Court, and with it the future of abortion rights, hangs in the balance with the upcoming election.
Because of the vacancy left by the death of Justice Antonin Scalia last winter, “it is so obvious, so simple to make the case” about the importance of who controls the White House and Senate when it comes to Supreme Court appointments, said Dannenfelser.
“We say the court’s always important,” said Tobias. “But this time we have solid proof.”
The groups also agree on something else — that despite the victory at the Supreme Court, abortion-rights forces are not winning the fight.
“The pro-life cause has never been stronger,” said Dannenfelser. “And our opponents’ position has never been weaker.”
Immediately after the court’s ruling, said Tobias, “Planned Parenthood came out and said they were going to pass pro-abortion legislation and repeal pro-life legislation.”
That is true. “Today’s victory means we can fight state by state, legislature by legislature, law by law, and restore women’s access to reproductive health care,” said Planned Parenthood Action Fund Executive Vice President Dawn Laguens in a statement.
But in fact, said Tobias, “they haven’t been able to do that in 40 years. The only way they make advances is through the courts. They don’t have the people” on their side.
In an interview, Laguens agreed that her side has more work to do. “We’ve got to change hearts and minds,” she said. But Laguens insists it is abortion opponents who are “out of sync with America and out of sync with the new generation.”
With a more “social justice minded” generation of millennials now coming of age, she said, it is abortion foes on the defensive. “They’re in a last gasp moment,” she said. “They feel it slipping away.”
Covered California, the state’s Obamacare health insurance exchange, said Tuesday that its premiums will balloon by a statewide average of 13.2 percent next year — more than triple the roughly 4 percent increases in each of the previous two years.
But the average rate hike doesn’t tell the full story for individual consumers. Health plan prices vary across the state, and within regions. How much you’ll pay depends on a variety of factors: where you live, how much money you make, what level of coverage you want and which insurer you choose.
Keep in mind that these premium increases affect only a fraction of insured Californians — not the majority, who get their coverage through work or a government program such as Medicare or Medi-Cal.
Here are some key questions and answers to help you better understand what today’s announcement means for you.
Q: When do these premium hikes take effect?
They start in January for 2017 policies.
Q: Are all Covered California plans going up 13.2 percent?
No. California is divided into 19 pricing regions, and not all 11 plans that participate in the exchange are offered in each region. Your options will depend partly on where you live and what plans are available in your area.
In some regions, the rate increase is higher than the statewide average. In others, it’s lower.Use Our Content This story can be republished for free (details).
Within regions, rate hikes vary by insurer. For instance, in the greater Sacramento area, rates will rise an average of 13.4 percent overall. However, rate increases within the region range from an average 5.8 percent for a Kaiser Permanente plan to 23.1 percent for a Blue Shield of California plan.
Anthem Blue Cross and Blue Shield of California account for the highest rate increases statewide, said Covered California Executive Director Peter Lee. Blue Shield said its average hike was 19.9 percent, the biggest among all insurers participating in the exchange. Anthem Inc. said its average increase in California was 17.2 percent, the second biggest.
Q: Where are the biggest increases and what accounts for them?
The biggest rate hike will be in the region that includes Monterey, San Benito and Santa Cruz Counties, coming in at a whopping 28.6 percent. Covered California premiums in Northeast Los Angeles County will rise an average of 16.4 percent. Exchange enrollees in San Luis Obispo, Santa Barbara and Ventura Counties will see a 15.8 percent average increase. San Francisco rates are increasing an average of 14.8 percent.
Lee attributed the increases to several factors, including the rising cost of health care —in particular the steep jump in specialty drug prices.
Q: Will I be able to keep the same plan I have this year?
It depends on where you live. United HealthCare, after just one year of limited participation in Covered California, is pulling out in 2017.
Other plans, including Oscar, Molina and Kaiser Permanente, are expanding into some regions.
But even if you can keep your plan, a rate hike could put it out of your financial reach.
To find a better price, more Covered California enrollees will have to switch plans, which means they could lose their current doctors. According to Lee, about 80 percent of Covered California consumers will be able to pay less than they do now or cap their rate increases at 5 percent if they shop around and buy the lowest-cost plan at their current benefit level.
Q: If the premium on my plan rises by 10 percent, does that mean I’m going to have to pay 10 percent more out of my pocket than I did this year?
About 90 percent of Covered California enrollees receive tax credits that help defray the cost of their premiums.
As premiums rise, so do tax credits, which means that, all things being equal, the tax credits will absorb at least some of the rate hike.
Consumers are eligible for sliding-scale tax credits if they make between 138 percent and 400 percent of the Federal Poverty Level. This year, that’s between $16,394 and $47,520 for an individual and $27,820 and $80,460 for a family of three. The more money you make, the smaller the tax credit you receive.
Remember, the size of the tax credit you receive may vary from year to year as a result of changes in your income, age or family size.
“It is a complex calculation based on a lot of factors,” said Amy Palmer, director of communications at Covered California.
Q: When can I shop for my 2017 coverage?
Open enrollment for individual and family plans begins Nov. 1 and ends Jan. 31, 2017. These dates apply to plans purchased through Covered California or the open market.
But you won’t be able to research your specific situation until the fall. Because Covered California is revamping its online shopping tool, which offers personalized searches, it won’t be available and updated for 2017 health plans until early October, Palmer said.
If you already have a Covered California plan, you will receive a notice from Covered California in October explaining how much your current plan’s premium will change and what your tax credits — if any — will be for next year. If your plan is being offered again next year, you can keep the same plan at the new rate or switch plans during open enrollment.
If you want to get a general idea of average rate increases across the state, check out Covered California’s 2017 rate plan booklet.