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Health Care

Caution: ‘Acceptable’ Black Women’s Hairstyles May Harm Health

CommonHealth (WBUR) - Mon, 07/14/2014 - 10:02am

(U.S. Army)

This spring, the Pentagon issued Army Regulation 670-1, which included bans on several hairstyles worn mainly by black women, including twists and multiple braids. After a major backlash that included accusations of racial bias, that grooming policy is now under review. Here, researchers at the Connors Center for Women’s Health at Brigham and Women’s Hospital argue that this is more than an issue of racial fairness; it could also cause harm to women’s health — and disproportionately impact black women, whose life expectancy is already five years less than white women’s.

By Tamarra James-Todd and Therese Fitzgerald
Guest contributors

We are encouraged by the news that the Pentagon is reviewing the Army’s grooming policy, Army Regulation 670-1, which many deemed to be racially biased because it banned hairstyles worn primarily by black women.

Such policies set unreasonable standards for what is appropriate or acceptable in our society, and promote the idea that natural “black” hair is somehow inappropriate and unacceptable.

But perhaps most disturbing is the growing evidence that the process involved in straightening curly hair and maintaining acceptable hairstyles is harmful to women’s health, disproportionately affecting black women and making the pervasive practice of banning “black” hair styles a major health equity issue.

The military’s previous position on this reflects a precedent that unfortunately continues to exist in corporate and private sector settings throughout the country. Labeled as “grooming” issues, companies have fired employees for wearing dreadlocks and a private school in Orlando, Florida threatened to expel a young girl if she refused to straighten or cut her natural black hair.

The public discourse around these biased policies should not only focus on the racism they perpetuate but also on the potential harmful health outcomes and health disparities they may leave in their wake now and for future generations.

In order to conform to the standards of appearance that these policies demand, black women and girls are often encouraged to straighten or otherwise change the texture of their natural “black” hair. Unfortunately, many of the hair relaxers, oils, creams and other products used to straighten or alter curly hair contain synthetic chemicals that disrupt the normal functioning of the human body’s endocrine system, which regulates and secretes hormones.

Based on hair product labels, nearly half (49%) of black women and girls use hair products that contain endocrine-disrupting chemicals compared to just 8% of whites, which could leave blacks with higher levels of these chemicals in their bodies compared to whites.

For example, phthalates, a class of endocrine-disrupting chemicals used in hair products, are known to be found at higher levels in blacks than whites. Research led by Dr. Tamarra James-Todd at the Connors Center for Women’s Health at Brigham and Women’s Hospital has revealed that higher phthalate levels are associated with a variety of poor health outcomes that disproportionately impact black women and girls including:

Type 2 diabetes, a condition twice as common among black women compared to white women, as well as insulin resistance and other associated conditions.

• Gestational diabetes, a form of diabetes that occurs during pregnancy that has negative implications for both mother and child health, including a higher likelihood of developing type 2 diabetes as well as cardiovascular disease, which affects twice as many black women as white women.

• Early-onset puberty (i.e., early breast development and early-onset menstruation), more common in black girls compared to white girls. Use of hair oils, many of which contained these synthetic endocrine-disrupting chemicals, presented a 40% increased risk of early onset of menstruation, a risk factor for breast cancer and metabolic diseases.

Research by others has shown that phthalate levels are associated with additional negative health outcomes, including:

Preterm birth, with rates in the U.S. 60% higher in black women than in whites. Preterm birth is associated with increased risk of developing cardiovascular disease and type 2 diabetes in mothers and greater risk of mortality, breathing problems, cerebral palsy, and developmental delays in infants.

Fibroids, a condition two to three times more prevalent in black women than white women. Fibroids can lead to uterine bleeding, pelvic pain, severe symptoms requiring hospitalization and major surgical interventions including hysterectomies— the latter is twice as common in black women as white women.

Childhood obesity, which is 40% higher in black children compared to their white peers. Obesity in children places them at increased risk of a variety of metabolic conditions, including type 2 diabetes in youth.

Today, a black woman’s life expectancy is five years less than a white woman’s. More research is needed to determine whether exposure to hair products containing these chemicals is a major contributor to these health disparities, but the evidence that already exists should inform the decision-making of consumers, policy-setting organizations, and the prevailing culture.

Tamarra James-Todd, PhD, MPH, is an Associate Epidemiologist at Brigham and Women’s Hospital and an Instructor in Medicine at Harvard Medical School. Therese Fitzgerald, PhD, MSW, is Director of the Women’s Health Policy & Advocacy Program for the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital.

Readers, thoughts? And if you’re wondering about the chemical content of a particular hair product, there doesn’t seem to be any one source that gathers all that information (please correct me if I’m wrong) but the Environmental Working Group offers a database of risk assessments on many cosmetic products, including hair care, here.

Categories: Health Care

VA Struggles With Sharp Rise In Disability Claims

Kaiser Health News - Mon, 07/14/2014 - 9:46am

Also in the news, efforts continue to unravel the scandals related to delayed care at veterans' facilities.

Los Angeles Times: With U.S. Encouragement, VA Disability Claims Rise Sharply
With the government encouraging veterans to apply, enrollment in the system climbed from 2.3 million to 3.7 million over the last 12 years. The growth comes even as the deaths of older former service members have sharply reduced the veteran population. Annual disability payments have more than doubled to $49 billion — nearly as much as the VA spends on medical care. More than 875,000 Afghanistan and Iraq war veterans have joined the disability rolls so far (Zarembo, 7/12).

USA Today: Report Cites VA Struggles With Benefits Paid To Veterans
The federal department responsible for caring for America's veterans, already mired in scandal over delays in health care, continues struggling with another major responsibility: paying compensation to those wounded or injured or who grew ill from service in uniform. While the VA managed last year to reduce a huge backlog in veteran claims for money, it was at the expense of appeals to those decision which are rapidly mounting, according to testimony slated for Monday by the VA Office of Inspector General (Zoroya, 7/14).

The Washington Post: VA Overhauling Medical Inspector’s Office After Scathing Report
The Veterans Affairs Department is overhauling its medical inspector’s office after a federal investigative agency slammed the division for its frequent use of the “harmless error” defense when problems occur within the VA health network. The agency this week appointed a new acting director for the medical inspector’s office and decommissioned the division’s hotline and its Web site: Individuals are now redirected to file concerns about the medical system with the VA’s inspector general (Hicks, 7/11).

Baltimore Sun:  VA Reports Mishandled Records At Baltimore Office
An employee at the Baltimore office of the U.S. Department of Veterans Affairs inappropriately stored thousands of documents — including some that contained Social Security data — according to testimony from an inspector general to be made public on Monday. About 8,000 documents, including claims folders, unprocessed mail and Social Security information of dead or incarcerated veterans were stored in an employee's office for "an extensive period of time," according to testimony from Linda A. Halliday, an assistant inspector general, that was reviewed by The Baltimore Sun. The incident is one of several examples included in a scathing assessment of the department that Halliday will offer in a hearing Monday before the House Committee on Veterans' Affairs. It also represents the latest problem for the Baltimore office, which has been among the nation's worst in processing veteran claims  (Fritze, 7/14).

Kaiser Health News: Veterans' Needs 'Should Drive Where They Get Their Care'
Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outside providers for medical care (Carey, 7/13).

In other news, NPR looks at how some veterans are dealing with PTSD and other problems without drugs -

NPR: Veterans Kick The Prescription Pill Habit, Against Doctors' Orders 
Troops coming home from war, like Will, are often prescribed drugs for PTSD and other conditions. Hundreds of thousands of veterans are on opiates for pain, and 1 in 3 veterans polled say they are on 10 different medications. While there is concern about overmedicating and self-medicating — using alcohol or drugs without a doctor's approval — there are also some veterans who are trying to do the opposite: They're kicking the drugs, against doctor's orders (Lawrence, 7/11).

Categories: Health Care

Senate Finance Committee Probing Prices For Hepatitis C Drug

Kaiser Health News - Mon, 07/14/2014 - 9:44am

Sens. Ron Wyden, D-Ore., and Charles Grassley, R-Iowa, send letter to the drug's maker requesting information about how it set the price, which runs about $84,000 for a standard three-month regimen.

The Wall Street Journal: Senate Committee Is Investigating Pricing Of Hepatitis C Drug
The U.S. Senate Finance Committee launched an investigation into Gilead Sciences Inc.'s high pricing of the hepatitis C drug Sovaldi, adding its voice to a chorus of criticism accompanying the highest-grossing drug launch in history. Sen. Charles Grassley, a longtime industry watchdog and member of the committee, and the panel's chairman, Sen. Ron Wyden, sent a letter to Gilead Chief Executive John Martin on Friday announcing the probe and requesting a wide range of documents on how the Foster City, Calif., company decided on the price. Sovaldi costs about $1,000 a pill, or about $84,000 for a patient on a standard, 12-week regimen (Loftus, 7/11).

Los Angeles Times: U.S. Senators Ask Gilead Sciences To Explain High Cost Of Hepatitis C Drug
Pharmasset, the drug's original developer, priced the treatment at $36,000, the senators wrote, citing documents filed with the Securities and Exchange Commission. Gilead acquired Pharmasset in 2012 for $11 billion. Sovaldi sales could hit around $8 billion this year, analysts estimated, which would make it one of the top-selling pharmaceutical drugs worldwide (Khouri, 7/11).

Reuters:  U.S. Senators Ask Gilead To Explain Cost Of Sovaldi Hepatitis Drug
Two members of the U.S. Senate Finance Committee, including Chairman Ron Wyden, on Friday asked Gilead Sciences Inc to defend the more than $80,000 cost of its breakthrough treatment for hepatitis C, citing the expense to federal healthcare programs. Sovaldi's cost can soar to $168,000 in patients that need longer treatment periods, not including the costs of other drugs used with it, the senators said (Pierson, 7/11).

Categories: Health Care

Lawmakers Seek Lower Price For Bill On Vets’ Care

Kaiser Health News - Mon, 07/14/2014 - 9:44am

Members of Congress are scrambling to lower the cost of a bill to fix veterans’ health care amid a growing uproar over long waits for appointments, meanwhile, The Wall Street Journal is reporting that congressional inaction is threatening a program for brain-damaged vets.

The Associated Press: Lawmakers Seek Lower Price For Bill On Vets’ Care
Stung by sticker shock, members of Congress are scrambling to lower the cost of a bill to fix veterans’ health care amid a growing uproar over long waits for appointments and falsification of records to cover up the delays at Veterans Affairs hospitals. At the same time, deficit hawks fear that letting veterans turn more to providers outside the VA for health care could cost far more if Congress, under pressure from powerful veterans groups, decides to renew that program rather than let it expire in two years (7/11).

The Wall Street Journal: Congressional Inaction Threatens Program For Brain-Damaged Vets
The Department of Veterans Affairs has begun ousting dozens of brain-damaged veterans from special therapeutic group homes, setting off a scramble for housing and care. In recent weeks, VA case workers have warned 53 veterans they'll have to leave the privately run homes by Sept. 15, according to the agency. Ten have already been discharged from the care facilities and sent to nursing homes, state veterans homes or to live with family members (Phillips, 7/11).

Categories: Health Care

Governors' Races Are Ground Zero For Health Law Politics

Kaiser Health News - Mon, 07/14/2014 - 9:44am

In November, Republicans will defend 22 of 36 governors' seats. Last time around, the health law appeared -- in many cases -- to work in GOP candidates' favor. Meanwhile, at the National Governors Association summer meeting, the health law also was a hot topic for at least one state executive eyeing a run for the White House.   

The New York Times: Republicans Replay 2010 Strategy At State Level
Four years after an economic crisis and opposition to Mr. Obama's health care law propelled Republicans to capture a lopsided majority of statehouses across the country, they are faced with a staggering political task: defending 22 of the 36 executive mansions that will be up for grabs in November, led by a governor who is trying to rebound from a scandal. While the sheer scale of Republican gains four years ago offers Democrats a wealth of opportunities to win, the political environment appears to be tilting again in the Republicans' direction (Martin and Confessore, 7/12).

The Hill: Christie Jabs Obama: Obamacare A 'Failure'
In what could be the latest move toward a 2016 presidential bid, New Jersey Gov. Chris Christie (R) offered a wide-ranging critique of President Obama’s domestic and foreign policies. Speaking to reporters at the National Governors Association on Saturday, Christie labeled Obamacare, the administration's signature legislation, a "failure on a whole number of levels" and said it should be repealed. "But has to be repeal and replace with what. It can’t just be about repeal," Christie told the audience. "What I've said before is, what Republicans need to be doing is putting forth alternatives for what should be a better healthcare system" (Matishak, 7/12).

The Associated Press: Biden Calls On Governors To Lead Nation
The vice president's comments came during the first day of the governors’ three-day conference in Nashville, where state leaders from both parties gathered to collaborate despite intensifying partisan differences on immigration, health care and education (Peoples and Schelzig, 7/11). 

Categories: Health Care

Battle Of The Medicare Ads In Kentucky Senate Race

Kaiser Health News - Mon, 07/14/2014 - 9:43am

Media organizations parsed ads by both Democratic challenger, Alison Lundergan Grimes, and GOP incumbent, Sen. Mitch McConnell, and found both sides making inaccurate claims about Medicare.

The Washington Post: A Kentucky Shootout Over Stale Medicare Claims
This pair of ads, which can be viewed with Truth Teller commentary above, hauls out each side’s favorite Medicare attack lines. ... The Democrats’ $6,000 figure is outdated and discredited (note the small type in the ad with citations from 2011). It’s worthy of Four Pinocchios. The Republicans’ $700 billion is a stretch, but at least it’s based on real numbers — and The Washington Post has reported that the reductions in spending for Medicare Advantage have led to thousands of doctors being terminated from the program. We have been monitoring the impact of the cuts but have generally awarded this claim Two Pinocchios (Kessler, 7/11).

Lexington Herald-Leader: McConnell Says Medicare Will Tank Without Changes, But Avoids Specific Solutions
U.S. Senate Minority Leader Mitch McConnell said on Friday that "no action is not a solution" to the solvency threat facing Medicare. ... He did not specify what changes should be made, but in late 2012, as McConnell and other congressional leaders wrangled over a budget deal to avoid the so-called fiscal cliff, The Wall Street Journal reported that McConnell pushed to include an increase in the Medicare eligibility age and higher Medicare premiums for the wealthy (Youngman, 7/11). 

Louisville Courier-Journal: Political Ads Long On Claims, Short On Truth
You can tell it’s getting near election season by the fact that both Alison Lundergan Grimes and U.S. Sen. Mitch McConnell took to the air with so-called “Medi-scare” ads this week. They are the tried and true method of riling up older voters, the ones most likely to cast ballots, by claiming one’s opponent wants to 1) cut Medicare benefits, 2) raise Medicare deductibles, or 3) do away with Medicare all together. And both the McConnell and Grimes ads, according to the Associated Press, were long on claims but short on truth (Carroll and Gerth, 7/12). 

PolitiFact: McConnell: Opponent Alison Lundergan Grimes Supports Obamacare, $700 Billion In Medicare Cuts
An ad out of the McConnell campaign said, "Grimes supports Obamacare, which cuts $700 billion from seniors’ Medicare." Grimes has been cautiously supportive of the Affordable Care Act, and she certainly does not oppose it as strongly as McConnell does. The law is projected to reduce spending on Medicare by about $700 billion over 10 years, but those reductions in spending are more of a slowed growth rate rather than a budget cut. We rate this claim Half True (Carroll, 7/11).  

Categories: Health Care

Hospitals, Consumer Groups Object To Medicare Rule On Observation Care

Kaiser Health News - Mon, 07/14/2014 - 9:43am

They say the government's effort to set rules for when someone is considered an admitted patient compromises care and still leaves many seniors with costly bills. In other Medicare news, a look at the unraveling of one scam and coverage of sex-reassignment surgery.

USA Today: Hospitals, Regulators Spar Over In-Patient Care Policy
Fewer patients linger for days in hospitals without being admitted because of a new federal rule, but hospital and consumer groups are suing the government because they say the policy compromises Medicare patients' care, and patients are often stuck with costly, unexpected bills. Doctors now have to certify that a patient has a serious enough condition to need at least two overnight stays for Medicare to cover an inpatient admission under the rule, which took effect in October. However, patients can remain in an outpatient or "observation" status — that can even include staying overnight for several nights in a typical hospital room — even though they haven't been formally admitted as an inpatient (O'Donnell, 7/13).

NPR/ProPublica: How A Fanny Pack Mix-Up Revealed A Medicare Drug Scam
Last year, ProPublica chronicled how lax oversight had led to rampant waste and fraud in Medicare's prescription drug program, known as Part D. As part of that series, we wrote about Dr. Carmen Ortiz-Butcher, a kidney specialist whose Part D prescriptions soared from $282,000 in 2010 to $4 million the following year. ... She stumbled across a sign of trouble last September, after asking a staffer to mail a fanny pack to her brother. Instead of receiving the pack, he received a package of prescriptions purportedly signed by the doctor, lawyer Robert Mayer said last year. ... Since then, investigators have uncovered a web of interrelated scams that, together, cost the federal government up to $7 million, documents show (Ornstein, 7/11).

Politico: Momentum Grows For Sex Reassignment Surgery Coverage
Medicare’s recent decision to cover sex-reassignment surgery was a victory for transgender advocates seeking broader access to medical care for a condition that still carries social stigma. After all, the federal health program was one of the first to exclude such treatments more than 30 years ago (Wheaton, 7/13).

On another issue, The Associated Press examines new rules that will let all patients find out what ties their doctors have to drug companies.

The Associated Press:  Sunshine Act Will Reveal Drug Companies Giving Gifts To Your Doctor
[N]early 95 percent of U.S. physicians accept gifts, meals, payments, travel and other services from companies that make the drugs and medical products they prescribe, according to the New England Journal of Medicine. ... Starting in September the federal government will make available an exhaustive online database of payments to U.S. physicians and hospitals, under a section of the health-care overhaul passed in 2010. The measure, known as the Sunshine Act, requires most makers of drugs and medical supplies to report all payments, gifts and other services worth $10 or more that they provide to health professionals (Perrone, 7/9).

Categories: Health Care

Some Doctors Refuse To See Obamacare Enrollees

Kaiser Health News - Mon, 07/14/2014 - 9:42am

Subscribers are running into closed doors from some doctors listed in their plans' networks, reports The Miami Herald. Meanwhile, Connecticut advocates express concern about how a proposed overhaul of the state's health care system could change Medicaid, and in Washington state, providers scramble to keep up with demand.

Miami Herald: Some South Florida Docs Decline To Accept Obamacare Insurance
After being without health insurance for two years, Miranda Childe of Hallandale Beach found a plan she could afford with financial aid from the government using the Affordable Care Act’s exchange. Childe, 60, bought an HMO plan from Humana, one of the nation’s largest health insurance companies, and received a membership card in time for her coverage to kick in on May 1st. But instead of being able to pick a primary care physician to coordinate her healthcare, Childe says she repeatedly ran into closed doors from South Florida doctors who are listed in her plan’s provider network but refused to see patients who bought their coverage on the ACA exchange (Chang, 7/12).

Seattle Times: Providers Mostly Keep Up With More Insured, But Worries Loom
The fear was this: The Affordable Care Act would give massive numbers of people new access to health care, creating a surge in demand for medical services and long waits to see the doctor. But in the seven months since new insurance plans began kicking in, Puget Sound-area primary-care providers so far seem to be keeping up with growing numbers of patients. The question now is, can they keep ahead of the demand as the formerly uninsured continue seeking care, and as baby boomers age and a sizable fraction of Washington’s physicians retire. In just the past year, Providence and Swedish clinics in Western Washington report a 10 percent increase in primary-care visits. But patients are waiting only four or five days for those appointments, and specialty and urgent-care services are available the same day (Stiffler, 7/12).

The CT Mirror: Health System Overhaul Plan Has Medicaid Advocates Worried
State officials are seeking millions of dollars in federal funds with the ambitious goal of redesigning how health care is paid for and delivered to the majority of Connecticut residents. But critics say a late addition to the application has the potential to significantly change Connecticut’s Medicaid program, in ways they worry could make it harder for low-income children and adults to receive care (Becker, 7/11).

Categories: Health Care

Glitch In Connecticut Exchange Resulted In Thousands Of Problems

Kaiser Health News - Mon, 07/14/2014 - 9:42am

Access Health CT is reaching out to 5,784 customers who were either inaccurately enrolled in Medicaid, or who received inaccurate bills because their insurers received incorrect information from the exchange, officials say. Meanwhile, developments related to Minnesota's and Colorado's exchanges are also covered.

The CT Mirror: Access Health CT Finds Glitch Behind Cancellations
When officials at Connecticut's health insurance exchange learned about customers having problems with their coverage in May, they thought they were isolated cases. When GOP legislators raised concerns last month about constituents having their policies canceled, exchange officials maintained the problem was not with their system. But after examining the problems, exchange officials and the vendor that developed the system discovered a programming flaw behind coverage problems affecting thousands of people (Becker, 7/11).

Minnesota Public Radio: Does Minnesota Really Need Still-Broken MNsure Site?
Consumers howled in anger and frustration last fall and winter because the MNsure website could not reliably process their health insurance applications. And a recent evaluation by Deloitte Consulting found the site's software still can't reliably perform nearly two thirds of all necessary functions. And yet, despite the seriously hobbled website, various workarounds, including lots of manually filled out paper applications, allowed a quarter of a million people to enroll in a health plan and reduce the number of Minnesotans who have no coverage by 41 percent (Stawicki, 7/13).

Denver Post: Colorado Health Exchange Short On Information About Enrollees
Colorado's health care exchange plans to spend more than $4 million this fiscal year on branding and to attract Latinos, young people and other groups to sign up for health insurance. But the exchange doesn't know the ethnic breakdown of the nearly 135,000 people who already signed up for insurance. And Connect for Health Colorado is planning to spend nearly $14 million this year toward operating a customer-service call center, but it cannot tell board members how much of phone operators' time various calls are taking up. Three months after open enrollment ended, exchange staff members still haven't done basic analysis that one board member says makes it impossible to budget and plan for the future (Kane, 7/14).

Categories: Health Care

National Medicaid Enrollment Nears 7 Million

Kaiser Health News - Mon, 07/14/2014 - 9:41am

The Obama administration released new enrollment figures showing 56 percent of those on the program are children. Meanwhile, Tennessee faces a deadline today for a plan to fix enrollment problems.

Reuters: U.S. Medicaid Enrollment Nears 7 Million Since ACA Rollout
New enrollments in Obamacare's Medicaid expansion and other healthcare programs for the poor have reached 6.7 million people since the launch of President Barack Obama's healthcare reforms last year, the administration said on Friday. The figures, which include state Medicaid plans that existed before Obamacare and the Children's Health Insurance Program, show enrollment climbing by 920,000 people during May, the latest month for which data is available. All told, new enrollments are up 11.4 percent since last October's Obamacare rollout (7/11).

The Hill: Administration Touts Benefits Of Medicaid Expansion For Children
States that expanded access to Medicaid under ObamaCare greatly increased access to healthcare for the poor, especially for children, according to the Obama administration. The Centers for Medicare and Medicaid Services (CMS) released a monthly report Friday showing 6.7 million more people had signed up for Medicaid or the Children’s Health Insurance Program (CHIP) by May compared to last September. The CMS says about 26.4 million children were enrolled in CHIP or Medicaid overall, and 56 percent of all enrollees in the programs are children. The Supreme Court ruled in 2012 that the federal government couldn't penalize states for not expanding Medicaid, leading a number of states to opt out of the expansion (Al-Faruque, 7/11).

The Tennessean: Nonprofit Legal Firms Keep Tabs On TennCare
TennCare faces the prospect of lawsuits if it fails to set up a state system for people to apply for Medicaid. Attorneys with the Tennessee Justice Center, Southern Poverty Law Center and National Health Law Program are closely watching to see how the agency responds to a federal demand for a correction plan. The plan is expected to be filed Monday. Tennessee ended face-to-face assistance for people seeking Medicaid coverage on Jan. 1, when the Affordable Care Act came into full effect, and, instead, began telling people to apply online at healthcare.gov. ... Cindy Mann, the federal director of Medicaid programs, put TennCare on notice in a June 27 letter that it had failed to provide required services and gave the state agency 10 days to submit a correction plan (Wilemon, 7/13).

Chattanooga Times Free Press: Gov. Haslam Hits Another Wall On Medicaid Expansion; TennCare Application Process Plan Due Today
He's dealing with a new U.S. Health and Human Services secretary, but Tennessee Gov. Bill Haslam is running into the same problem with Sylvia Mathews Burwell as he did with her predecessor when it comes to winning federal approval of his Medicaid-expansion plan. Haslam said Sunday he personally spoke with Burwell, who succeeded Kathleen Sebelius, about his long-stalled effort to gain federal approval for his "Tennessee Plan" on expanding Medicaid to an additional 160,000 low-income people under the Affordable Care Act. The Republican also said he spoke with Burwell about the federal Centers for Medicare and Medicaid Services chief's recent harsh critique of his administration's failure to provide an adequate application process for TennCare, the state's version of Medicaid, under the ACA (Sher, 7/14).

In other news, an Arkansas legislator announces plans to further refine that Medicaid program -

Arkansas News: State Senator To Pursue New Waiver For Health Care Innovation
A state senator says he plans to file legislation next year that would authorize Arkansas to seek a federal waiver to allow innovations on health care coverage that could go far beyond what the state did with the so-called private option. Sen. David Sanders, R-Little Rock, one of the architects of the private option, Arkansas’ version of Medicaid expansion, said he will file a bill in the 2015 session to authorize application for an "innovation waiver" under Section 1332 of the federal Affordable Care Act. "The 1332 waivers really give a state wide discretion to customize an approach to health care — waiving complete portions of the Affordable Care Act," he said (Lyon, 7/13).

The Medicaid expansion issue is also coming into play in a variety of campaigns-

Arizona Republic: Medicaid Fight Re-Emerges In GOP Legislative Primaries
Last year's fight at the Arizona Legislature to expand the state's Medicaid program isn't over. It's continuing to play out this summer in the Republican primaries, and the direction of the next Legislature likely hangs in the balance (Pitzl, 7/13).

Sioux Falls Argus Leader: Medicaid A Vital Issue For Wismer In Governor’s Race
Will Medicaid expansion be a winning issue for Susan Wismer in her battle to unseat Gov. Dennis Daugaard? Wismer, the Democratic nominee for governor, is campaigning across the state in favor of covering tens of thousands of low-income South Dakotans in an expanded Medicaid program. She said it not only would help the uninsured but would bolster hospitals by covering medical care they now are absorbing themselves (Montgomery, 7/14).

Hattiesburg American: Medicaid Expansion Could Be Campaign Issue In Senate Races
The debate over whether to expand Medicaid could be a key issue in the competitive Senate races in Louisiana and Mississippi, political experts say. "This is an issue that would seem to have a lot of potential because both states have large populations of uninsured people,'' said Albert Samuels, a political scientist at Southern University in Louisiana. ... The issue is particularly thorny in the Deep South, which has become more conservative and where two of the nation's most competitive Senate races are under way. Republican candidates have sided with GOP Govs. Bobby Jindal of Louisiana and Phil Bryant of Mississippi, who decline to expand Medicaid. Democrats argue that expansion would help thousands of uninsured and working poor in the two states (Berry, 7/13).

Categories: Health Care

Truvada Becomes Flashpoint In N.Y. Gov's Anti-AIDS Plan; LA County To Consider Court-Ordered Mental Health Treatment Proposal

Kaiser Health News - Mon, 07/14/2014 - 9:41am

A selection of health policy stories from Connecticut, New York, Wyoming, Kentucky, Ohio, Massachusetts, Texas, Illinois, Maryland and Florida.  

The Wall Street Journal: Truvada, The Drug In Cuomo's AIDS-Eradication Plan, Spurs Debate
A cutting-edge medication that can help prevent HIV in healthy individuals is gaining favor with government officials, including New York Gov. Andrew Cuomo. But in advocating for the drug, sold under the brand name Truvada, officials seeking to curtail HIV/AIDS infections are going up against some surprising opponents: high-profile AIDS activists who say they have serious questions about the drug's cultural and health impacts (Vilensky, 7/13).

CT Mirror/Hartford Courant: Children In Crisis: ER System Failing Those With Mental Health Needs
The number of children and teens going to emergency rooms in mental health crisis, some waiting days for an inpatient bed, has been growing for more than a decade. ER staff are used to seeing a bump in patients at the end of each school year. But what happened this spring was unprecedented, say people who work at Connecticut Children's Medical Center, parents of kids with psychiatric illnesses and community mental health providers. "I don't remember a period like that before where the volume was so high and we had so many kids where there wasn't a place to facilitate them to, there wasn't a place for them to go to," said Gary Steck, CEO of Wellmore Behavioral Health, based in Waterbury (Levin Becker, 7/13). 

Los Angeles Times: L.A. County Board To Vote On Court-Ordered Mental Health Treatment Law
The Board of Supervisors is expected to vote Tuesday on a proposal that would increase money for outpatient treatment of people with a history of mental illness and expand efforts to identify potential patients. The vote would also set in motion a process that would allow family members, treatment providers and law enforcement officers to seek a court order to make people take part in the program, under which people can be ordered to undergo treatment but can't be forced to take medication (Sewell, 7/13). 

The New York Times: Rikers: Where Mental Illness Meets Brutality In Jail
The study, which the health department refused to release under the state’s Freedom of Information Law, found that over an 11-month period last year, 129 inmates suffered “serious injuries” — ones beyond the capacity of doctors at the jail’s clinics to treat — in altercations with correction department staff members. The report cataloged in exacting detail the severity of injuries suffered by inmates: fractures, wounds requiring stitches, head injuries and the like. But it also explored who the victims were. Most significantly, 77 percent of the seriously injured inmates had received a mental illness diagnosis (Winerip and Schwirtz, 7/14).

The Associated Press: Wyoming Is No. 3 Spender On Inmate Health Care
Wyoming spent about $20.7 million on prison health care services in 2011, ranking it third-highest among states in such spending per inmate, according to a new report. A study released this past week by the State Health Care Spending Project found that Wyoming spent an average of $10,870 on health care per inmate in 2011, the latest year that nationwide statistics were available. Wyoming had an average daily prison population of 1,905 in 2011. The national average was for states to spend about $6,000 per inmate during that time. Only California and Vermont spent more per inmate than Wyoming (7/14).

Kaiser Health News: Kentucky Law Gives Nurse Practitioners More Flexibility
Starting July 15, nurse practitioners in Kentucky who have completed a four-year collaboration with a physician will be allowed to prescribe routine medications without a doctor’s involvement, a major shift that could help improve consumers’ access to care. The law that makes this possible passed after five years of legislative debate. Nurse practitioners are fighting in other states for more authority to treat patients at a time of rising concern over the impact of the federal health law. As more Americans get insurance, there may be shortages of primary care doctors, especially in states like Kentucky that have many rural areas (Gillespie, 7/14).

The Boston Globe: Walsh Announces Plan To Aid Alzheimer’s Victims
Alzheimer’s disease is a personal issue for Martin J. Walsh. The Boston mayor remembers his grandmother reverting to childlike behaviors when her children implored her to remember them. She did not recognize her children, or her grandchildren, or any of the family members who surrounded her in her home in Ireland in the last years of her life. Walsh talked about his late grandmother, Mary Ann O’Malley, when he announced an Alzheimer’s initiative Friday that will make Boston the first major city to join the Alzheimer’s Workplace Alliance. The national group has nearly 2,000 companies and organizations that support employees with information on Alzheimer’s (Abutaleb, 7/11).

Texas Tribune: Women Wants State’s Help In Pelvic Mesh Fight
When Aaron Leigh Horton’s mother received a plastic mesh implant in 2009 to repair her pelvic organ prolapse, a type of pelvic floor disorder, she expected her pain to recede. Instead, she faced complication after complication — resulting in a surgical implant removal that her daughter says left her bedridden. Horton, who founded the Mesh Warrior Foundation, is among the thousands of women across the country who are engaged in lawsuits against manufacturers of pelvic mesh implants after suffering severe complications, including extreme pain, bleeding and infections.  In Texas, a coalition of “pelvic mesh survivors” has asked Texas Attorney General Greg Abbott, who is also the state’s Republican nominee for governor, to pursue legal action against Johnson & Johnson, one of the largest implant makers. The women say Johnson & Johnson violated a state law that prohibits deceptive business practices, citing the company’s “knowledge of the inherent danger” of the mesh implants and the cost to Texans of subsidizing care for women treated at taxpayer-funded facilities (Ura, 7/14).

Baltimore Sun: Planned Drug Treatment Clinic In Maryland Sparks Conflict
The developer says his planned center for heroin addicts in a North Baltimore neighborhood would be revolutionary: a primary care facility that would treat all aspects of addict's lives, not just dole out methadone. But Harwood residents see it as more of the same for a community they say is already filled with people bused in for addiction services. More addicts, they say, lead to more public urination, drug use and crime. The issue of how and where to treat Baltimore's population of addicts is always cause for debate, but this one has reached a fever pitch. City Council members Carl Stokes and Mary Pat Clarke have introduced a bill to rezone the area, which could halt the project, at least temporarily. And developer Noah Nordheimer inflamed tempers last week by bringing about 100 protesters to picket a meeting of the Central Baltimore Partnership — paying some of them with $20 bills (Broadwater and Campbell, 7/13).

Baltimore Sun: Group Home For Disabled Children Struggled To Provide Adequate Care
The recent death of a 10-year-old disabled foster child at an Anne Arundel County group home was just the latest in a series of problems at LifeLine, the state contractor that has been paid millions in taxpayer funds to care for "medically fragile" individuals, a two-month investigation by The Baltimore Sun has found. Even before Damaud Martin's death on July 2, LifeLine had struggled for years to provide around-the-clock care for its residents — adults and foster children often confined to a bed or wheelchair by paralysis, cerebral palsy and other disabilities. Its founder, Randall Martin Jr., is imprisoned for felony arson, the state disciplined the company for inadequate care after the death of three adult residents, and it is burdened by tax liens and other debts (Donovan, 7/12).

ProPublica: Why Are Obstetricians Among The Top Billers Of Psychotherapy In Illinois?
A few years ago, Illinois' Medicaid program for the poor noticed some odd trends in its billings for group psychotherapy sessions. Nursing home residents were being taken several times a week to off-site locations, and Medicaid was picking up the tab for both the services and the transportation. And then there was this: The sessions were often being performed by obstetrician/gynecologists, oncologists and urologists — "people who didn't have any training really in psychiatry," Medicaid director Theresa Eagleson recalled. So Medicaid began cracking down, and spending plummeted after new rules were implemented. In July 2012 the program stopped paying for group psychotherapy altogether for residents of nursing homes. Yet Illinois doctors are still billing the federal Medicare program for large numbers of the same services, a ProPublica analysis of federal data shows (Ornstein, 7/13).

The Associated Press: Ohio Rural Hospitals Face Financial Woes
Rural hospitals across Ohio face financial straits worse than their urban counterparts as expenses rise and health care reimbursements decline. A January snapshot by iVantage Health Analytics found hospitals in the state's metropolitan counties were running slightly in the black, while those in non-metro counties — often the largest employers — showed narrow losses, The Columbus Dispatch reported Sunday. Four years ago, struggling hospitals in Washington Court House and Logan closed their maternity units. More recently, hospitals in Chillicothe and Zanesville saw their bond ratings downgraded (7/13).

Tampa Bay Times: The Buzz: Gov. Scott Vetoed Money To Fight Health Care Fraud
Gov. Rick Scott, who will spend the next few months fending off familiar criticism of the health care fraud at his former hospital company, had a chance to put more money into fighting health care fraud in Florida. But to the disappointment of a key Republican lawmaker, he said no. One of Scott's little-noticed line-item vetoes in the new $77 billion budget would have set aside more money to investigate fraud in the Medicaid program. Scott gave no reason for the veto at the time he signed the budget (Bousquet and Leary, 7/12). 

Categories: Health Care

Dozens Of Religious Groups Refuse To Sign Contraceptive Opt-Out Form

Kaiser Health News - Mon, 07/14/2014 - 9:40am

The two-page form, designed to accommodate religious beliefs, is regarded as an untenable compromise by some religious employers, reports The New York Times. Meanwhile, GOP governors see little fallout from the Supreme Court's contraceptive coverage decision and a poll shows growing Republican support for the court.

The New York Times: A Two-Page Form Spawns A Contraceptive Showdown
A two-page federal form has provoked a titanic clash between the government and many religious organizations. The form allows some religious organizations to opt out of providing contraceptive coverage, which many insurers and group health plans are required to provide under the Affordable Care Act and related rules. The opt-out sounds like a way to accommodate religious beliefs. But many religious employers like Wheaton College and the Little Sisters of the Poor are unwilling to sign the form. By signing it, they say, they would authorize their insurers or plan administrators to pay for contraceptives, including some that they believe may cause abortion (Pear, 7/12).

Politico: GOP Governors See Scant Hobby Lobby Political Fallout
Democrats see the Supreme Court decision of limiting birth control coverage in some employee health plans as galvanizing voters for November, but Republican governors say the Hobby Lobby case is barely a blip, let alone a reprise of the “war on women.” Republicans interviewed at the National Governors Association summer meeting here this weekend described the high court ruling exempting some religious owners of for-profit businesses from the Obamacare contraceptive coverage requirement as a welcome brake on President Barack Obama and his intrusive health law. And they didn’t see it causing problems (Cheney, 7/13). 

Politico: Poll: Most GOP Approve Of SCOTUS
Republican support for the Supreme Court has increased 21 percent since last September, a new poll says. According to a Gallup poll released Monday, 47 percent of Americans approve of the high court, compared with 46 percent who disapprove, nearly identical results to last September. … Democrats have had a relatively high approval rating of the court since 2012, when the Supreme Court preserved the Affordable Care Act’s individual mandate and largely upheld President Barack Obama’s health care law as constitutional. Sixty-eight percent of Democrats reported approving of the court then. In its most recent term, the court delivered several landmark conservative decisions. In Burwell v. Hobby Lobby, the court ruled 5-4 that for-profit corporations could decline to pay for contraceptive coverage under the ACA, citing religious opposition (Topaz, 7/14). 

Categories: Health Care

CDC Closes Labs After Anthrax, Flu Accidents

Kaiser Health News - Mon, 07/14/2014 - 9:40am

Federal government labs in Atlanta were temporarily shut after it was discovered they had improperly sent potentially deadly pathogens, including anthrax, botulism and virulent bird flue virus, to other labs.

The Washington Post: CDC Says It Improperly Sent Dangerous Pathogens In Five Incidents In Past Decade
Federal government laboratories in Atlanta improperly sent potentially deadly pathogens, including anthrax, botulism bacteria and a virulent bird flu virus, to other laboratories in five separate incidents over the past decade, officials said Friday (Sun and Dennis, 7/11).

The New York Times: CDC Closes Anthrax And Flu Labs After Accidents
After potentially serious back-to-back laboratory accidents, federal health officials announced Friday that they had temporarily closed the flu and anthrax laboratories at the Centers for Disease Control and Prevention in Atlanta and halted shipments of all infectious agents from the agency’s highest-security labs. The accidents, and the CDC’s emphatic response to them, could have important consequences for the many laboratories that store high-risk agents and the few that, even more controversially, specialize in making them more dangerous for research purposes (McNeil, 7/11).

The Wall Street Journal: CDC Closes Labs After Accidents With Flu, Anthrax Samples
CDC Director Tom Frieden on Friday said a lab that works regularly with flu viruses at the agency had accidentally cross-contaminated a low-pathogenic H9N2 virus sample with a strain of H5N1 flu, one of the most deadly viruses known. The sample was then shipped to a lab at the U.S. Department of Agriculture, which discovered the contamination, he said. Dr. Frieden said he found the flu lab incident particularly distressing because it happened six weeks ago, yet he learned about it only this week (McKay, 7/11).

Categories: Health Care

Viewpoints: Hasty Congressional Response To Hobby Lobby; Medicaid 'Charade' In Va.; Brain Science Problems

Kaiser Health News - Mon, 07/14/2014 - 9:40am

Los Angeles Times: Some (Considered) Fixes To The Religious Freedom Restoration Act
When the Supreme Court unwisely ruled that some companies can decline on religious grounds to cover contraceptives in their employee health plans, it was interpreting not the 1st Amendment but a federal statute, the Religious Freedom Restoration Act. That means Congress has the authority to revisit and change the 1993 law. It can and should do so, not just to overrule the court's decision as it affects healthcare for women but also to address other possible consequences of the majority's expansive holding that for-profit corporations are "persons" that can raise religious objections to complying with a host of laws. But haste in responding to the decision makes waste, as is evident in the incomplete proposal unveiled last week by Sens. Patty Murray (D-Wash.) and Mark Udall (D-Colo.) (7/13).

Los Angeles Times: The Supreme Court And The Flow Of History
The case that raises the thorniest questions over the court's standing among the public and in the flow of history is the Hobby Lobby case, in which owners of family companies claimed their religious freedom was infringed by a federal law requiring that the health insurance plans they provide to employees include contraception. It's unclear whether the decision places the court truly at odds with public sentiment. In part that's because the breadth of the decision is still unclear, even though Justice Ruth Bader Ginsburg, in her dissent, warned that it would lead the court "into a minefield" of differing religious claims (Michael Hiltzik, 7/12). 

Reuters: What's The 2014 Election Really About? Religious Vs. Women’s Rights
Religious rights versus women’s rights. That’s about as fundamental a clash as you can get in U.S. politics. It’s now at the core of the 2014 election campaign, with both parties girding for battle. What generated the showdown was last week’s U.S. Supreme Court decision in the Hobby Lobby case. The decision instantly became a rallying cry for activists on both the right and left. Congressional Democrats are already proposing a law to nullify the decision (Bill Schneider, 7/10).

Journal of The American Medical Association: The ACA's Contraceptive Mandate
Hobby Lobby does not undermine the core components of the ACA such as affordable access to services. The decision, however, does potentially affect women's reproductive health and could signal a "chipping away" at the margins of this historic health care entitlement. Beyond the ACA, the case solidifies a growing trend in Supreme Court jurisprudence defending corporate personhood, which is becoming a major impediment to public health regulation (Lawrence O. Gostin, 7/11).

The Wall Street Journal: A Republican Victory On The Front Lines Of ObamaCare
The biggest ObamaCare fight in the country is ruffling the politics of Virginia. The issue is whether the state should expand Medicaid to 400,000 more Virginians, as President Obama's health-care law prescribes. Gov. Terry McAuliffe, the pal of the Clintons and a former Democratic National Committee chairman, is committed to expansion; Republican House Speaker Bill Howell is opposed. Though the struggle is far from over, Mr. Howell has the upper hand, and Mr. McAuliffe is increasingly exasperated. He's been outsmarted at every turn by Mr. Howell, whose maneuvers should be a lesson for foes of enlarging Medicaid in other states where it's still an issue (Fred Barnes, 7/11).

The Washington Post: The Virginia GOP's Medicaid Charade
Having handed Gov. Terry McAuliffe (D) a stinging defeat by refusing to extend Medicaid coverage under Obamacare to as many as 400,000 low-income Virginians, Republican leaders in Richmond now say they intend to convene the legislature in September to conduct a "full and fair" discussion of the question — which they have already decided. By transforming the General Assembly into a stage for Kabuki theater, the GOP leaders have called attention to their glaring failure to propose any alternative to expanding Medicaid (7/11).

The Wall Street Journal: Why States Are Hesitating To Expand Medicaid
The Pew Trusts also released a data compilation last week. But that one showed why many states, which had large and growing Medicaid programs even before Obamacare, have not rushed to embrace greater expansion. Pew examined data from 2000 to 2012 and found large increases in state Medicaid spending even after adjusting for inflation. Nationally, Medicaid spending grew an average of 4% more than inflation every year during this period. All but two state Medicaid programs grew at real (inflation-adjusted) rates greater than 2% annually. In addition, programs in eight states and the District of Columbia grew at rates exceeding 5.9% per year–meaning that spending doubled during the 12-year period, even after accounting for inflation (Chris Jacobs, 7/11). 

The Tennessean: Medicaid Expansion Is The Conservative Choice
The Tennessean's Tom Wilemon did a superb job this past week illustrating the human costs that our obstinate legislature and Gov. Bill Haslam force on folks instead of dealing forthrightly with the issues around an expansion of TennCare to include 162,000 uninsured Tennesseans eligible for coverage under the revised Medicaid rules established by the Patient Protection and Affordable Care Act passed by Congress in 2010. Yes, the ACA is flawed legislation, but when repeated Republican efforts to repeal the law failed before its implementation in January, intransigence by state legislators made bad business sense (Frank Daniels III, 7/13).

The Washington Post: The Real Medicaid Problem
The White House recently put out a 40-page report arguing that the 24 states that have not expanded Medicaid coverage under the Affordable Care Act (ACA or "Obamacare") are hurting their poor and themselves. It’s an easy case to make, but it’s incomplete and misleading. The further truth is that Medicaid also threatens to crowd out spending for many traditional state and local functions: schools, police, roads, libraries and more (Robert J. Samuelson, 7/13). 

The New York Times: Obamacare Fails To Fail
How many Americans know how health reform is going? For that matter, how many people in the news media are following the positive developments? I suspect that the answer to the first question is "Not many," while the answer to the second is "Possibly even fewer," for reasons I'll get to later. And if I'm right, it's a remarkable thing — an immense policy success is improving the lives of millions of Americans, but it's largely slipping under the radar (Paul Krugman, 7/13). 

In other health care issues-

The New York Times: An Inadequate Response To Concussions
The National Collegiate Athletic Association, which is currently embroiled in a lawsuit over its ostrichlike response to concussions, released new voluntary guidelines on Monday for concussion safety. But these won't necessarily fix the problem. ... A larger issue is that the guidelines provide no mechanism for oversight or enforcement. Experience has shown that it is dangerous to rely on individual athletic programs to police themselves (7/11). 

The New York Times: The Trouble With Brain Science
[H]undreds of neuroscientists from all over the world issued an indignant open letter to the European Commission, which is funding the Human Brain Project, an approximately $1.6 billion effort that aims to build a complete computer simulation of the human brain. The letter charges that the project is "overly narrow" in approach and not "well conceived." While no neuroscientist doubts that a faithful-to-life brain simulation would ultimately be tremendously useful, some have called the project "radically premature." The controversy serves as a reminder that we scientists are not only far from a comprehensive explanation of how the brain works; we're also not even in agreement about the best way to study it, or what questions we should be asking (Gary Marcus, 7/11).

The Wall Street Journal: The Corruption Of Peer Review Is Harming Scientific Credibility
Academic publishing was rocked by the news on July 8 that a company called Sage Publications is retracting 60 papers from its Journal of Vibration and Control, about the science of acoustics. The company said a researcher in Taiwan and others had exploited peer review so that certain papers were sure to get a positive review for placement in the journal. ... Acoustics is an important field. But in biomedicine faulty research and a dubious peer-review process can have life-or-death consequences. In June, Dr. Francis Collins, director of the National Institutes of Health and responsible for $30 billion in annual government-funded research, held a meeting to discuss ways to ensure that more published scientific studies and results are accurate (Hank Campbell, 7/13). 

The Boston Globe: How Should Lawmakers Decide What Deserves Mandatory Coverage?
Governor Patrick’s move last month to require health insurers to cover gender reassignment surgery revived a perennial flash point: For health insurers and the employers who pay most premiums, opting not to cover some services makes insurance cheaper. But for people with expensive medical conditions, these decisions often seem arbitrary or unjust. Over the years, lawmakers have wrestled with requiring insurers to pay for treatments for a variety of conditions, from infertility to tobacco addiction to gender dysphoria. So which criteria should be used in the decision-making process? (7/13).

Categories: Health Care

Political Cartoon: 'Prescribed Viewing?'

Kaiser Health News - Mon, 07/14/2014 - 9:39am

Kaiser Health News provides a fresh take on health policy developments with "Prescribed Viewing?" by Chris Wildt.

Meanwhile, here's today's haiku:

A ISSUE OF PAIN MANAGEMENT

No analgesic
is enough to dull the pain
for Argentine fans
-Anonymous

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

Categories: Health Care

Kentucky Law Gives Nurse Practitioners More Flexibility

Kaiser Health News - Mon, 07/14/2014 - 7:35am

Starting July 15, nurse practitioners in Kentucky who have completed a four-year collaboration with a physician will be allowed to prescribe routine medications without a doctor’s involvement, a major shift that could help improve consumers’ access to care.

The law that makes this possible passed after five years of legislative debate. Nurse practitioners are fighting in other states for more authority to treat patients at a time of rising concern over the impact of the federal health law. As more Americans get insurance, there may be shortages of primary care doctors, especially in states like Kentucky that have many rural areas.

Kentucky’s action offers a possible compromise for states trying to define the roles of nurse practitioners while assuaging the concerns of doctors.  But some experts question whether this approach will provide a model for others.

For nearly two decades, nurse practitioners in the state have been able to prescribe drugs such as antibiotics and blood pressure medicine only if they had a collaborative agreement with a doctor, who can charge a fee for it. But if the doctor pulled out of the agreement, the nurse practitioners were forced to find other physicians or limit their practices by not prescribing. Most practices cannot survive doing only diagnostic tests and physicals, according to Beth Partin, vice president at the Kentucky Coalition of Nurse Practitioners & Nurse Midwives.

The new law, passed earlier this year, offers experienced NPs much more flexibility and sets up a framework to help those without four years of collaboration find a physician willing to oversee their work.

State Sen. Paul Hornback, a Republican who was the main sponsor of the bill, said the four-year rule seemed appropriate because it somewhat mimicked the concept of a medical residency period. “I didn’t think it was correct for a NP to come directly out of school and open their own practice,” he said. The real problem, he added, was finding physicians willing to collaborate.

The law sets up a six-member committee to create a list of doctors willing to enter into these agreements. If the nurse practitioner can’t find someone from the list within 30 days, the committee must furnish a physician. After four years, NPs no longer need an agreement to prescribe most medications.

Certain drugs, such as Adderall, oxycodone, testosterone, Ambien and cough syrup with codeine, still require a collaborative agreement. Of the 5,410 nurse practitioners in the state, 1,948 have an agreement to prescribe these more restrictive drugs, according to the Kentucky Board of Nursing.

Having this framework in place would have made a big difference for Brenda Pittman, a nurse practitioner in Mt. Sterling, Ky. One doctor withdrew from an agreement with her in June 2013, then another did so last March. In both cases, the doctors’ practices were bought by large hospital systems that did not permit them to continue the agreements.

“I called a dozen doctors,” Pittman said, recalling her frantic scramble after the agreements ended. Both times, she came up empty and had to close her practice for four days, losing an estimated $12,000. “This ate away at my budget and many patients complained that they could not be seen, could not get their refills,” said Pittman, who under the new law will no longer be required to be associated with a collaborating physician to prescribe most drugs. 

Rules Vary Among States

Nurse practitioners, who have at least a graduate-level education, have long argued that when it comes to primary care, pediatric care and women’s health, they are qualified to treat chronic illness and provide preventive services without a physician’s oversight. On the other side are those who say these health professionals do not have the hands-on experience or academic training to provide the same quality of care as doctors, who undergo years of training and residency.

“The concern is that you don’t know what you don’t know,” said Robert McLean, an internist in New Haven, Conn., where a 2014 state law requires nurse practitioners to spend 2,000 hours in a collaborative agreement with a physician before practicing independently. “There are plenty of nurse practitioners delivering good services, but if you make a law allowing them to be independent even if they’re not experienced, how many patients will get less-than-ideal care?”

Currently, 19 states require that NPs have a collaborative arrangement for the entirety of their careers, and 12 others require supervision or team management with a physician, with those nurses prescribing through the doctors, according to the American Association of Nurse Practitioners (AANP). Collaborative agreements, which are made official with forms signed by the NP and the doctor, can vary widely. Kentucky, for instance, has never required physicians to review the NPs’ prescribing patterns or to meet with them regularly, but some states do.

The remaining 19 states and the District of Columbia allow nurse practitioners to practice independently of a physician. Of those, five states in addition to Connecticut -- Minnesota, Vermont, Nevada, Maine and Colorado -- require NPs to spend a set time in an arrangement with a doctor before they gain independent prescribing rights.

Sheila Schuster, a lobbyist for the nurse practitioners and midwives coalition, said replacing the career-long requirement with the four-year collaborative arrangement “is a significant step forward in affirming the independent practice.”

“Kentucky will face a large influx of Medicaid beneficiaries [under the health law], and right now there are not enough physicians to go around,” said Dr. Nancy Swikert, vice chair of the Kentucky Medical Association Alliance Foundation. “We’re hoping rural physicians might be able to find NPs and were hoping NPs will find physicians to help them. We hope it’s win-win.”

A Model For Other States?

Nationally, however, stakeholders have doubts about whether this approach is indeed an innovative compromise. “Making it easier for someone to achieve an unnecessary burden to meet the requirements doesn’t negate the fact that it’s a burden,” said Tay Kopanos, AANP vice president for state government affairs. She said the collaborative agreement for controlled drugs, which are deemed more dangerous and addictive by the government, is a huge barrier.

Kopanos and other advocates point to a 2006 Colorado law that mandates that, for the first 1,800 hours of practice, a newly graduated NP must get a physician to sign off on all prescriptions. Then, they must complete another 1,800 hours in a formal mentorship agreement with a doctor who has to review their prescribing patterns.

That measure also set up the Nurse Physician Advisory Taskforce for Colorado Healthcare, Kopanos said. Though it does not have the same mandate as Kentucky’s committee, she and others had hoped it would aid NPs in finding physicians, but has thus far been a disappointment.

“The hope and the promise … didn’t materialize. So when I see other state legislatures making similar compromises … it’s hard to … anticipate a different outcome,” Kopanos said.

Meanwhile, Joanne Spetz, a professor of health policy studies at the University of California, San Francisco, who specializes in workforce issues, says the success of Kentucky’s law will depend on whether the new committee can bring about the necessary level of cooperation.

“Their main role will be to help ensure there are enough physicians available to collaborate while NPs develop their knowledge about prescribing and gain the confidence of the provider community,” she said. It’s possible the panel “won't have sufficient resources to do this work effectively” or will be “stymied by other political issues,” she added.   

Categories: Health Care

First Edition: July 14, 2014

Kaiser Health News - Mon, 07/14/2014 - 7:07am

Today's headlines include coverage of Medicare, the health law and veterans' care policy issues as well as reports from the campaign trail.   

Kaiser Health News: Veterans' Needs 'Should Drive Where They Get Their Care'
Kaiser Health News staff writer Mary Agnes Carey reports: “On Capitol Hill, lawmakers resume work this week to resolve differences over legislation aimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times. Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.” Carey recent spoke with Dr. Kenneth Kizer, a former VA undersecretary for health, about the issue of the VA contracting with outside providers for medical care (Carey, 7/13). Read the edited transcript of that interview

The New York Times: A Two-Page Form Spawns A Contraceptive Showdown
A two-page federal form has provoked a titanic clash between the government and many religious organizations. The form allows some religious organizations to opt out of providing contraceptive coverage, which many insurers and group health plans are required to provide under the Affordable Care Act and related rules. The opt-out sounds like a way to accommodate religious beliefs. But many religious employers like Wheaton College and the Little Sisters of the Poor are unwilling to sign the form. By signing it, they say, they would authorize their insurers or plan administrators to pay for contraceptives, including some that they believe may cause abortion (Pear, 7/12).

Politico: Electronic Health Records Ripe For Theft
America’s medical records systems are flirting with disaster, say the experts who monitor crime in cyberspace. A hack that exposes the medical and financial records of hundreds of thousands of patients is coming, they say — it’s only a matter of when. As health data become increasingly digital and the use of electronic health records booms, thieves see patient records in a vulnerable health care system as attractive bait, according to experts interviewed by POLITICO. On the black market, a full identity profile contained in a single record can bring as much as $500 (Pittman, 7/13). 

USA Today: Hospitals, Regulators Spar Over In-Patient Care Policy
Fewer patients linger for days in hospitals without being admitted because of a new federal rule, but hospital and consumer groups are suing the government because they say the policy compromises Medicare patients' care, and patients are often stuck with costly, unexpected bills. Doctors now have to certify that a patient has a serious enough condition to need at least two overnight stays for Medicare to cover an inpatient admission under the rule, which took effect in October. However, patients can remain in an outpatient or "observation" status — that can even include staying overnight for several nights in a typical hospital room — even though they haven't been formally admitted as an inpatient (O'Donnell, 7/13).

NPR/ProPublica: How A Fanny Pack Mix-Up Revealed A Medicare Drug Scam
But no one in Medicare bothered to ask her about the seemingly huge change in her practice, Ortiz-Butcher's attorney said. She stumbled across a sign of trouble last September, after asking a staffer to mail a fanny pack to her brother. Instead of receiving the pack, he received a package of prescriptions purportedly signed by the doctor, lawyer Robert Mayer said last year. Ortiz-Butcher immediately alerted authorities. Since then, investigators have uncovered a web of interrelated scams that, together, cost the federal government up to $7 million, documents show (Ornstein, 7/11).

Politico: Momentum Grows For Sex Reassignment Surgery Coverage
Medicare’s recent decision to cover sex-reassignment surgery was a victory for transgender advocates seeking broader access to medical care for a condition that still carries social stigma. After all, the federal health program was one of the first to exclude such treatments more than 30 years ago (Wheaton, 7/13).

The New York Times: Republicans Replay 2010 Strategy At State Level
Four years after an economic crisis and opposition to Mr. Obama’s health care law propelled Republicans to capture a lopsided majority of statehouses across the country, they are faced with a staggering political task: defending 22 of the 36 executive mansions that will be up for grabs in November, led by a governor who is trying to rebound from a scandal. While the sheer scale of Republican gains four years ago offers Democrats a wealth of opportunities to win, the political environment appears to be tilting again in the Republicans’ direction (Martin and Confessore, 7/12).

The Washington Post: A Kentucky Shootout Over Stale Medicare Claims
The Democrats’ $6,000 figure is outdated and discredited (note the small type in the ad with citations from 2011). It’s worthy of Four Pinocchios. The Republicans’ $700 billion is a stretch, but at least it’s based on real numbers — and The Washington Post has reported that the reductions in spending for Medicare Advantage have led to thousands of doctors being terminated from the program. We have been monitoring the impact of the cuts but have generally awarded this claim Two Pinocchios (Kessler, 7/11).

The Associated Press: Biden Calls On Governors To Lead Nation
The vice president’s comments came during the first day of the governors’ three-day conference in Nashville, where state leaders from both parties gathered to collaborate despite intensifying partisan differences on immigration, health care and education (7/11). 

Politico: GOP Governors See Scant Hobby Lobby Political Fallout
Democrats see the Supreme Court decision of limiting birth control coverage in some employee health plans as galvanizing voters for November, but Republican governors say the Hobby Lobby case is barely a blip, let alone a reprise of the “war on women.” Republicans interviewed at the National Governors Association summer meeting here this weekend described the high court ruling exempting some religious owners of for-profit businesses from the Obamacare contraceptive coverage requirement as a welcome brake on President Barack Obama and his intrusive health law. And they didn’t see it causing problems (Cheney, 7/13). 

Politico: Poll: Most GOP Approve Of SCOTUS
Republican support for the Supreme Court has increased 21 percent since last September, a new poll says. According to a Gallup poll released Monday, 47 percent of Americans approve of the high court, compared with 46 percent who disapprove, nearly identical results to last September. … Democrats have had a relatively high approval rating of the court since 2012, when the Supreme Court preserved the Affordable Care Act’s individual mandate and largely upheld President Barack Obama’s health care law as constitutional. Sixty-eight percent of Democrats reported approving of the court then. In its most recent term, the court delivered several landmark conservative decisions. In Burwell v. Hobby Lobby, the court ruled 5-4 that for-profit corporations could decline to pay for contraceptive coverage under the ACA, citing religious opposition (Topaz, 7/14). 

The Washington Post: VA Overhauling Medical Inspector’s Office After Scathing Report
The Veterans Affairs Department is overhauling its medical inspector’s office after a federal investigative agency slammed the division for its frequent use of the “harmless error” defense when problems occur within the VA health network. The agency this week appointed a new acting director for the medical inspector’s office and decommissioned the division’s hotline and its Web site: Individuals are now redirected to file concerns about the medical system with the VA’s inspector general (Hicks, 7/11).

Los Angeles Times: With U.S. Encouragement, VA Disability Claims Rise Sharply
With the government encouraging veterans to apply, enrollment in the system climbed from 2.3 million to 3.7 million over the last 12 years. The growth comes even as the deaths of older former service members have sharply reduced the veteran population. Annual disability payments have more than doubled to $49 billion — nearly as much as the VA spends on medical care. More than 875,000 Afghanistan and Iraq war veterans have joined the disability rolls so far (Zarembo, 7/12).

USA Today: Report Cites VA Struggles With Benefits Paid To Veterans
The federal department responsible for caring for America's veterans, already mired in scandal over delays in health care, continues struggling with another major responsibility: paying compensation to those wounded or injured or who grew ill from service in uniform. While the VA managed last year to reduce a huge backlog in veteran claims for money, it was at the expense of appeals to those decision which are rapidly mounting, according to testimony slated for Monday by the VA Office of Inspector General (Zoroya, 7/14). 

The Associated Press: Lawmakers Seek Lower Price For Bill On Vets’ Care
Stung by sticker shock, members of Congress are scrambling to lower the cost of a bill to fix veterans’ health care amid a growing uproar over long waits for appointments and falsification of records to cover up the delays at Veterans Affairs hospitals. At the same time, deficit hawks fear that letting veterans turn more to providers outside the VA for health care could cost far more if Congress, under pressure from powerful veterans groups, decides to renew that program rather than let it expire in two years (7/11).

The Wall Street Journal: Congressional Inaction Threatens Program For Brain-Damaged Vets
The Department of Veterans Affairs has begun ousting dozens of brain-damaged veterans from special therapeutic group homes, setting off a scramble for housing and care. In recent weeks, VA case workers have warned 53 veterans they'll have to leave the privately run homes by Sept. 15, according to the agency. Ten have already been discharged from the care facilities and sent to nursing homes, state veterans homes or to live with family members (Phillips, 7/11).

NPR: Veterans Kick The Prescription Pill Habit, Against Doctors' Orders 
Troops coming home from war, like Will, are often prescribed drugs for PTSD and other conditions. Hundreds of thousands of veterans are on opiates for pain, and 1 in 3 veterans polled say they are on 10 different medications. While there is concern about overmedicating and self-medicating — using alcohol or drugs without a doctor's approval — there are also some veterans who are trying to do the opposite: They're kicking the drugs, against doctor's orders (Lawrence, 7/11).

The Wall Street Journal: Senate Committee Is Investigating Pricing Of Hepatitis C Drug
The U.S. Senate Finance Committee launched an investigation into Gilead Sciences Inc. 's high pricing of the hepatitis C drug Sovaldi, adding its voice to a chorus of criticism accompanying the highest-grossing drug launch in history. Sen. Charles Grassley, a longtime industry watchdog and member of the committee, and the panel's chairman, Sen. Ron Wyden, sent a letter to Gilead Chief Executive John Martin on Friday announcing the probe and requesting a wide range of documents on how the Foster City, Calif., company decided on the price. Sovaldi costs about $1,000 a pill, or about $84,000 for a patient on a standard, 12-week regimen (Loftus, 7/11).

Los Angeles Times: U.S. Senators Ask Gilead Sciences To Explain High Cost Of Hepatitis C Drug
Pharmasset, the drug's original developer, priced the treatment at $36,000, the senators wrote, citing documents filed with the Securities and Exchange Commission. Gilead acquired Pharmasset in 2012 for $11 billion. Sovaldi sales could hit around $8 billion this year, analysts estimated, which would make it one of the top-selling pharmaceutical drugs worldwide (Khouri, 7/11).

The Washington Post: CDC Says It Improperly Sent Dangerous Pathogens In Five Incidents In Past Decade
Federal government laboratories in Atlanta improperly sent potentially deadly pathogens, including anthrax, botulism bacteria and a virulent bird flu virus, to other laboratories in five separate incidents over the past decade, officials said Friday (Sun and Dennis, 7/11).

The New York Times: CDC. Closes Anthrax And Flu Labs After Accidents
After potentially serious back-to-back laboratory accidents, federal health officials announced Friday that they had temporarily closed the flu and anthrax laboratories at the Centers for Disease Control and Prevention in Atlanta and halted shipments of all infectious agents from the agency’s highest-security labs. The accidents, and the C.D.C.’s emphatic response to them, could have important consequences for the many laboratories that store high-risk agents and the few that, even more controversially, specialize in making them more dangerous for research purposes (McNeil, 7/11).

The Wall Street Journal: CDC Closes Labs After Accidents With Flu, Anthrax Samples
CDC Director Tom Frieden on Friday said a lab that works regularly with flu viruses at the agency had accidentally cross-contaminated a low-pathogenic H9N2 virus sample with a strain of H5N1 flu, one of the most deadly viruses known. The sample was then shipped to a lab at the U.S. Department of Agriculture, which discovered the contamination, he said. Dr. Frieden said he found the flu lab incident particularly distressing because it happened six weeks ago, yet he learned about it only this week (McKay, 7/11).

The Wall Street Journal: Truvada, The Drug In Cuomo's AIDS-Eradication Plan, Spurs Debate
A cutting-edge medication that can help prevent HIV in healthy individuals is gaining favor with government officials, including New York Gov. Andrew Cuomo. But in advocating for the drug, sold under the brand name Truvada, officials seeking to curtail HIV/AIDS infections are going up against some surprising opponents: high-profile AIDS activists who say they have serious questions about the drug's cultural and health impacts (Vilensky, 7/13). 

Los Angeles Times: L.A. County Board To Vote On Court-Ordered Mental Health Treatment Law
The Board of Supervisors is expected to vote Tuesday on a proposal that would increase money for outpatient treatment of people with a history of mental illness and expand efforts to identify potential patients. The vote would also set in motion a process that would allow family members, treatment providers and law enforcement officers to seek a court order to make people take part in the program, under which people can be ordered to undergo treatment but can't be forced to take medication (Sewell, 7/13). 

The New York Times: Rikers: Where Mental Illness Meets Brutality In Jail
The study, which the health department refused to release under the state’s Freedom of Information Law, found that over an 11-month period last year, 129 inmates suffered “serious injuries” — ones beyond the capacity of doctors at the jail’s clinics to treat — in altercations with correction department staff members. The report cataloged in exacting detail the severity of injuries suffered by inmates: fractures, wounds requiring stitches, head injuries and the like. But it also explored who the victims were. Most significantly, 77 percent of the seriously injured inmates had received a mental illness diagnosis (Winerip and Schwirtz, 7/14). 

Check out all of Kaiser Health News' e-mail options including First Edition and Breaking News alerts on our Subscriptions page.

Categories: Health Care

Veterans' Needs 'Should Drive Where They Get Their Care'

Kaiser Health News - Mon, 07/14/2014 - 5:08am

On Capitol Hill, lawmakers resume work this week to resolve differences over legislation aimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times.  Five senior VA leaders – including former department secretary Eric Shinseki – have resigned in the past six weeks.

Dr. Kenneth Kizer

Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.

Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outside providers for medical care. Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.

An edited transcript of that interview follows.

Q: Both the House and Senate bills include a provision allowing the VA to contract with non–VA medical providers to ease waiting lists.  What are some of the challenges the VA faces in creating new outside networks of providers. 

A: The challenges in creating new networks are the same that everybody faces. Who are the providers? What are their credentials? Can you find the types of providers that you need? What’s the quality of care? How will the information, the exam reports, the consultation reports, how will that information be fed back into the system?  It’s not unlike some of what you’re seeing being played out right now with the health plans which are competing under the Affordable Care Act provisions for the health insurance exchanges. Regardless of who the payer is, you have the same problems.

There are shortages of primary care physicians and mental health professionals everywhere. The VA has done a good job in bolstering the number of mental health providers that it has. But the mental health system in this country is broken. The system just doesn’t work well, so referring veterans out for mental health services may be problematic for a whole host of reasons.

Q: The VA currently has a program that allows it to contract with outside medical providers to make sure veterans receive timely and accessible care.  How would a new contracting program compare to what is currently being done?

A: That’s going to depend on the specific language [that Congress passes]. The VA currently spends about $5 billion a year on what’s called fee-basis care, basically sending people out for services. The need to send veterans out for services that the VA has difficulty sometimes providing is not a new issue. This has been going on for years. The amount of care that’s being provided outside of the VA has increased dramatically in recent years. 

There was a particular program Congress implemented called Project Hero. The VA contracted with some managed care providers – three providers in four geographic areas – to help ease the waiting list issue. Some of the problems they encountered there were the ones we’re talking about—getting into the [providers’] networks and ensuring [that providers] actually were in the network. Sometimes they have availability. You can get an appointment in a short time but they might be a long distance away. Veterans complain, “Yeah, they can get me in next week but I had to drive 100 miles to get there.” 

In that program there was difficulty getting information back to the VA. The private providers would often dictate their reports, which would have to be sent to the plan, which would then fax a copy and send it to the VA and then that had to be scanned into the electronic health record. Sometimes that might take weeks or more. 

Q: What level of reimbursement is needed to encourage non-VA providers to accept these patients?

A: The complaints you hear from private providers is not so much about the rate the VA pays – those rates are often determined locally -- but it’s the difficulty in getting paid.  It’s the contracting rules and cumbersome mess of the payment process that have been more of a barrier to providers often than the amount of payment per se.  It’s just part of government contracting.  Even if substantial amounts of money are appropriated--which it sounds like they will be--if the contracting mechanisms don’t get more facile, then there’s going to be a lot of frustration. 

Many of these private providers are happy to take care of veterans. They feel an obligation and they’re willing to do it for whatever the payment amount is. But it’s just getting it that is so difficult and frustrating for them.

Q: What can lawmakers do to assure the medical care given to these veterans is the highest quality, the most appropriate, the most efficient care?

A: Other than some general verbiage it’s hard for legislation to put those sorts of provisions into law. Certainly going forward if more care is going to be provided in the private sector, the VA needs to focus on a couple of things.

One is ensuring that the quality of care provided by contractors is as good as what’s provided in the VA, which has been an issue in the past. Because VA on quality performance, by and large, does quite well.  The other problem that needs to be addressed is getting the information back into the system. One of the problems with contracting out is that it is promoting more fragmented care, which is a problem. We know that fragmented care leads to bad things.

We need to focus on what the end game is, which is more rapid access to care, on higher quality care and we want integrated services.

Q: Are there veterans who may be best handled by VA personnel and not sent outside the VA system?

A: Every patient should be looked at, and what their needs are should drive where they get their care.  For many of the complicated patients, if they have amputations, they may have chronic medical conditions, if they have mental health issues, you really want as much of that care being provided within the system so that everyone on the team knows what’s going on. 

Someone may need a colonoscopy or some other procedure where you might be able to contract out if the information gets back into the system in a timely manner and if you’re confident in the quality of that exam.

Q: Both the House and Senate bills would sunset the non-VA care provision in two years. What happens then?

A: The access problems aren’t going to go away in two years. You have a backlog that you need to work through, but access is not a new problem in the VA, nor is it a new problem in any of the government-funded programs or in the private sector.  In some cases, there’s this delusion that access is rapid and speedy in the private sector and that’s not necessarily the case, as anyone who’s tried to get care can tell you.  

Categories: Health Care

If You Find A Tick: Why I Resorted To Mooching Pills To Fight Lyme Disease

CommonHealth (WBUR) - Fri, 07/11/2014 - 11:49am

A March 2002 file photo of a deer tick under a microscope in the entomology lab at the University of Rhode Island in South Kingstown, R.I. (Victoria Arocho/AP)

I’ve never done anything like this before. I’m a good little medical doobie. I’m wary of pills, take them only with prescriptions, and follow the instructions to the letter. But last month, I “borrowed” a friend’s extra 200 milligrams of doxycycline — the onetime antibiotic dose shown to help prevent Lyme disease soon after a prolonged tick bite.

What brought me to that desperate point? A doctor declined to prescribe the pills, even though this is prime Lyme disease season and the patient, my family member, fulfilled every one of mainstream medicine’s requirements for the single dose aimed at preventing Lyme. To wit:

• The tick was a fully engorged deer tick that had been attached for more than 36 hours.

• We sought treatment within three days of removing it.

• The tick came from a Lyme-endemic area.

• And the patient had no medical reason to avoid antibiotics.

The antibiotics I “borrowed” from a generous friend (Carey Goldberg/WBUR)

But still. The doctor argued that the chances of contracting Lyme from the tick were very small, perhaps 1 in 50, and that overuse of antibiotics contributes to the growing problem of drug-resistant bacteria. This is what he would do for his own family member, he said: skip the doxycycline, wait to see if Lyme develops, and treat it with a full 10-day course of antibiotics if it does.

I was frustrated and frankly a bit appalled. WBUR ran a series on Lyme disease in 2012, and I knew that controversy raged around many aspects of the disease, particularly the use of long-term antibiotics to treat long-term symptoms. But I was just trying to follow the widely accepted guidelines written by the Infectious Disease Society of America, to be found in reputable medical venues like UpToDate. And I knew from that same series that Lyme is rife in New England, and so are personal stories of health and lives ruined or seriously harmed.

Still, maybe I was overreacting? I’ve since sought a reality check from three experts, including the lead author of the guidelines. And here’s what I come away with: No, I was not unreasonable in seeking the preventive doxycycline. Arguably, though I hate to admit it, the doctor was not being totally unreasonable in declining it. The guidelines say a doctor “may” prescribe the antibiotic; it’s not a “must.”

In the end, I think, the crux of the question may lie in how you see the doctor’s role: Is it to lay out the risks and benefits and then let the patient choose? Or to impose his or her own best medical judgment on the patient? (You can guess where I come down on that one.) Also, “better safe than sorry” tends to rule when it comes to my loved ones. But what if the risk is small and the benefit uncertain?

A 2102 map of Lyme disease risk, released by the Yale School of Public Health. Massachusetts is high-risk territory. (AP)

I spoke first with Dr. George Abraham, governor of the American College of Physicians for the state of Massachusetts, a practicing primary care physician and infectious disease specialist, and a professor of medicine at UMass Medical School:

He described the preventive use of doxycycline if all the guideline requirements are met as “Good medicine — scientifically based, it is absolutely sound.”

So why might a physician refuse, and is such resistance widespread?

“There might be a minority of physicians who still feel it might be inappropriate for one of two reasons,” he said. “Either concerns of antimicrobial resistance — although a single dose of antimicrobials is very unlikely to breed resistance, so that might be a bit unfounded — or just lack of awareness.”

I confessed my pill-cadging peccadillo and he responded that it is simply not good medicine to use somebody else’s prescription. “But I think the moral of the story is, if the person in question knows that they’re appropriately asking for an agent and don’t get it, I would seek a second opinion, see a different physician, use a local emergency room,” he said. “Most emergency rooms are pretty savvy on this, just because they deal with this on a more frequent basis. Or even ask for a referral to an infectious disease specialist. It should be relatively easy. But the short answer is, there are ample other ways to get the medication.”

I spoke next with Dr. Alfred DeMaria, medical director for the Bureau of Infectious Disease of the Massachusetts Department of Public Health. He listened to my tale and began with the evidence base:

“There’s one published study on which the recommendations are based and that was a study — I think there were 200 to 250 people in each group, where they treated some people with 200 milligrams of doxycycline after tick attachment and others with placebo. And they found for the people who had an engorged tick — not for people who just had the flat tick attached, for people who had the engorged tick, where the estimation was that the tick could have been attached up to 24-to-72 hours — there was a reduced likelihood of Lyme disease developing if they got the 200 milligrams of doxycycline. Of course, there was also a 30 percent adverse reaction in those who got the doxycycline. I think that needs to be incorporated into the decision. But ultimately it’s the only study that has shown that.

It’s generally felt that if it’s an engorged tick, there are two options: One is to treat with 200 milligrams of doxycycline and watch for Lyme disease. Or just watch for evidence of Lyme disease in terms of a rash. That’s sort of what the recommendation is on our website.

I think what happens is, there are competing concerns about drug reactions and about antibiotic resistance which counterweigh the decision to use the  doxycycline, although 200 milligrams of doxycycline is not a lot of antibiotic therapy. But I think sometimes what happens in the community is that people have a tick attachment and no matter how long it’s attached, they wind up on two weeks of doxycycline, which is really not recommended.

The other thing you have to consider is the risk of an individual tick being infected. What’s good there is that we have Dr. Steve Rich at UMass, who’s been testing ticks, and people on Cape Cod who’ve been testing ticks, and infection rates can vary from year to year, from place to place, anywhere from 5 percent to 50 percent of the ticks. What we’ve learned from some people on the Cape is: They collect ticks from the same place every year, and from year to year it can vary from 5 percent to 50 percent. And it can be 5 percent on one side of the road and 50 percent on the other side of the road. It is highly variable.

The worst probable chance is a roughly 50 percent chance the tick is infected, but that also doesn’t mean every tick that’s infected is going to transmit the disease. So it’s a complicated situation, and I can understand a clinician going one way or another.

I think in an ideal situation a clinician would discuss it with a patient and they would make a judgment about how much risk they wanted to take and come to a conclusion that way. Unfortunately, the health care delivery system does not allow a lot of time to do that. But I would understand why a clinician would be resistant to doing it and I can understand why a clinician would want to do it under the circumstances that we recommend considering it.

It truly is a judgment call. I think some people would argue if the chances are only 1 in 10 or 1 in 20 that you’ll get Lyme disease from that tick, you could watch for signs, because early treatment is highly effective, and you could avoid unnecessary antibiotic use. That’s why we sort of say you should consider either option.”

One thing is clear, Dr. DeMaria said: Lyme disease is a huge problem and “this is prime time,” when the young “nymph” ticks are out looking for their “blood meals.” So “the best course of action is to avoid ticks, or do those tick checks.”

For a final word, I spoke with Dr. Gary Wormser, lead author of the IDSA guidelines and chief of infectious disease at New York Medical College. He, too, listened to my tale, and then began with how the team at the Lyme Disease Diagnostic Center at New York Medical College would have reacted:

“If you came to us and said you had the tick bite but didn’t have the tick with you, [then we'd advise] no prophylactic antibiotics. If you had come to us with the tick and we could confirm it was actually a deer tick and it was on you for at least 36 hours, the prophylaxis could be started within 72 hours of tick removal and there were no contraindications to taking doxycycline, we would have offered you the 200 milligrams prophylactically, informing you that it would not necessarily be 100 percent effective and you should still be wary of the possibility of getting Lyme disease and/or other tickborne infections. I don’t know the infection rate of deer ticks where you were, but in our area now 25 percent of the nymphal stage deer ticks are infected.

We have a lot of people who come in here and say they have engorged ticks and then we actually look at the tick, and it isn’t even a tick, or if it’s a tick it’s not a deer tick. We’ve had all kinds of things brought in to us, from scabs to thorns to beetles to pubic lice — you name it, we’ve seen it. And also, the patient’s concept of whether it’s been on for at least 36 hours isn’t very accurate, in our experience.

So it is a little bit tricky. That’s why the IDSA guidelines actually say that routine use of antimicrobial prophylaxis is not recommended, and only under very special circumstances would it be recommended. And so if a person met all those circumstances, we would do it. I think it’s a very interesting question about the long-term implications in terms of antibiotic resistance, which we’re all having to deal with on a day-to-day basis as infectious disease doctors, but in terms of the individual patient with a tick bite, we’re still offering prophylaxis under those very specific circumstances.

Keep in mind that pregnant women and children under 8 aren’t eligible for the doxycycline. And we don’t think it’s 100 percent effective either. So in other words, it would be a little misleading to people at times to believe that it’s 100 percent effective. It isn’t.

Let me give you some statistics you may not be aware of: The fact that you found the deer tick means the odds overall of getting Lyme disease, having done nothing more than finding the tick, are 2.2 percent. If you take doxycycline, the risk of Lyme disease goes from 2.2 percent to 0.8 percent. But the confidence interval — the range of potential possibilities — varies from .02 percent to 2.1 percent. So in other words, it has been shown to be effective but unfortunately the study that was done, which was a pretty large study, wasn’t large enough in terms of numbers of cases of tick bites that were prevented to narrow down the exact efficacy rate. It was 87 percent effective but it could have been as low as 25 percent effective based on pure statistical variation.

So it’s very important to understand the limitations. We know it has some efficacy and we know it’s not like giving a full course of antibiotics. There are data that if you gave patients a 10-day course of antibiotics it would be essentially 100 percent effective. We knew that was being done, but we just didn’t recommend it because, why would you want to treat every tick bite as if the patient actually already had Lyme? The beauty of this [200-milligram dose] was that it’s only a single dose and it has, at least in the study that was done, over 85 percent efficacy. It’s just that we couldn’t be precise, we couldn’t give a precise efficacy rate in what we call the 95 percent confidence interval surrounding the actual efficacy, meaning it could be less effective than that.”

Dr. Wormser confirmed that the preventive doxycycline is a reasonable approach, if you fulfill the requirements. And some more reassurance: Just finding the tick means you’re ahead of the curve.

“There are two ways to look at this,” he said. “One way is to say that if the efficacy study we did was 100 percent accurate, that you have an 87 percent further reduction in the risk of getting Lyme disease. Or you can look at it this way: It’s 2.2 percent risk going down to 0.4 percent or in that range. So if you look at it in those absolute percentages, it doesn’t seem as dramatic.”

I must say, those numbers calmed me down quite a bit. But even a small chance of a frightening possible outcome seems worth trying to head off.

Dr. Wormser understood. “First of all, everything to do with Lyme disease is anxiety-provoking,” he said. “That’s the nature right now of the reputation that this disease seems to have. So that’s one of the reasons we offer this service, in part — not that we think it’s the end of the world if the patient should get a rash at the site of the tick bite, because then we just give them 10 to 14 days of an appropriate antibiotic and everyone gets better. It’s just that given the circumstances — the reputation and implications that people have drawn about this disease, whether they’re accurate or not — it has caused so much anxiety and concern for many people that we’re happy to offer the service of telling them yes, you might benefit from the 200 milligrams.”

Well, if we lived in New York, I’d have been happy to receive that service for my family member.

Readers, what would you do? Say you meet all the requirements, would you want the single dose of antibiotics? How far would you go to get it?

Further Reading:

Categories: Health Care

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