Indiana Gov. Mike Pence is in the spotlight this week as the man Donald Trump has picked to be his running mate. Pence’s decisions about health and health care in Indiana have drawn attention from within and outside the state. His record could be important in November, because Trump doesn’t have a legislative record at all.
Here’s a quick look at the governor’s history in terms of health policy in Indiana.
Pence has always been a vocal opponent of the Affordable Care Act, even after the federal law passed in 2010 and was upheld by the Supreme Court.
But when faced with the choice of whether to expand Medicaid to cover Indiana residents who earn incomes that are 138 percent or below the federal poverty level — a key part of the ACA — Pence made a compromise. He debuted a conservative-friendly version of the expansion, one that requires Medicaid recipients to pay a monthly contribution, based on income, into a health savings account. Recipients who miss a payment can be bumped to a lower level of coverage, or lose it entirely, for six months.This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News. It can be republished for free. (details)
Now, after a year and a half, the Healthy Indiana Plan, or HIP 2.0, has enrolled about 190,000 more people into health coverage.
Caitlin Priest, director of public policy at Covering Kids & Families of Indiana, said the plan has helped many people get health insurance for the first time in their lives.
“It’s really been a wonderful way to move the needle both on health care access and ultimately on long-term health outcomes,” Priest said.
Pence took criticism from the right for accepting a component of Obamacare, but his conservative tweaks to Medicaid have other Republican-led states looking at that model.
Pence drew criticism from local and national infectious disease experts for his response to an urgent health crisis in Indiana. In February 2015, the state reported an outbreak of HIV in Scott County, blamed on opioid addiction and needle sharing.
It got so bad — growing to more than 80 cases in the month after the announcement, and more than 190 to date — that the CDC came to Indiana to investigate, and public health experts began calling for a needle exchange. At the time, syringe exchanges were illegal in the state and Pence was opposed to changing that, at first.
He later signed an emergency declaration allowing Scott County to start a needle exchange program. Rather than legalize such exchanges statewide, Pence signed a bill that forces counties to ask permission to start a needle exchange.
Only a few counties have done it, so far, because the process takes a lot of planning, local support and money, which the state doesn’t provide, said Carrie Lawrence, a researcher with the Rural Center for AIDS/STD Prevention.
“If you’re the health department with only two part-time staff, and a full-time health director, who’s going to do this, and when is it going to happen?” Lawrence said.
Public Health Budgets
The HIV crisis also brought some attention to Indiana’s lack of public health funding in general, Lawrence said.
“I think we are dealing with the consequences of the fact that that we don’t have a strong infrastructure for public health in the state,” she said.
As governor, Pence signed legislation that slashed Indiana’s budget for public health programs, despite the state’s many pressing public health problems. Indiana has a high smoking rate, high obesity rate, and high infant mortality rate. The state is ranked nearly last for both federal and state public health funding. According to Trust for America’s Health, Indiana spends just $12.40 per resident on public health. West Virginia, in contrast, spends more than $220.
As a member of Congress from 2001 to 2013, Pence voted against funding for health programs such as the State Children’s Health Insurance Program and the Prevention and Public Health Fund.
As a congressman, Pence was an early advocate for defunding Planned Parenthood, and this year, women’s health advocates have clashed with him again.
In March, the governor signed a bill that’s been cited as one of the most restrictive in the U.S., barring abortion on the basis of disability, gender or race of the fetus. It also requires women to get an ultrasound at least 18 hours before the procedure and requires that the fetal remains be buried or cremated.
Some Indiana women responded by updating the governor’s office with (sometimes graphic) news on their menstrual cycles by phone and on social media with hashtag #periodsforpence. The social media backlash mirrors #periodsarenotaninsult, which took aim at Donald Trump last year.
The Indiana ACLU brought a lawsuit against the state’s abortion restrictions — and a judge has since blocked portions of that law. “What the state of Indiana has attempted to do here … grossly flies in the face of existing law,” saidACLU attorney Ken Falk.
There are a lot of people suffering from a mental health condition who need therapy. And there are a lot of therapists who want to help them. But both sides believe the insurance companies that are supposed to bring them together are actually keeping them apart.
Insurance companies, for their part, say there’s a shortage of therapists.
But it’s not that simple. Especially in urban areas, there are lots of therapists. They just don’t want to work with the insurance companies.
Take Michael Klein, a psychologist practicing in San Francisco for more than 20 years. He considers it his spiritual calling to help people calm their social anxiety and to help couples stop fighting and build trust.
“With the right kind of support, they blossom,” he said.This story is part of a partnership that includes KQED, NPR and Kaiser Health News. It can be republished for free. (details)
Klein doesn’t accept insurance. In fact, nearly half of therapists in California don’t take insurance, according to a recent survey from the California Association of Marriage and Family Therapists. The same is true of psychiatrists. There are two reasons why, Klein says.
“One, because the reimbursement rates don’t provide a living wage,” Klein said. “You can’t own a home and drive a car and survive on what in-network providers pay you.”
Most insurance companies pay therapists in their networks between $60 and $80 per session. In the San Francisco area and Los Angeles, therapists say the market rate for therapy is more like $150 to $200 a session.
“The second thing is the paperwork. For an hour of psychotherapy you spend a half-hour on paperwork,” Klein said. “I got into this field because I don’t like paperwork,” he said, laughing.
On that first point — money — insurance companies acknowledge that they may have to raise their rates to attract more therapists, particularly in rural areas. But they also say it’s on therapists to compromise.
“I think it’s unrealistic to expect either the state of California taxpayers or for health plans to just pay providers whatever they ask to be paid,” said Charles Bacchi, CEO of the California Association of Health Plans, a trade group for the insurance industry.
“That’s not sustainable,” he continued. “So you’re either in the system, and you want to be part of our health care system. Or you want to do concierge service outside of it and just pretend our health care system doesn’t exist. That’s your choice as a provider. Our job is to find providers that are willing to be part of the solution and willing to provide coverage to those of low and moderate income.”
That’s exactly how San Francisco psychologist Jonathan Horowitz feels. He wants to take insurance, but he has hit roadblock after roadblock. He sent out 10 applications to insurance companies and got nowhere.
“I might knock on Cigna’s door and say, ‘Hey, are you guys accepting any new therapists in 94105?’ ” he said, referring to his ZIP code. “And they might say, ‘No, we’re not doing that. We’re totally full.’ ”More KHN Coverage
The Business of Therapy
Six different companies told Horowitz their networks were full.
So even though a patient might call seven therapists in her insurance network and not be able to get an appointment, insurance companies are telling new and willing therapists that there’s no demand for them.
“I definitely think it’s to control costs,” Horowitz said. “That’s very clear.”
He says he tried for a year, and one company finally said yes. Sort of. Horowitz never got a formal notice saying his clinic was admitted to the network.
“It was just like, ‘Oh wait, it looks like we’re suddenly getting a couple referrals from them. I wonder if we’re in their directory,’ ” he explained.
They were. Sort of. The clinic was listed in the directory. But the therapists who work at the clinic weren’t approved yet, meaning there was no one who was allowed to see the clients calling the clinic.
So Horowitz tried to call the insurance company to clear things up. He tried many, many times. I sat with him during a recent attempt to navigate the automated phone system:
Insurance company automated attendant: First I’ll need your provider identification number. If you need a moment, say, hold on.
Horowitz: Hold on.
Sound familiar? Turns out therapists get the automated run around as much as patients do. Horowitz persevered.
Insurance company: OK, please say or enter your PIN.
Horowitz: My PIN? Is this my PIN?
He enters a few numbers.
Insurance company: I’m sorry I couldn’t find an account using the info you gave me. Do you already belong to the network?
Horowitz: I think so?
Insurance company: Sorry, yes or no.
Horowitz: Um, I don’t know … yes?
Insurance company: All right. And have you already requested a credentialing application?
Insurance company: Sorry, could you repeat that?
These experiences didn’t bode well. “Honestly, I got a really bad feeling about it,” he said.
Horowitz figured, if this is what it’s like just finding out if he’s in the network, how’s it going to be when he has a problem with a claim?
“I could just see that getting out of hand really quickly,” he said. “So at that point we just said, do we really even want to do this?”
Furthermore, he says, the reimbursement rate was even lower than he expected, and the billing was so complicated that he was going to have to hire someone to do it. He says he couldn’t afford that.
“We made the decision that we’re just going to cancel the contract and continue to go with cash,” he said.
Easier said than done. Horowitz hasn’t been able to get through to anyone on the phone to cancel the contract. In the meantime, prospective patients are finding his name on the directory and are calling for appointments. Horowitz says he just has to say no.
California is overhauling the way it collects information for its massive cancer database in the hope of improving how patients are treated for the disease.
Pathologists at a dozen hospitals in the state are part of a pilot project — the first of its kind in the United States — in which they are reporting cancer diagnoses in close to real-time to the California Cancer Registry. And they are using standardized electronic forms to make their reporting more consistent and accurate.
That represents a significant change for the registry, which traditionally relies on data up to two years old.
Physicians and researchers say the state’s partnership with St. Joseph Health in Orange County and UCSF Benioff Children’s Hospital in Oakland could become a model for cancer registries in other states. The changes in California are in line with Vice President Joe Biden’s “cancer moonshot,” which is intended, among other things, to facilitate cures through better data sharing, they said.
California’s registry, run by the state Department of Public Health, has amassed data on more than 4.5 million cancer patients since it began collecting information in 1988. It contains data on cancer diagnoses, including the type and extent of the cancer, screening, patient demographics, initial treatments and outcomes.Use Our Content This story can be republished for free (details).
If the cancer registry had current information from around the state, medical providers could see what treatments were most effective and make more informed and timely decisions with their patients, said Dr. Lawrence D. Wagman, executive medical director of the Center for Cancer Prevention and Treatment at St. Joseph Hospital in Orange. That, he said, could improve outcomes.
Eventually, doctors could also use it to direct patients to suitable clinical trials, said Michelle Woodley, chief nursing information officer at St. Joseph Health System.
“Our driving force is making sure we can get the patient to the right treatment, the right trials as quickly as possible,” she said.
Real-time reporting in cancer registries might eventually make it easier for doctors to obtain important information on their patients if they go to different places for radiology, oncology and surgery — or if they switch physicians or hospitals. Currently, however, the data does not include patients’ identities.
Researchers regularly use the California database to search for trends, confirm potential cancer clusters and identify disparities in screening and outcomes.
They’ve used the information to determine that cancer patients on Medi-Cal have lower survival rates than those privately insured, that the risk of childhood cancers may vary depending on where the mothers were born, and that the social benefits of marriage could help patients live longer.
State cancer registries across the nation report data to the Centers for Disease Control and Prevention, where it is compiled into an annual report used for research.
But pathologists and medical providers said the lack of consistency and timeliness of the registries in California and elsewhere limits their value in helping individual patients. Registries have been used primarily for research and surveillance of cancer trends based on historic data.
“The current system is not working as well as it should,” said Bob Achermann, executive director of the California Society of Pathologists. “There are long delays … You would assume that a program that has been around as long as it has would be more sophisticated, but it is not.”
State law requires hospitals and cancer centers to report nearly all cancer diagnoses to the state registry. Only about five percent of diagnostic data is currently being sent in real-time, but California health officials plan to expand that to as much as 10 percent by next June and 65 percent by 2022. The ultimate goal is for 100 percent of reporting to be in real time, though there is no specific time frame for achieving it.
Pathologists say the technological groundwork is already there, in part because of the electronic medical records used by most hospitals. But public health officials said that hospitals and cancer centers also may have to upgrade their information systems.
Assemblywoman Susan Bonilla (D-Concord) has proposed legislation that would require pathologists, beginning in 2019, to use an electronic medical record or a web portal when they report cancer diagnoses to the state registry. Currently, most pathologists report new diagnoses with written paragraphs about a patient, and specific information is pulled out of the text. Supporters of the bill argue that the registry needs to be updated so it can be used by oncologists making critical decisions about treatments.
The electronic reporting forms used by hospitals in the pilot project, developed by the College of American Pathologists, are checklists that ask for specific information about patients and their cancer diagnoses.
The checklists can be much more easily analyzed than written paragraphs about a patient, said Robert Hiatt, chair of the department of epidemiology and biostatistics at the University of California, San Francisco. “You don’t have to … try to interpret texts,” he said. “It is collecting data from the get-go that is standardized. That is a very good thing.”
The pilot project is a collaboration among the hospitals, the College of American Pathologists, software developer mTuitive Inc., and the public health department, which is the primary funder.
Having access to current and standardized data could change the way registries are used, said Samantha Spencer, director of structured reporting at the College of American Pathologists. In addition to being used for surveillance, the registries — a “warehouse of critical information” — could also improve patient care, she said.
“It is not just having the information,” Spencer said. “It is acting on it.”
California public health officials said they will be able to generate real-time surveillance statistics, identify cases for ongoing research and implement a statewide program to improve the quality of cancer treatment.
“The environment within health care provider organizations and specifically cancer reporting facilities has changed significantly in the last 10-plus years,” the California Department of Public Health said in a statement. “As technology in every aspect of our lives has drastically changed, so has the expectation of physicians, laboratories, facilities and facility groups about what types of data they need.”
Blue Shield of California Foundation helps fund KHN coverage in California.
When most people think of the victims of the nation’s opioid abuse epidemic, they seldom picture members of the Medicare set.
But a research letter published Wednesday in JAMA Psychiatry found Medicare beneficiaries had the highest and most rapidly growing rate of “opioid use disorder.” Six of every 1,000 recipients struggle with the condition, compared with one out of every 1,000 patients covered through commercial insurance plans.
The letter also concluded that Medicare beneficiaries may face a treatment gap. In 2013, doctors prescribed a high number of opioid prescription painkillers for this population — which put patients at risk for addiction — but far fewer prescriptions for buprenorphine-naloxone, the only effective drug therapy for opioid use disorder covered by Medicare Part D.
“The take home message is we have very effective treatments,” said Anna Lembke, one of the research letter’s authors and assistant professor at the Stanford University School of Medicine. “But they’re not widely accessible.”
Researchers analyzed 2013 Medicare Part D claims to count the number of prescriptions for Schedule II opioids and buprenorphine-naloxone. The latter drug curbs addiction by partially stimulating the same brain receptors as a stronger opioid, but with a lower risk of overdose.Use Our Content This KHN story can be republished for free (details).
The data showed the number of doctors who prescribed buprenorphine-naloxone equaled less than 2 percent of the 381,575 prescribers responsible for 56,516,854 Schedule II opioid claims. For instance, the researchers found that for every 40 family physicians prescribing pain killers, only one family physician prescribed the addiction management drug.
The letter also found states in the northeast, including Maine, Massachusetts and Vermont, had the highest ratio of buprenorphine-naloxone claims in the country, more than 300 times the national average.
In the last decade, the incidence of opioid addiction in the United States has reached crisis levels. According to the latest data from the Centers for Disease Control and Prevention, more than 19,000 Americans died from prescription opioid overdoses in 2014.
More than 300,000 Medicare recipients battle with opioid use disorder, according to the study. Among beneficiaries, hospitalizations due to complications caused by opioid abuse or misuse increased 10 percent every year from 1993 to 2012.
Lembke said part of the reason doctors do not prescribe more addiction management medications is because they view the problem as one of medicine’s lost causes.
“Doctors feel helpless and hopeless when it comes to addiction,” she said. “They feel that nothing can be done for them.”
And Medicare patients face additional obstacles when it comes to addiction treatment. First, Part D, Medicare’s prescription drug program, only covers buprenorphine-naloxone. Other effective treatments such as methodone are not covered, posing a barrier to access, said Lembke.
Buprenorphine-naloxone also usually requires prior authorization before a patient can receive the treatment. In addition, in order to prescribe it, physicians must take an 8-hour class, apply for a waiver and receive a special Drug Enforcement Administration number in addition to his or her regular DEA registration number. It becomes a hassle many medical professionals do not feel is worth the time, said Dr. Jonathan Chen, co-author of the study and instructor at Stanford.
“Why is it hard to [prescribe buprenorphine-naxolone], yet so easy for me to hand out things that get people dependent in the first place?” he said.
A different JAMA study found only 2 percent of doctors nationwide had obtained the authorization needed to prescribe the medication in 2014. And over half of the nation’s counties did not have a health provider with the ability to prescribe the medication.
But the letter’s authors note that physicians who prescribe opioid painkillers have in place a relationship with their patients that makes them well-positioned — with some additional training — to take steps to intervene when opioids are being misused.
“The bottom line is it’s a heck of a lot more work to get patients off of opioids than to get them on opioids,” said Lembke.
KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.
Dr. Thomas Gallagher has been through many tough conversations with patients. He remembers once standing in front of a patient and the patient’s family, preparing to tell them about a mistake that had occurred.
“This is a topic I think about all the time and it was still very nerve-racking and embarrassing,” said Gallagher, an internist and a professor at the University of Washington’s medical school specializing in quality and patient safety issues. The patient had been sent to another clinic an hour away to get an MRI, but because of a miscommunication, the MRI was done in the wrong area of the body and would have to be repeated.
“The patient was disgusted,” Gallagher recalled about the event that occurred before he came to Washington. “His family was furious … that after all the patient had gone through to get this test … we still couldn’t even figure out something this basic.”Use Our Content This KHN story can be republished for free (details).
Medical mistakes often happen. National guidelines call for doctors to provide full disclosure about adverse events, and studies have shown that those discussions benefit patients. But new research finds that the act of disclosure, combined with stress from the procedure gone wrong, can be an anxious experience for some doctors — and more training is needed to help them engage in these difficult conversations.
The study, published in JAMA Surgery Wednesday, examines what surgeons tell patients and what effect those discussion can have on the doctor.
“For a long time in the field, people thought that the primary reason that physicians have trouble reporting adverse events is that they were worried about being sued, but there are other barriers that are more important,” said Gallagher, one of the authors of the study. “This paper helps highlight how embarrassing and upsetting these events are for clinicians … (and) makes it difficult for the physician to admit to the patient, ‘Here is exactly what happened.’”
The researchers used surveys of surgeons who reported adverse events at three Veterans Affairs medical centers. They found that about 90 percent of the surveys showed that doctors said they had disclosed the event to patients or their families within 24 hours, expressed concern for the patient’s welfare, explained why the event happened, expressed regret and discussed with patients steps to treat subsequent problems.
But only about half showed the doctors discussed whether the event was preventable and a third reported they talked about how it could be avoided in the future. Just over half apologized to the patient.
The study also reported that those surgeons who find an event very or extremely serious and who had difficulty discussing that event are more likely to suffer anxiety over the experience. That was also true of surgeons who feared negative reaction from patients, an impact on their reputations, bad publicity or a malpractice suit.
“These surgeons who have volunteered to participate probably feel very comfortable talking to patients compared to those who didn’t participate, and even among these surgeons there was a lot of anxiety,” said A. Rani Elwy, an associate professor at Boston University and an investigator and researcher at the VA Boston Healthcare System who was the lead author of the study. “I can only imagine it is much more accentuated among the bigger population.”
Initial questionnaires were administered to 67 surgeons between January 2011 and December 2013. Of those doctors, 35 contacted the researchers during the study period to report adverse events and filled out 62 individual surveys on those events. Surgeons could complete up to three surveys for the study.
Elwy said that the VA surgeons who participated in the study had not been taught how to deal with patients on these situations and the study called for more training to create a “culture of professionalism” that will help surgeons better handle patients’ needs and allow for “self-care following disclosures [that] may also increase surgeons’ well-being.”
“Lots of clinicians don’t feel comfortable about these conversations, and doctors say they don’t know what to say, they don’t know how to say it,” Gallagher said. “I’ve had no training on having these conversations in medical school or residency.”
That’s also a concern of Dr. Marjorie Stiegler, an associate professor of anesthesiology at University of North Carolina at Chapel Hill who was not associated with the study.
“Every physician, perhaps every clinician, at some point will have some kind of adverse event,” she said, adding, “It’s never easy to break bad news to a family member of a loved one.”
She wrote an article in JAMA in 2015 arguing for more awareness of physicians’ well-being when faced with clinical adverse events. She noted a study that found physicians were twice as likely to commit suicide than the general population and a survey documenting post-traumatic stress disorder symptoms among anesthesiologists involved in surgical deaths.
Gallagher said that in the case of the botched MRI he apologized to the patient and tried to help the family figure out the next steps.
“At the end of the conversation, while they were unhappy, they felt like they were getting care at an organization that would tell them if there was a problem,” he said.
Twenty years after Temporary Assistance for Needy Families’ (TANF) inception, few poor families actually receive cash assistance under it and, for those who do, state benefit levels are low and are losing value. Our new series of maps illustrates the decline of this cash assistance safety net.