State Highlights: Fla. Targets For-Profit Stem Cell Clinics; Ga. Gov. Proposes Extra $23M For Children’s Mental Health Services
Dr. Mahendra Patel, a pediatric cancer doctor, has begun giving away medications to some of his patients, determined not to disrupt their treatments for serious illnesses like leukemia, should Congress fail to come up with renewed funding for a key children’s health program now hostage to partisan politics.
In his 35 years of practice, Patel, of San Antonio, has seen the lengths to which parents will go to care for their critically ill children. He has seen couples divorce just to qualify for Medicaid coverage, something he fears will happen if the Children’s Health Insurance Program (CHIP) is axed. He said: “They are looking at you and begging for their child’s life.”
The months-long failure on Capitol Hill to pass a long-term extension to CHIP that provides health coverage to 9 million lower-income children portends serious health consequences, with disruption in ongoing treatments.
While funding promises and estimates of dates for it disappearing vary from week to week and state to state, treatment plans for serious diseases span months into the future, leaving some doctors, like Patel, to jury-rig solutions. The challenges are particularly great for kids with chronic or ongoing illnesses such as asthma or cancer.
Dr. Joanne Hilden, a pediatric cancer physician in Aurora, Colo., and past president of the American Society of Hematology-Oncology, said cancer patients who are worried their CHIP funding will run out can’t schedule care ahead of time.
A San Antonio pediatrician, Dr. Carmen Garza, is advising parents to be sure to keep their children’s asthma medications and other prescriptions current and fill any refills that they can so they don’t get left without vital medicines if CHIP expires.
Federal funding for CHIP originally ran out Oct. 1. In December, Congress provided $2.85 billion to temporarily fund the program. That was supposed to help states get through at least March, but it is coming up well short. The Centers for Medicare & Medicaid Services (CMS) last week said it couldn’t guarantee funding to all states past Jan. 19.
About 1.7 million children in 20 states and the District of Columbia could be at risk of losing their CHIP coverage in February because of the shortfall, according to a report Wednesday by the Georgetown University Center for Children and Families.Email Sign-Up
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A few states, including Louisiana and Colorado, plan to use state funds to make up for the lack of federal funding. But that is a drastic step, since the federal government pays on average nearly 90 percent of CHIP costs. Most states cannot afford to make up the difference and will have to freeze enrollment or terminate coverage when their federal funding runs out.
Virginia and Connecticut can promise to keep their CHIP program running only through February, officials said.
The largest states seem to be in the best shape, though even that guarantees only a few months of care. Florida, California and Texas officials said they have enough CHIP funding to last through March. New York officials said they have enough money to last at least into mid-March.
Before the short-term funding was passed in late December, CHIP programs survived on the states’ unspent funds and a $3 billion redistribution pool of CHIP dollars controlled by CMS.
Republicans and Democrats on Capitol Hill say they want to continue CHIP, but they have been unable to agree on how to continue funding it. The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.
The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.
But two key Republican lawmakers — Sen. John Cornyn of Texas, who is part of the Senate leadership, and Rep. Greg Walden of Oregon, who chairs the House Energy and Commerce Committee — told reporters Wednesday that they think an agreement is close.
Alabama and Utah are among several states unsure how long their federal CHIP funding will last, according to interviews with state officials. Part of the problem is they have not been told by CMS how it will be disbursing money from the redistribution pool. Under the pool restrictions, states with excess dollars would have to give money to states running low.
Although health care provider groups and child health advocates have for months been sounding the alarm about CHIP, the Trump administration has kept quiet, saying it’s up to Congress to renew the program.
When Marina Natali’s younger son broke his arm ice-skating last year, she did not have to worry about paying: CHIP footed all of his medical bills.
Had that accident happened this year, though, Natali, 50, of Aliquippa, Pa., might be scrambling. She cannot afford private coverage for her two children on her dental hygienist pay.
“It’s creating a lot of anxiety about not having insurance and the kids getting sick,” she said.
Dr. Todd Wolynn, a Pittsburgh pediatrician, said families are reacting with “fear and disbelief” to CHIP’s uncertain future. The group practice hasn’t changed any scheduling for CHIP patients, but he said “families are terrified” about the program having to be terminated.
Pennsylvania officials sent a notice to CHIP providers in late December — who then sent it to enrollees — saying it would have to end the program in March unless Congress acts.
“These families don’t know if the rug is being pulled out from them at any time,” he said.
Dr. Dipesh Navsaria, a Madison, Wis., pediatrician and vice president of the state’s chapter of the American Academy of Pediatrics, said many parents and doctors have been told for months that Congress would firm up long-term funding for CHIP, but those promises have been dashed.
“If CHIP coverage disappears, we run the risk of kids going without care or emergency room visits going up,” he said.
Navsaria also worries that many parents will be surprised if their children are suddenly without coverage. They may not know the state-branded programs they use, such as BadgerCare Plus in Wisconsin, Healthy Kids in Florida and All Kids in Alabama, are part of the CHIP program.
Ariel Haughton of Pittsburgh said she’s upset her federal lawmakers have left CHIP in flux for her two children and millions of kids around the country. “They seem so cavalier about it,” she said.
If CHIP gets canceled by the state, she likely won’t bring Javier, 2, for his two-year checkup if nothing seems wrong. “We will have to decide between their health and spending the money on something else,” she said.
Doctors at some of the largest U.S. hospital chains admit they went overboard with opioids to make people as pain-free as possible, and now they shoulder part of the blame for the nation’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain.
“I had the C-section, had the kiddo,” said Michelle Leavy of Las Vegas. “And then they tell me, ‘It’s OK, you can keep taking the pain medications, it’s fine.'”
Leavy is a mother of three and a paramedic who has dealt with many patients coping with addiction. She welcomed the high-dose intravenous narcotics while in the hospital and, upon her release, gladly followed doctors’ orders to keep ahead of the pain with Percocet pills.
But then she needed stronger doses. Soon, she realized, she was no longer treating pain.
“Before I went to work, I took them, and to get the kids after school, I had to take them,” she said. “Then I was taking them just to go to bed. I didn’t really realize I had a problem until the problem was something more than I could have taken care of myself.”
She said she was becoming like the patients with addiction problems that she transported by ambulance, lying to emergency room doctors to con a few extra doses.
Soon she lost her job and her fiancé, before going to rehab through American Addiction Centers and stitching her life back together.Email Sign-Up
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A 180 On Opioids
Opioid addiction is a reality that has been completely disconnected from where it often starts — in a hospital. Anesthesiologist David Alfery said he was rarely stingy with the pain medicine.
“If I could awaken them without any pain whatsoever, I was the slickest guy on the block, and it was a matter of enormous pride,” he said.
Alfery is part of a working group at the Nashville-based consulting firm Health Trust behind hospital efforts to set aside rivalry and swap ideas about a top priority: reducing opioid use.
“It starts with patient expectations, and I think, over the years, patients have come to expect more and more in terms of, ‘I don’t want any pain after surgery,’ and it’s an unrealistic expectation,” Alfery said.
That expectation exists in part because pain treatment was institutionalized. Hospitals are graded on how well they keep someone’s pain at bay. And doctors can feel institutional pressure, and on a personal level.
“I just wanted my patient not to be in pain, thinking I was doing the right thing for them and certainly not an outlier among my colleagues,” said Mike Schlosser, chief medical officer for a division of HCA, the nation’s largest private hospital chain.
Schlosser spent a decade as a spinal surgeon putting his patients at HCA’s flagship facility in Nashville through some of the most painful procedures in medicine, like correcting back curvature. He said he genuinely wanted to soothe the hurt he caused.
“But now looking back on it, I was putting them at significant risk for developing an addiction to those medications,” he said.
Using HCA’s vast trove of data, he found that for orthopedic and back surgeries, the greatest risk isn’t infection or some other complication — it’s addiction.
So the nation’s largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.
“We will treat the pain, but you should expect that you’re going to have some pain. And you should also understand that taking a narcotic [dose so high] that you have no pain, really puts you at risk of becoming addicted to that narcotic,” Schlosser said, recounting the new recommended script for surgeons speaking to their patients.
Besides issuing the uncomfortable warning, sparing use of opioids also takes more work on the hospital’s part — trying nerve blocks and finding the most effective blend of non-narcotic medicine. Then after surgery, the nursing staff has to stick to it. If someone can get up and walk and cough without doubling over, maybe they don’t need potentially addictive drugs, or at least not in high dosage, he said.
There are potential benefits aside from avoiding addiction.
“I’ve had people tell me that the constipation [resulting from opioid use] was way worse than the kidney stone,” said Valerie Norton, head of the pharmacy and therapeutics council for Scripps Health System in San Diego, which is participating in the Health Trust working group.
“There are lots of other complications from opioids — severe constipation, nausea, itching, hallucinations, sleepiness. We really need to treat these drugs with respect and give people informed consent. And let people know these are not benign drugs.”
Managing The Optics
Of course, business-wise, no one wants to be known as the hospital where treatment hurts more.
“You don’t want to portray the fact that you’re not going to treat people appropriately,” said John Young, national medical director of cardiovascular services for LifePoint Health, another player at the table with Health Trust. The Nashville-based hospital chain is putting special emphasis on how it handles people coming into the ER looking for pain medicine.
Young said tightening up on opioids becomes a delicate matter but it’s the right thing to do.
“We really do have a lot of responsibility and culpability and this burden, and so we have to make sure we do whatever we can to stem this tide and turn the ship in the other direction,” he said.
While hospitals get their ship in order, some patients are taking personal responsibility.
Now that she’s in recovery, Michelle Leavy won’t touch opioids. That meant she had emergency gallbladder surgery in 2017 without any narcotics. Leavy said she was nervous about telling her doctors about her addiction, but they were happy to find opioid alternatives.
“I mean, it hurt,” she said. “But I lived.”
Washington State is about to implement its Medicaid waiver from the federal Centers for Medicare & Medicaid Services (CMS) to expand services that help beneficiaries with significant physical or behavioral health conditions gain access to housing and employment. That waiver is a positive step forward because it will support work by giving Medicaid beneficiaries more tools to secure employment.