Wednesday, 30 March 2016

Thursday, 24 March 2016

Viewpoints: Patent Laws And High Drug Prices; Medicare’s Move To Step Up Diabetes Prevention

A selection of opinions from around the country.

Philanthropist Aims To Shed Light On ‘Dark Matter Of Bioscience’ With $100M Commitment

Billionaire philanthropist Paul Allen's goal is to give money to scientists who have out-of-the-box ideas and unconventional approaches to projects in tissue regeneration, antibiotic resistance, gene editing and the development of brain circuitry.

Fentanyl’s Lethal Role In Sweeping Drug Epidemic

The powerful synthetic drug is causing scores of overdoses throughout the states, and its use with heroin is only spreading. Heroin is highly addictive, Bridget Brennan, New York's special narcotics prosecutor says. “You put fentanyl in there, and all bets are off.”

Novartis Agrees To SEC Settlement

The company will pay about $25 million in a settlement with the Securities and Exchange Commission related to bookkeeping failures. Bristol-Myers-Squib will acquire a privately held company that will move it into the auto-immune disease drug market, and Propeller Health enters a digital partnership. News outlets also provide the latest on biosimilars and blood thinners,

Tuesday, 22 March 2016

Hackers Seek Ransom From Two More California Hospitals

Hackers demanded a ransom from two more Southern California hospitals last week and federal authorities are investigating the case.

Prime Healthcare Services Inc., a fast-growing national hospital chain, said the attackers infiltrated computer servers on Friday at two of its California hospitals, Chino Valley Medical Center in Chino and Desert Valley Hospital in Victorville.

The company said the cyberattack had not affected patient safety or compromised records on patients or staff.

Two sources familiar with the investigation said the hackers had demanded a ransom to unlock the hospital computer systems, similar to what happened last month at Hollywood Presbyterian Medical Center in Los Angeles. Hollywood Presbyterian said it paid $17,000 in bitcoin to hackers to regain access to the institution’s computers.

Fred Ortega, a spokesman for Prime Healthcare, declined to comment on whether Prime received a ransom demand or paid any money, citing the ongoing investigation.

“This is similar to challenges hospitals across the country are facing, and we have taken extraordinary steps to protect and expeditiously find a resolution to this disruption,” Ortega said. “The concern now is to let law enforcement do their thing and find the culprit.”

FBI spokeswoman Laura Eimiller said Tuesday “we are investigating a compromise of the network at these locations.” She declined to discuss specifics of the case. The FBI also has been investigating the attack at Hollywood Presbyterian.

Ortega said the two hospitals affected remain operational and steps are being taken to restore their computer systems to full functionality. He said some IT systems were shut down by hospital staff as a preventive measure so malicious software didn’t spread further.

hacker-computer-code-e1458648376542The company said it’s working with data security experts and the California Department of Public Health on the matter.

Prime Healthcare, based in Ontario, Calif., has acquired struggling hospitals across the country and has become one of the nation’s largest health systems. It runs 42 hospitals in 14 states. The company is led by its outspoken chairman and chief executive, Dr. Prem Reddy.

A series of high-profile data breaches in the past year have raised fresh questions about the ability of hospitals, health insurers and other medical providers to safeguard the vast troves of electronic medical records and other sensitive data they are stockpiling on millions of Americans.

Prime Healthcare has faced trouble over lapses on patient privacy in the past.

In 2013,  the company agreed to a $275,000 settlement to resolve a federal investigation involving a breach of patient confidentiality. Officials found that Prime’s Shasta Regional Medical Center had shared a woman’s medical files with journalists and sent an email about her treatment to all hospital employees.

Friday, 18 March 2016

Viewpoints: More Health Law Vulnerabilities; Some Drugs Have High Costs For A Reason

A selection of opinions from around the country.

State Highlights: State Prisons Bear Burden Of Elderly Inmates; N.C. To Consolidate State-Funded Mental Health Services

News outlets report on health issues in North Carolina, Mississippi, Minnesota, Oregon, Washington, Idaho, Missouri, Texas and Maryland.

At Ohio Hospital, Health Leads Program Helps Patients Meet Basic Needs

The program is new to Cleveland's University Hospital but already operational in five other states. Meanwhile, in other hospital news, ProPublica examines the link between industry funding and teaching hospitals, and operating rooms were shut down in an Arkansas hospital after a deadly disease was detected.

With Eye On Improving Costs, Walgreens Forms Partnership With UnitedHealth

Under the deal, the insurer will charge its patients less if they fill their prescriptions at Walgreens stores.

Medicare Payment Lobbying War Heats Up As More Voices Join The Fight

The campaigns center around a proposed 1.35 percent boost to Medicare Advantage. Kaiser Health News looks at how the Obama administration is trying to borrow ideas from the private sector with its Medicare plan, Medicare beneficiaries could face higher out-of-pocket drug costs as a result of the trend toward coinsurance rather than co-payments, and Rep. Pat Tiberi, R-Ohio, is urging his fellow lawmakers to consider changes to the Medicare Advantage program.

Viewpoints: CDC’s Response To Opioid Abuse; Analysts Sour On Valeant

A selection of opinions from around the country.

Friday, 11 March 2016

State Highlights: Fla. Senate OKs Transparency Bill; Effort To Restore Ariz. KidCare Health Insurance Program Stalls

News outlets report on health issues in Florida, Arizona, Kentucky, California, New York, Michigan and New Jersey.

Viewpoints: Strengthening Medicaid; ERISA And The Goals Of Transparency

A selection of opinions from around the country.

Research Roundup: Medicare Drug Plans; ACA Patient Losses; Hospital Readmissions

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Making It Easier To See The Doctor — Minute Clinics And ER Adjustments

NPR reports on how some hospital emergency rooms are adapting to make it easier to provide regular care to patients. Meanwhile, The Washington Post notes that minute clinics are making more people more likely to go to the doctor.

Back From The Brink, A Rural Texas Hospital Shines

FREDERICKSBURG, Texas — Brad and Sheryl Kott didn’t think much of it seven years ago when their 13-year-old son, Quinn, complained his arm felt tingly. But later that day, Mr. Kott found Quinn — a friendly, energetic athlete — on the bathroom floor. His speech was garbled.

Read Related Story: Hospital Closures Rattle Small Towns

“We loaded him in the back of our pickup in the second seat, and we start heading to town to the emergency room right away,” Brad Kott recalled. “And on my way, my wife said, ‘I think he’s had a stroke.’”

After the family arrived at Hill Country Memorial, the local hospital in Fredericksburg, the Kotts say Quinn’s medical care went terribly wrong. Quinn waited in a wheelchair in the emergency room for hours despite his drooping face and slurred speech, and his parents and former hospital administrators say, the ER doctor was inattentive, callous and at a point late in the evening, decided to send Quinn home.

As Brad Kott brought his son out to his truck in the parking lot, his wife refused to take their son home. She rushed back into the ER and demanded to see the doctor.

“I met the doctor coming down the hall, and I said, ‘Something is wrong with Quinn.’ And he shushed me,” Sheryl Kott recalled. “And I said, ‘No, don’t you tell me to shush. You’re the doctor. I’m the mom. There’s something wrong with my son and I need to know what’s wrong with my son, and we are not taking him home.’”

It wasn’t until the next morning that a pediatrician finally examined Quinn. He was rushed to a hospital in San Antonio, about 70 miles south, and died soon after. He had suffered a massive stroke.

For Dr. Michael Williams, then Hill Country Memorial’s chief executive officer, Quinn Kott’s death in 2009 was a crucible moment.

“We had a clear opportunity to either do what most hospitals do and what we had done previously, which was get our attorneys involved, be prepared for a lawsuit,” Williams said. “Or we could take a different approach and work directly, reach out to the family and ask them to partner with us in really transforming the hospital.”

I met the doctor coming down the hall, and I said, ‘Something is wrong with Quinn.’ And he shushed me.

Sheryl Kott

In truth, the hospital’s problems went well beyond the emergency department. “The hospital was in the red on an annual basis,” said Williams, who is now president of the University of North Texas Health Science Center in Fort Worth. “The patient satisfaction was very low. The employee satisfaction was very low. And across the board, what we heard from people, was that this used to be the community’s hospital, and now people are leaving the community to go get their care elsewhere.”

Yet fixing the problems would not be easy because the troubled hospital in Fredericksburg was caught up in larger forces.

Since 2010, more than 50 rural hospitals have closed across the country and hundreds more are in fragile financial condition. Rural populations have declined, and, in many places, those that remain are largely elderly or uninsured. At the same time, congressional budget agreements and the Affordable Care Act reduced Medicare reimbursement and subsidies for the uninsured. Many rural hospitals have been unable to withstand the revenue losses.

The hospital in Fredericksburg, a town of about 10,000 deep in the heart of Texas Hill Country, could easily have faced a similar fate.

Despite the area’s live music scene and strong tourist economy, the hospital was the town’s largest employer and cherished for much of its history. When it opened in 1971, 93 percent of the county’s households contributed money — including Quinn Kott’s grandparents — and old photographs show thousands of people lined up to have a first look.

Years later, as the hospital faced the crisis of Quinn Kott’s death, Williams was determined to bring back that spirit. He studied the Toyota plant in San Antonio and hired former Toyota employee Jeff Darnaby to help bring the car company’s revered assembly line principles to Hill Country Memorial.

“The Toyota production system basically allows you to identify waste, and remove that waste from your processes,” Darnaby said. “Anything that doesn’t add value to the customer, to the process, is considered waste.”

Today at Hill Country Memorial, each department candidly displays specific goals for everyone to see: reduce ER wait times, eliminate falls and improve customer satisfaction. In addition to Toyota, Williams turned to a former executive with Southwest Airlines to remake the hospital’s values and culture, and he hired a former trainer from Ritz Carlton, known for its legendary customer service, to change how patients and families were treated.

“We took the approach that if we took patients and we treated them better than they’d ever been treated before, that at the end of the day, they would drive the bottom line,” said Williams.

They take such good care of you. It’s like doing business in a small-town bank.

George Brannies

Seven years after Quinn’s death, Hill Country Memorial now ranks among the top 100 hospitals in the country and recently won the nation’s highest presidential honor for excellence through innovation and leadership.

The sweeping changes can be seen everywhere: staff members, including physicians, greet visitors in the hallway and ask if they need directions; during a daily afternoon quiet time, the hallway lights darken so patients can rest; and the kitchen staff, in an attempt to reduce waste, cut their egg budget in half. Along with other cost saving measures, the hospital cut costs by $600,000.

Emily Padula, the hospital’s chief strategy officer, says whatever the goal — reducing costs, growing market share, perfecting customer service — rural hospitals should not think they need a lot of money to improve. “We found that our costs are about the average for the country for a hospital, employee staffing is about average for the country, and yet our patient satisfaction is in the top 5 to 10 percent of the nation. So it’s not that you have to put in place all these fancy things to make a difference,” Padula said.

In response to trends affecting hospitals across the country — fewer in-patient visits, declining Medicare reimbursement and Texas officials’ refusal to expand Medicaid — Hill Country Memorial employees stake out new lines of business in weekly meetings in the so-called War Room. Those efforts have led the hospital to diversify its offerings to include a breast health center with high-tech imaging, home hospice care and a wellness center.

To capitalize on the abundance of Medicare-insured retirees in Texas Hill Country, the hospital developed a well-regarded hip and knee replacement program that has attracted patients like George Brannies, a fifth generation Texan from the nearby town of Mason. After a riding accident a few years ago, Brannies, 72, sought care from a renowned surgeon in San Antonio. When the hip surgery failed, the rancher and bank chairman decided to try Hill Country Memorial. His surgeon and nurses were so exceptional, Brannies said, that he was back on his horse in four weeks.

“They take such good care of you. It’s like doing business in a small-town bank. They give you their cell numbers. They say now if you have a problem, you call us. Try this with one of those big-city hospitals. It doesn’t happen,” he said.

Brannies’ surgeon, Dr. Chuck Romanick, has helped steer Hill Country Memorial’s hip and knee replacement program to more than 400 surgeries a year.

“In this community, if you do a bad job, everybody knows about it,” Romanick said. “You will see your bad jobs down at the grocery store or whatever, so you have to focus on quality. And that’s, I think, what we’ve done.”

Now the hospital markets its nationally recognized program well beyond the Texas Hill Country.

Jayne Pope became chief executive officer of Hill Country Memorial in 2013, and she attributes much of the hospital’s success to its fervent and never-ending focus on improving patient care.

“We know as a rural center, we can’t do everything,” Pope said. “But what we do, we determine what those core competencies are, and invest in those skills so that our patients have the best of care.”

In this community, if you do a bad job, everybody knows about it.

Dr. Chuck Romanick

But not every rural hospital can replicate Hill Country Memorial’s success.

Len Nichols, a health economist at George Mason University in Fairfax, Virginia, says many small towns simply can’t sustain an acute care hospital.

“We probably have roughly 20 to 30 percent more hospitals beds than we actually need and so who’s going to lose in the long run?” said Nichols. “It’s going to be those hospitals that are the least efficient, those who cannot deliver good, quality services for the lowest possible cost.”

Instead, the dozens of rural hospitals that have closed — and hundreds more at risk — should consider converting to urgent care centers and partnering with larger regional hospitals, Nichols said, to allow rural residents to be stabilized and moved quickly to hospitals where doctors often have more expertise.

The changes at Hill Country Memorial came too late for the Kott family. They’re still haunted by the treatment Quinn received and the hospital’s advertising campaign that trumpets its care as “remarkable.”

“At first it makes me sick to my stomach, because the hospital was not remarkable at all. It just, it tears at you when you see a billboard that says that,” Brad Kott said. “However, I know that it has transformed into that, and it makes me proud that people in my community took a bad situation, took our tragedy and worked to turn it around.”

This story was reported in collaboration with PBS NewsHour producer Jason Kane.

A Tragedy Becomes A Crucible Moment For Texas Hospital

The death of a 13-year-old boy who suffered a stroke and sought treatment from Hill Country Memorial was a turning point for the hospital, which had been struggling with budget and poor customer and employee satisfaction. But other rural hospitals have not fared as well.

Thursday, 10 March 2016

Cigna Profits As Medicare Softens Penalty Policy

Cigna will get to keep hundreds of millions of dollars in bonus payments for some of its Medicare Advantage plans, despite recently-imposed sanctions for mismanaging those plans in ways that federal officials said threatened seniors’ health and safety.

Securities analysts are raising their 2017 earnings estimates for Cigna in reaction to a broad policy change that Medicare quietly released in a memo Tuesday. At the same time, consumer advocates are raising concerns that the Obama administration’s move will hurt efforts to keep pressure on the private insurance plans, which are an alternative to traditional Medicare. The federal government pays the plans to handle beneficiaries’ care.

The revision suspends the government’s practice of dropping its star ratings on Medicare Advantage plans when the private insurers that offer them are sanctioned for violations. That can be costly for an insurer because plans that get above-average ratings earn quality bonuses from Medicare worth millions of dollars, but if the violations aren’t resolved quickly, the plans won’t qualify for the extra funding.

The policy preserves Cigna’s entitlement to bonuses payable in 2017 — estimated between $213 million and $350 million by some securities analysts — while it continues to resolve the issues that led to an audit of its Medicare plans and sanctions in January. CMS stopped Cigna from enrolling new members or marketing its plans and those sanctions remain in effect.

The Centers for Medicare & Medicaid Services said the policy revision was in response to numerous comments arguing that it was unfair to highly ranked plans. Its memo did not refer to the Cigna case nor indicate whether Cigna had submitted comments on the issue.

When asked about the change, Cigna issued a two-sentence statement: “As a company committed to delivering quality products and services, we focus on putting customers first. We continue to address the matter in full partnership with CMS.”

Securities analysts said Cigna is the only beneficiary they are aware of.

“The suspension is a significant positive for Cigna. Candidly, this is the first time that we can remember CMS making such a significant policy change for a specific carrier” outside of a preliminary or final rule, said Barclays analyst Joshua Raskin in a report.

Cigna’s stock closed at $142 a share Thursday, up $2 in regular trading.

Its Medicare plans cover about 493,000 members in 18 states. Six of the insurer’s plans qualified for bonuses when CMS announced 2016 ratings Oct. 8. One got the top five-star rating and five others got either four or 4.5 stars.

Had Cigna lost its bonuses, that would have cut the insurer’s 2017 profits by 10 cents to 25 cents per share, Raskin previously estimated.

heap of dollars with stethoscope

After the sanctions were announced in January, analyst Ana Gupte of Leerink Research said she cut her 2017 earnings-per-share estimate for Cigna by 50 cents — to $10.25 per share — and 40 cents of that was due to sanctions’ potential impact. She had estimated Cigna would get $213 million in bonuses and half of it would contribute to 2017 profits.

“We are more positive on Cigna and reiterate our top pick status” on its stock, she said.

Consumer advocates questioned why Cigna and other insurers should get Medicare bonus money when caught breaking government rules.

“We are discouraged by CMS’ announcement, which diminishes accountability and transparency related to plan sanctions,” said Stacy Sanders, federal policy director at the Medicare Rights Center.

“There is a disconnect from the information available to consumers about plan performance and how plans are being punished for bad behavior,” said David Lipschutz, managing attorney with the Center for Medicare Advocacy.

CMS sanctioned Cigna in January following a two-week audit that began in October — three days before 2016 star ratings on Medicare plans were announced. In a searing 12-page enforcement letter explaining its decision, CMS disclosed Cigna had received “numerous” notices of noncompliance, warning letters and corrective notices over the previous several years. The agency said Cigna “had experienced widespread and systemic failures” affecting Cigna enrollees’ ability to obtain medical services and prescription medications.

But none of that information was available to consumers during Medicare Advantage’s enrollment period — Oct. 15-Dec. 7.

CMS said its policy decision followed industry criticism that when bonus-eligible plans were sanctioned — those with four stars or more — were automatically dropped to 2.5 stars while plans already at 2.5 stars were only dropped one star. One of the parties that filed comments was America’s Health Insurance Plans, a trade group.

Given the growth in higher-rated plans, insurers saw the more severe punishment for those plans as unfair. Almost half of Medicare Advantage plans, representing 71 percent of all plan enrollees, are rated at 4 stars or above, compared to an estimated 17 percent in 2009, CMS said in its letter.

Sanders said that instead of entirely suspending star ratings reductions, CMS should have adopted a one-star reduction policy for high-rated plans.

State Highlights: Ballot Initiative Seeks To Limit The Range Of Care Costs At Mass. Hospitals; N.H., Calif. Make Progress On Health Care Transparency

News outlets report on health issues in Massachusetts, New Hampshire, California, Connecticut, North Carolina, Pennsylvania, Texas, Florida and Wisconsin.

Uterus Removed After First-In-The-Nation Transplant Fails

The 26-year-old woman had a "sudden complication," the details of which have not been revealed.

Critics Of Medicare Drug Proposal Say It Focuses On Money, And Not Patients’ Health

The Obama administration on Wednesday released a plan for a new way to reimburse doctors for prescription drugs under Medicare, which is already drawing backlash from manufacturers and health care providers. However, Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt defended the proposal, saying, “There is nothing that we propose to do, or should do, in any way, that prevents a patient from getting a prescription medicine that they need."

N.H., Calif. Seek To Help Consumers Get Details On Health Care Prices

Two states are making inroads into revealing some of the biggest secrets of health care by publishing price information to help consumers comparison shop for doctors, dentists and prescription drugs.

New Hampshire, which already had the nation’s most advanced website allowing people to compare the cost of specific medical procedures, last week added prices for 16 dental procedures and 65 prescription drugs. The website,, is run by the state insurance department and lets consumers see how much they would have to pay based on the price their insurer negotiated with each provider, rather than the sticker price that is charged. The site also shows the price uninsured people must pay.

California on Wednesday released an expanded version of its quality report cards on 154 large physician groups. Those cards, which already assess clinical quality and patient experiences, take a different tack than New Hampshire. Instead of drilling down on specific procedures, the report cards summarize the total cost of medical services run up by the average patient of each group. The medical groups care in total for more than 9 million people.

Elizabeth Abbott, the director of California’s patient advocate office, which put together the report cards, said that by coupling the cost rating with similar star ratings for quality, consumers and those who decide which medical groups to include in insurance networks will see that the most expensive medical groups may not be the ones that provide the best care.

“We want to have human resources departments and executives for health providers look at this to guide their decisions,” Abbott said.

nh-ca_770New Hampshire’s and California’s efforts follow a setback last month for states seeking to compile price listings through insurance claims data. The U.S. Supreme Court ruled that Vermont officials cannot force insurers to turn over the information. It is not clear yet how that ruling will affect other states that already collect insurance information. Along with New Hampshire, those include Kansas, Maine, Maryland, Massachusetts, Minnesota, Oregon, Rhode Island, Tennessee, Utah and West Virginia, according to the APCD Council, which tracks all-payer claims databases.

The New Hampshire initiative offers consumers a broad array of pricing information based on claims insurers must report. For instance, around Concord, the state capital, 90 10-milligram pills of atorvastatin, the generic of the blood thinner Lipitor, cost on average $30 at Walmart, $74 at the supermarket Hannaford Brothers, $98 at CVS, and $118 at Walgreens, according to the website. Depending on the dentist, the average price of a silver filling around Concord varied from $138 to $242. The prices might be lower for patients who have insurance that picks up some of the cost.

“Adding dental and pharmacy will be powerful” in New Hampshire because these are items consumers often do shop around for, said Suzanne Delbanco, director of Catalyst for Payment Reform, a San Francisco-based-nonprofit that rates how transparent each state makes health care prices. “The hope is that once consumers get used to shopping for these types of services, they will feel more comfortable looking for other more complex and costly services.”

The California report cards assign one to four stars to summarize the overall average cost for patients of each medical group. The average cost of care for a patient of a four-star group is below $3,158. The average cost for a patient being cared for by a one-star group is more than $4,744.

The ratings take into account the location of each medical group and how healthy or sick its patients are. The difference in ratings is due to discrepancies in the prices the practices charge and the type of treatments their patients get, according to Jill Yegian, an executive at the Integrated Healthcare Association, which collected and helped analyze the data for the patient advocate’s office.

“It could be they are not very efficient, they do not coordinate care well, they do not do things to keep the prices within reason,” Abbott said.

Minnesota is the only other state that offers that same type of information. California relies on voluntary cooperation from medical groups for the data collections, so the Supreme Court ruling should not affect them.

Most studies have found that consumers have limited power to shop for medical services by price. An analysis this month by the Health Care Cost Institute found that a majority of health spending went to services where that would not be possible, such as emergency hospitalizations. But 43 percent of health care spending went to services where patients could potentially shop around, such as drugs, doctors, colonoscopies and hip and knee replacements.

“This is an interesting finding — that consumers might be able to effect, on average, up to nearly half of their yearly out-of-pocket payments by price shopping,” the report said. But it added that even in those circumstances, consumers had less financial motivation to seek better deals because insurance benefit designs shield them from the majority of costs.

“Overall, we come to the conclusion that the potential gains from the consumer price shopping aspect of price transparency are modest,” the analysts wrote.

In New Hampshire, about 3,000 people a month use the website, said Maureen Mustard, director of health care analytics at the insurance department. The state is hoping that more consumers will pay attention following this month’s re-launch.

This story was updated to correct the average costs noted on the California report cards.

Viewpoints: Medicare’s Art Of Compromise; Consumerism And Health Care

A selection of opinions from around the country.

A Growing Problem For Hospitals, Medical Practices: Unpaid Bills

The Tennessean examines the issue of unpaid medical bills. Also in the news, more than a million doses of controlled drugs have been stolen from Emory University Hospital Midtown, and a controversial ballot issue in Massachusetts is causing a split within the hospital industry.

Even With Insurance, Many Can’t Keep Up With Health Care Bills

In a recent poll, 26 percent of people said health care expenses have taken a serious toll on their finances, with 7 percent of those respondents ending up in bankruptcy.

At Debate, Clinton Defends Support For Universal Coverage, Sanders Praises Cuba’s Health System

Hillary Clinton and Bernie Sanders jabbed at each other over health care and immigration in the eighth Democratic debate, which came a day after Clinton's surprising loss in Michigan.

Hospital Closures Rattle Small Towns

RICHLAND, Georgia — For years, Sybil Ammons was the director of nursing at Stewart County’s only hospital. Now, she’s the county coroner.

Since the hospital here closed three years ago, Ammons says more than a dozen local residents were unable to get medical care quickly enough and were either harmed or died because of the delays. “We’ve had a stroke, several heart attacks,” she said, standing along Richland’s main street in this small town about 150 miles south of Atlanta. “We’ve had traumas out on the four-lane.”

Across the country, more than 50 rural hospitals have closed over the last six years, and another 283 are in fragile financial condition, according to the National Rural Health Association. With rural populations long in decline in the United States, small-town hospitals have lost customers and struggled to keep pace with the striking advancements in medical technology.

But the pace of closures has escalated in recent years, hastened by a series of budget control measures passed by Congress that reduced Medicare payments and by the Affordable Care Act, which is slowly restructuring the health care industry. The law rewards scale and connectivity — difficult goals for rural hospitals that are, by their geographic nature, low-volume and remote.

Compounding their financial troubles, 19 states have not taken advantage of a key provision in the health law to expand their Medicaid programs. That’s left many rural hospitals with uninsured patients just as federal subsidies for taking care of the uninsured are being reduced.

It’s Hurting A Lot’

As hospitals have closed in Georgia, hundreds of people have lost their jobs, and many small towns have been left reeling.

When the Lower Oconee Community Hospital in Glenwood, two and a half hours southeast of Atlanta, abruptly laid off its workers, transferred its remaining patients and locked the front door nearly two years ago, it was yet another blow to a rural town accustomed to hardship. The hospital was the town’s largest employer and without the daily traffic from its 100 employees and families and friends of its patients, the town’s only restaurant closed, followed soon by its only bank.

“After the hospital closed, we dropped about 30 percent sales,” said D.K. Patel, owner of the local grocery store that sits on the edge of Glenwood’s town square. “All I can say is it’s been hurting a lot.”

The town’s mayor, G.M. Joiner, who has held his elected post for three decades, and whose father was mayor before him, laments the hospital’s decision to close. “It was our lifeblood,” he said. “It’s not overemphasizing or trying to be a doomsday prophet, but it’s devastating.”

Joiner has been courting suitors for the shuttered hospital, but with little success. The building sits eerily abandoned. At a nurses’ station, antiquated security cameras flicker between images of empty hallways and patient rooms with the beds still crisply made; dead cockroaches litter the floors; vials of patient blood sit in refrigerators, long ago unplugged, in the hospital laboratory.

For many residents, the disruption in medical care caused by the hospital closures has been deeply unsettling and, for some, life threatening.

It only takes one tragedy to realize how detrimental losing this facility is.

Dawn Malin

At her home in Folkston, near the Okefenokee Swamp, Pam Renshaw had to bypass her town’s closed hospital when she needed it most. After a day of yard work, Renshaw accidentally overturned her four-wheeler and spilled into a fire pit used to burn trash. Her then boyfriend, Billy Chavis, pulled Renshaw from the fire and patted down the flames on her body with his bare hands. Chavis got her into his truck and started driving down the long dirt road for help.

“And the whole time I’m driving to town, I said, ‘Where do I go? Where do I go?’”

The hospital in Folkston had closed just months before Renshaw’s accident, and Chavis scrambled to find help. He first tried the EMT office but when he didn’t find anyone, he ran to the police station and a dispatcher summoned an ambulance. Renshaw was driven to a nearby landing strip and airlifted to a hospital 100 miles away in Gainesville, Florida. Doctors finally tended to the burns, which covered 45 percent of her body, an hour and a half after the initial accident.

She spent weeks in in a medically induced coma and nearly eight months in the hospital.

Renshaw’s accident spooked this small town of 5,000 people, where dangerous, industrial jobs drive the local economy, and made clear just how vulnerable residents could be during a crisis at home or at work.

“When you have a timber industry, you’re dealing with saws, you’re dealing with heavy equipment,” said Dawn Malin, executive director of the Folkston Chamber of Commerce. “It only takes one tragedy to realize how detrimental losing this facility is.” The hospital’s closure has caused worries about workplace accidents at a local paper plant, Malin said, and hampered her group’s effort to attract new businesses.

Difficulties For Seniors

For many elderly residents of small towns, the price of the hospital closures has been steep. When the hospital closed in Glenwood, the remaining doctors moved out of the county, and residents like Joe and Sue Connell now must drive two hours round trip for medical care.

“I’m seeing about four different doctors in Dublin. This week, we’re making three trips,” said Joe Connell, 77. “Ninety percent of the miles put on our cars is going to the doctor in Dublin. It costs us, costs a bunch of money to go back and to.”

For pregnant women in rural Georgia, the hospital closures can mean dwindling access to prenatal care and longer trips when labor begins. In Waynesboro, Georgia, Dr. Frank Carter, a prenatal specialist, said after the troubled local hospital there closed its labor and delivery unit, his patients — largely poor women with little money for transportation — face an hour’s drive to deliver their babies.

“They’re going to have to be prepared and willing to travel,” Carter said. “And that’s the reality.”

It’s not overemphasizing or trying to be a doomsday prophet, but it’s devastating.

G.M. Joiner

Adjusting to that new reality is difficult for many rural residents. Hospitals are often a vital part of small-town life, said Chuck Adams, vice president of the Georgia Hospital Association.

“Towns like Glenwood have always had a hospital. When that hospital closed, then these residents immediately lost access without an opportunity to figure out what that next access model was,” said Adams. “When you have time to figure it out, I think there are models out there that could work.”

Effect On Health Unclear

But while hospital closures in rural areas can unsettle residents’ nerves and force them to travel farther distances, the effect on health outcomes remains unclear. Researchers have found that closing down a rural hospital does not increase the chance of death, and, an investigation by the Wall Street Journal found surgeries at many rural hospitals carried a greater risk of complications. Indeed, for some emergencies, patients can receive better quality care at larger hospitals that treat more cases.

“There has to be sort of a critical mass to be able to make any business viable, and especially a community hospital,” said Alan Kent, chief executive officer of Meadows Regional Medical Center, a bustling modern hospital in Vidalia, Georgia, that has taken in patients from neighboring towns like Glenwood. While rural residents need access to primary and urgent care, not every town can sustain a hospital with costly medical equipment and a roster of specialists.

“We have to be more efficient in hospitals if we are going to be sustainable, and I think that’s one of the things that you’re seeing that’s driving the consolidation in the industry,” Kent said.

But for elderly residents like the Connells, the closures have forced them to reconsider their retirement plans. Sitting on the porch of his house in Glenwood with his wife, Sue, age 75, Joe said, “I don’t know what we’re going to when she gets where she can’t drive.”

This story was reported in collaboration with PBS Newshour producer Jason Kane.

Monday, 7 March 2016

Managing Depression A Challenge In Primary Care Settings, Study Finds

Often referred to as the “common cold of mental health,” depression causes about 8 million doctors’ appointments a year. More than half are with primary care physicians. A new study suggests those doctors may not be the best to treat the condition due to insurance issues, time constraints and other factors.

The paper, published Monday in the March issue of Health Affairs, examines how primary care doctors treat depression. More often than not, according to the study, primary care practices fall short in teaching patients about managing their care and following up regularly to track their progress. That approach is considered most effective for treating chronic illnesses.

That’s important. Most people with depression seek help from their primary care doctors, the study notes. Why? Patients often face “shortages and limitations of access to psychiatrists,” the authors write. For example, patients sometimes have difficulty locating psychiatrists nearby or those who are covered by their insurance plans. Plus, there’s stigma: Patients sometimes feel nervous or ashamed to see a mental health specialist, according to the authors.

Meanwhile, physicians and health experts have increasingly been calling for mental health conditions — such as depression and anxiety — to be treated like physical illnesses. Historically, those have been handled separately and, experts say, without the same attention and care as things like high blood pressure and heart disease.

The researchers compared strategies for treating depression with those used for asthma, diabetes and congestive heart failure. They surveyed more than 1,000 primary care practices across the country to determine how often doctors’ offices used five specific steps — considered “best practices” — to manage patients’ chronic conditions. They include employing nurse care managers, keeping a registry of all patients with a condition that requires regular follow-up, reminding patients to comply with their treatment regimens, teaching them about their illnesses and giving doctors feedback. Those approaches track with recommendations from the Department of Health and Human Services Agency for Healthcare Research and Quality.

On average, the practices surveyed were least likely to follow those protocols when treating depression. About a third kept registries of patients with depression, and the other steps were less commonly used. Less than 10 percent of practices, for instance, reminded patients about their treatments or taught them about the condition.

Doctors were most likely to use those best practices for treating diabetes. Most practices followed at least one of the strategies for managing chronic illness.

“The approach to depression should be like that of other chronic diseases,” said Dr. Harold Pincus, vice chair of psychiatry at Columbia University’s College of Physicians and Surgeons and one of the study’s co-authors. But “by and large, primary care practices don’t have the infrastructure or haven’t chosen to implement those practices for depression.” Pincus is also director of quality and outcomes research at New York Presbyterian Hospital.

That’s a problem, said Dr. Tara Bishop, an associate professor of healthcare policy and research at Weill Cornell Medical College, the study’s main author. Effectively treating any chronic illness requires working with patients beyond single visits. For depression, that means things like following up to see if medication is working, or if a dose should be adjusted.

“When we treat high blood pressure, the blood pressure may start at 150 over 95, and then it’s monitored over time until it gets to a level that’s being aimed for,” said Dr. Jeffrey Borenstein, president of the Brain and Behavior Research Foundation. The foundation funds mental health research but was not involved with this study. “If somebody has depression, their symptoms need to be monitored until it gets to a level that the depression is lifted.”

Depression can contribute to other health problems, like pulmonary disease or diabetes, Bishop said. It can make people less productive at work or less able to have healthy relationships. Unchecked, it can result in suicide.

“If we actually treat depression as a chronic illness and use the level of tools we’re using for diabetes, then we’ll be able to better treat patients — and help them live healthier lives and more productive lives,” she said.

The study didn’t delve into why the gap exists between depression and other medical conditions. But the authors pointed to potential explanations. One is that there’s been a decades-long push to improve how doctors treat diabetes — an effort that has almost been “the poster child” for how to monitor and treat a long-term illness, Pincus said.

And there are time pressures. Diagnosing a patient with depression — and following up regularly — can take more time than a diabetes blood test or insulin check. Cramming that into a 15-minute visit can get difficult, Bishop said, especially as doctors are increasingly asked to do more with less time.

Plus, she said, while there’s been an effort nationally for the medical profession to better address mental wellness, individual physicians may still struggle.

“It’s almost like a subconscious divide of mental health issues versus physical health issues,” she said. That may also contribute to why the treatment of depression sometimes falls short.

Some cited money as a key obstacle. Dr. Wanda Filer, president of the American Academy of Family Physicians, noted that, despite federal law, it’s still difficult to get insurers to pay for mental health care. That circumstance, she said, could discourage or impede primary care doctors from taking a comprehensive approach to treating it.

“Most depression cases we can manage quite easily — family physicians are well-trained to manage this particular condition,” said Filer, also a practicing family doctor in York, Pennsylvania. The problem is that “there are all these barriers to improving mental health.”

But Bishop said that, as doctors and policymakers take a broader interest in the issue, those barriers could come down and change how doctors practice.

“We’re starting to realize that mental health care, and depression in particular, are very important illnesses. They affect a large part of our population, and they have a lot of repercussions for patients and society,” she said.