From Health Care

Podcast: KHN’s ‘What The Health?’ Live from Aspen!

With President Donald Trump and Republicans in Congress stymied in their efforts to change the nation’s health care system, individual states are wrangling with public ire over price and coverage.

Two guests this week, Democratic Govs. John Hickenlooper of Colorado and Steve Bullock of Montana, have made health a priority in their states and are among the governors who have signed on to bipartisan efforts to shore up parts of the Affordable Care Act that are not working. Both governors are also among the long list of Democrats mentioned as possible presidential candidates in 2020.

Meanwhile, actions in Washington, including this week’s regulation expanding the availability of association health plans, often leave states scrambling to figure out what it will mean for their own health insurance markets.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Both governors said they think health care will be a dominant voting issue in 2018 and 2020. They say governors are among the few who are able to work on the issue on a bipartisan basis.
  • The conservative health plan unveiled this week as a replacement for the Affordable Care Act would give states more flexibility. It also would likely pose an enormous challenge because, over time, it would reduce the amount of federal health care dollars and wouldn’t give states much time to implement their programs.
  • If a federal court in Washington, D.C., opts to throw out Kentucky’s Medicaid work requirement for nondisabled adults, expansion plans in a number of states could be thrown into disarray. Some of them, like Kentucky, say they will not keep the expansion without the work requirement.
  • Montana offered a somewhat different path to work for people who are covered under the Medicaid expansion. Eighty percent of them are working already. Instead of being punitive, Bullock said, the state made a number of support services and employment training options available and, in turn, that raised the number of those working by 9 percent.
  • Hickenlooper said that in Colorado, because the unemployment rate is below 3 percent, most of the nondisabled adults who were covered under Medicaid expansion and not working are instead caring for their children or elder family members.

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Must-Reads Of The Week From Brianna Labuskes

A turbulent news week is capped off by a bit of hope arising from Alzheimer’s research. Disappointment and dashed hopes are the norm in the field, but there’s been a tiny breakthrough: Scientists uncovered a link between the disease and common viruses that lay dormant in the brain after childhood. There’s lots of cautionary language being bandied about (like, don’t get association and causation confused!), but it does open new possibilities for research that has been at a standstill for decades.

And now for what you might have missed this week.

Dr. Atul Gawande, who has just been named to head the health initiative formed by Amazon, Berkshire Hathaway and JPMorgan Chase, has said the U.S. health system is like a car built with Porsche brakes, a Ferrari engine and a BMW chassis. “You put it all together and what do you get? A very expensive pile of junk that does not go anywhere.” Now that Gawande is in the driver’s seat, will he actually be able to do anything about high costs? Those in the medical field were quick to praise him as a “luminary,” but many had concerns about his lack of experience managing a large organization — and the fact that he seems to have lots of other big jobs from Harvard to The New Yorker already demanding his time.

Bloomberg: Can This Surgeon Help Buffett, Bezos and Dimon Solve America’s Health-Care Crisis?

Bloomberg: Doctor and Journalist Atul Gawande Picked for Dimon-Bezos-Buffett Health Firm

And, pharma might be breathing a small sigh of relief. Gawande insists that, despite all the headlines, drug costs aren’t what’s driving spending. The No. 1 culprit according to him? Surgery.

Reuters: Head of New U.S. Corporate Health Plan Cites Surgery As Biggest Cost

President Donald Trump ended his policy to separate migrant children from their parents this week, but chaos at the border continues. Mental health experts and physicians are focusing on the lasting psychological and physical toll on the kids — many who remain in detention centers. Other questions are percolating as well, like: Who benefits from the business of separation? Providing care for those who have been detained is expensive and private contractors are lining up for the work.

Modern Healthcare: Immigrant Detention Crisis Could Yield Profit for Some Providers and Payers

Los Angeles Times: ‘Children Must Not Be Abused for Political Purposes’: What Health Groups Say About Family Separation

Back before the health law, “unauthorized or bogus” insurance schemes were thick on the ground. Now that Trump has released his rule on association health plans (which give small businesses access to insurance options like those available to large companies and let them skirt some of the health law’s requirements), fraud experts are worried the era is going to make a return.

Modern Healthcare: Fraud Fears Rise As Feds Expand Access to Association Health Plans

And if you thought repeal-and-replace was a thing of the past, a group of conservatives helmed in part by the Heritage Foundation have released a new “repeal” plan. While it is extremely unlikely any Republicans in Congress will touch it with a 10-foot pole this close to midterms, the blueprint does show that there’s still an appetite to completely upend the health law.

The Hill: Conservative Groups Outline New ObamaCare Repeal Plan

What’s in a name? Well, critics of the administration’s plans to rename HHS — replated as the Department of Health and Public Welfare — says it means quite a lot. As part of a larger shake-up of agencies, Trump wants to tuck all public assistance programs (like SNAP) into HHS and change its name. But while officials say that adding “welfare” to the department’s title would make it clear what services it provides, others say the word brings with it a negative connotation that would make the programs vulnerable to budget cuts. (Spoiler alert: These moves require congressional approval and would strip some lawmakers of authority, so they’re unlikely to actually come to pass.)

Modern Healthcare: White House Proposes HHS Restructuring and Renaming to Consolidate Welfare Programs

The Wall Street Journal: Trump Proposes Combining Workforce Training, Welfare Programs in Agency Revamp

In the miscellaneous file this week: Some disabled veterans are being told they owe the government thousands of dollars because of an insurance program they didn’t even know existed; it’s not often you can all but feel the giddiness radiating off of articles, but these jaw-dropping results from a new therapy for Duchenne muscular dystrophy is getting everyone emotional; a drugmaker rode a nice wave of good PR and marketing for donating anti-overdose injectors to police departments. One little problem — the drugs were almost expired. And remember that NIH alcohol study where scientists courted the industry for funding? It was yanked after an internal investigation revealed that “so many lines” were crossed that “people were frankly shocked.”

The New York Times: Veterans Owe the D.O.D. Thousands for Survivor Benefits. Why Can’t They Opt Out?

Stat: Sarepta’s Gene Therapy for Duchenne Raises Hopes for ‘Real Change’

Stat: Drug Maker’s Donations of Overdose Antidote Were Close to Expiring

The New York Times: It Was Supposed to Be an Unbiased Study of Drinking. They Wanted to Call It ‘Cheers.’

And, as we head into the weekend, a question you can consider: What would you sacrifice for cheaper premiums?

Cigna To Step Into War Against Opioid Epidemic

The health insurer plans to use predictive analytics to identify customers who are at the highest risk for an opioid overdose and develop partnerships in those areas to help combat the crisis. In other news: the government pulls funding for a pain relief training; a lobbying blitz has been launched on Capitol Hill as lawmakers vote on opioid measures; and more.

Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass

What’s the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section?

That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation’s epidemic of opioid overuse and abuse.

The answer isn’t clear-cut.

Surgeon Marty Makary wondered why and what could be done.

So, Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures.

After all, most doctors usually make this decision based on one-size-fits-all recommendations, or what they learned long ago in med school.

Even Makary admitted that for most of his career he “gave [painkillers] out like candy.”

In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: What should we be prescribing for operation X?”

The answer was illuminating.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, says Dr. Marty Makary, who’s leading an effort to curb overprescribing by offering procedure-specific guidelines for opioid painkillers. (Courtesy of Johns Hopkins Medicine)

“The head of the hospital’s pain services said, ‘You’re the surgeon, what do you think?’” recalled Makary.

Makary didn’t know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.

“Wow,” recalls Makary of that day when they first considered appropriate limits. “We’re the experts, the heads of this and that, and we don’t know.”

After a quick couple of weeks of intense discussion, Makary’s group reached consensus and gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 different common surgical situations, from relatively minor procedures to coronary bypass surgery.

“We’re in a crisis,” said Makary, explaining why the group didn’t go a more traditional route and publish its findings in a medical journal first, which could take months.

Sometimes the right number of opioids is zero, concluded the group.

Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or after cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages.

For certain types of knee surgery, such as arthroscopic meniscectomy, the guidelines recommend no more than 12 pills upon discharge, while a patient going home after an open hysterectomy could require as many as 20.

Optimally, “no one should be given more than five or 10 opioid tablets after a cesarean section,” Makary said.

Oh, and for cardiac bypass surgery? No more than 30 pills.

But What About The Pain?

Tens of thousands of Americans are dependent upon opioid medications. An increasing number are dying from overdoses, both from prescription medication and street drugs.

Knowing that, Makary, as well as other surgeons, hospitals and organizations, are taking steps to change how they practice medicine.

After all, many experts view the use of opioid prescription painkillers after surgery as a gateway to long-term use or dependence. A study published last year in the journal JAMA Surgery found that persistent use of opioids was “one of the most common complications after elective surgery.”

In that study, University of Michigan researchers found that 6 percent of people who had never taken opioids but received them after surgery were still taking the medications three to six months later.

With about 50 million surgeries that occur in the U.S. each year, “there are millions who may become newly dependent,” said Chad Brummett, the study’s lead author and an associate professor of anesthesiology at the University of Michigan Medical School.

Smokers, and those diagnosed with certain conditions such as depression, anxiety or chronic pain before their operations, were most at risk of long-term use.

Each refill or additional week of use makes for a greater risk of misuse, other studies have shown.

Additional research points to another reason for concern. If patients don’t take all the pills they are prescribed following an operation, those pills can be stolen or diverted to other people, who then run the risk of becoming dependent.

Still, there is debate in medical circles about just how effective recommendations and guidelines will be in stemming the epidemic.

For one thing, some experts worry that if the fight against opioids focuses only on safe prescribing at the expense of seeking alternatives, it may miss the bigger picture.

“Are there better methods than opioids in the first place?” asks Lewis Nelson, chair of emergency medicine at Rutgers New Jersey Medical School. “Could you put a lidocaine patch over the wound or is there a better way to immobilize a joint?”

Studies have shown that sometimes a combination of ibuprofen and acetaminophen can be just as good as or better than opioids.

Alternatives should always be considered first, agreed Makary.

Another concern is that guidelines for prescribing relief — even those aimed at short-duration, acute pain, such as that following surgery — have carryover effects on patients with long-term pain. Advocates say all the attention around prescribing limits have made it difficult for chronic pain patients to get the medications they need.

Some people even apply these concerns to recommendations about the treatment of acute pain.

“It’s important for a physician to have the ability, if they feel there’s a medical necessity, to write a prescription for a longer duration,” said Steven Santos, president of the American Academy of Pain Medicine. “It’s challenging to lump all patients into one basket.”

A Different Focus: Duration

Lawmakers — desperate to address overdose problems that are destroying families and communities — have gone where they usually don’t: setting specific rules for doctors.

Legislatures in more than a dozen states, including New Jersey, Massachusetts and New York, have set restrictions, often on the number of days’ worth of pills prescribed for acute pain.

“States said that since physicians haven’t self-regulated, we’re going to do it for them,” said Nelson at Rutgers.

Congress, too, is getting involved, holding a flurry of hearings this spring, and considering legislation that would, among other things, set limits on prescribing opioids for acute pain. The recently passed federal spending bill includes $3 billion in new funding to help states and local governments with opioid prevention, treatment and law enforcement efforts.

To be sure, the medical profession has also responded to the crisis — with medical societies and other expert groups offering a growing number of standards for prescribing opioids.

Some are fairly generic, recommending the lowest dose for the shortest period of time for acute pain. Some are more prescriptive.

None is meant to address the needs of chronic pain patients or those with cancer.

And state rules vary. New Jersey’s, for example, says patients with acute pain should, initially, get no more than a five-day supply, while Massachusetts sets the cap at seven days for a patient prescribed opiates for the first time.

The Centers for Disease Control and Prevention recommends three days.

Makary and some other experts say that, while well-intentioned, such durational rules are too blunt.

A day’s worth of pills can vary, depending on how often the doctor instructs patients to take them. Under many of the state rules, patients could still head home with more than 50 pills.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, said Makary.

Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management, supports guidelines but wants states to take their rules a step further.

“I don’t think the way the states are going at this makes much sense because the issue with overprescribing was quantity, yet they’re passing laws around duration,” he said.

Instead, the laws should require that “if physicians are going to prescribe more than three days, they have to warn the patients that this is an addictive drug and that taking it every day for as little as five days may cause them to become physiologically dependent,” Kolodny said.

That would create a disincentive to prescribing more than three days’ worth of opioid painkillers, he added, and lead to more informed patients among those who need a longer supply.

Rutgers’ Nelson, who sat on the CDC panel that developed recommendations, said durational rules — like those adopted by the states — can be effective.

“I personally think three days is enough,” said Nelson. “That doesn’t mean pain goes away in three days, but most people get better within three to five days.”

That said, Nelson called the Hopkins’ approach an “excellent idea” and one he has tried to do. “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.

To get around overprescribing — or setting one-size-fits-all guidelines — physicians at Dartmouth-Hitchcock Medical Center have a developed their own data-based approach.

Dr. Richard Barth, the chief of general surgery at Dartmouth, and colleagues studied 333 patients discharged from the hospital following six common surgeries that included bariatric procedures; operations on the stomach, liver, colon and pancreas; and hernia repair.

Surveying the patients, they asked how many opioid pills they went home with, how many they actually took, how many went unused and how much pain they experienced.

The data helped them land on a way to recommend a specific number of pills. “If they took none the day before discharge, then over 85 percent of patients did not take any when they went home,” said Barth.

Dartmouth-Hitchcock now uses that data as a recommended starting point for physicians.

Under the guidelines, patients taking no opioid pain pills the day before discharge go home with none. Those who take one to three pills get 15, an amount Barth’s study found satisfied 85 percent of patients, and those who took four or more get 30 pills.

“We came out with a very easy to implement and remember guideline,” said Barth. “We actually called patients and asked them how many [pills] they used. That’s what differentiates us from other places.”

Brummett, at Michigan, says the Opioid Prescribing Engagement Network, a collaboration of hospitals, insurers, physicians and others in his state, has used similar data methods to come up with procedure-specific guidelines.

“We’ve taken a data-driven approach,” he said. “We believe patient-reported outcomes are a better way to guide than expert consensus.”

For his part, Makary admitted it is harder to develop guidelines like those at Hopkins and Dartmouth, but he said the effort is vital.

“It’s mind-boggling to me” that so many opioid-prescribing guidelines do not specify the procedure, said Makary. “An ingrown toenail is not the same as cardiac bypass surgery.”

Researcher Zeroes In On The Pre-Clinical Phase Of Alzheimer’s As Way To Stop Disease From Progressing

Reisa Sperling looks at the ten to fifteen year span before the onset of the disease when patients already have build-up of a protein that is believed to trigger the deterioration of the brain. In other public health news: pancreatic cancer, gout, depression, genetic testing, grandchildren for hire, and more.

Risk Level For Harmful Chemicals In Drinking Water Needs To Be 7-to-10 Times Lower Than EPA Recommended, Study Finds

“This study confirms that the EPA’s guidelines for PFAS levels in drinking water woefully underestimate risks to human health,” said Olga Naidenko, senior science adviser at the Environmental Working Group. Other news on the safety of drinking water comes from New York and Cleveland.

Intimidation, Fear Used To Prevent Potential Whisteblowers From Speaking Out, VA Employees Claim

“If you say anything about patient care and the problems, you’re quickly labeled a troublemaker and attacked by a clique that just promotes itself. Your life becomes hell,” said one longtime employee at the Central Alabama Veterans Health Care System. In other veterans’ health care news: a lawsuit over burn pits, the nomination hearing for the president’s pick to lead the VA, and staffing issues at medical centers.

Atul Gawande Says U.S. Health System Is ‘Very Expensive Pile Of Junk.’ As Head Of Billionaires’ Initiative, Will He Be Able To Fix It?

The health world has been closely watching to see who Amazon, Berkshire Hathaway and JPMorgan Chase would choose to lead their health care initiative geared toward reining in astronomical costs. Atul Gawande, a highly respected doctor and writer on health care policy, is a “well-known luminary” in the field, but the pick was also a surprise to some because he lacks hands-on experience running a large organization.