From Medicine and Health

Must-Reads Of The Week (Some Flying Below The Radar)

Your wonderfully entertaining compiler of “The Friday Breeze,” Brianna Labuskes, is off today, so I’m jumping in to keep you abreast of this week’s vital health care news. Here’s what I found most fascinating, some of it far away from the headlines.

Let’s dive into my “Department of Health Studies,” where I found several worthy of your time.

First, the scourge of fentanyl drug overdoses is rising most sharply among African-Americans. The CDC’s National Center for Health Statistics, which did the study, said the synthetic opioid is also a factor in the rise of death rates across other demographic groups.

The Washington Post: Fentanyl Drug Overdose Deaths Rising Most Sharply Among African Americans

A group of academics studying anti-vaccination posts on Facebook found that it’s not just the unfounded fear of autism driving the sentiment. While 86 percent of the posters were women, their motivation varied from conspiracy — as in poliovirus does not exist and pesticides caused the clinical symptoms of polio — to a belief in alternative medicine — eating yogurt cures human papillomavirus.

Science Direct: It’s Not All About Autism: The Emerging Landscape of Anti-Vaccination Sentiment on Facebook

Many news outlets reported on a study on the Apple Watch and its heavily promoted ability to detect an irregular heartbeat. The Apple-funded study, which has not been published or peer-reviewed, concluded the watch works.

CNN: Apple Watch App Could Detect Life-Threatening Irregular Heartbeat, Study Says

Moving on to data, the Robert Wood Johnson Foundation issued its county health rankings this week. It’s a user-friendly display of a matrix of health indicators that lets you spot the country’s trouble spots. This year’s report, the foundation explains, tried to get at the relationship of the cost of housing to health. “The research reveals that in the most segregated counties nearly one in four black households spends more than half their income on housing, compared with one in 10 white households.”

Robert Wood Johnson Foundation: How Healthy Is Your Community?

Doctors will like this one: a study comparing hospital CEO salaries — nonprofit hospital CEOs, mind you — with physician salaries. CEO salaries are five times higher than surgeons’ salaries, up from a ratio of 3-to-1 only 10 years earlier.

Healthcare Dive: CEO Salaries at Nonprofit Hospitals Up 93% Since 2005

Drug prices remain the hot topic this week in health care news. The BBC looked at the high drug prices in the U.S. compared with the prices in Great Britain and chortled a bit.

BBC News: The Human Cost of Insulin in America

Elisabeth Rosenthal, the editor-in-chief of KHN, wrote an analysis in The New York Times of Eli Lilly’s baffling public relations move to cut insulin prices in the U.S. with an “authorized generic.” She writes, “It is, perhaps, a sign of how desperate Americans are for something — anything — to counteract the escalating price of drugs that Lilly’s move was greeted with praise rather than a collective ‘Huh?’”

The New York Times: Why Should Americans Be Grateful for $137 Insulin? Germans Get It for $55

While we are on the topic of the high cost of health care, the federal government’s General Accountability Office issued a report on air ambulances and the sky-high bills the companies send patients. (KHN featured the problem in its “Bill of the Month” series and the St. Louis Post-Dispatch did some excellent pieces on the problem last year.) Bob Herman of Axios noted that the report found that the median price of medical helicopter transport in 2017 was $36,400.

Government Accountability Office: Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk

I’d be remiss if I didn’t mention a fabulous article by another KHN staffer, Fred Schulte, who with Erika Fry of Fortune magazine wrote about the mess that electronic health records have become. It’s long, but so good at illuminating a problem that is largely invisible to patients.

Fortune: Death by a Thousand Clicks: Where Electronic Health Records Went Wrong

The Baltimore Sun produced a great graphic, a live map of sewage pollution in the city. The accompanying article says: “More than 14 million gallons of sewage-tainted water has washed into Baltimore streams over the past two months, but city officials haven’t alerted the public of the contamination.”

The Baltimore Sun: Baltimore Launches Live Map of Sewage Pollution — and Temporarily Stops Alerting the Public to Contamination

Enjoy the weekend with this selection of things to read.

‘A Huge Step Forward’: Research Breakthrough Sparks Hope For Preserving Fertility Of Young Boys With Cancer

“Fertility issues for kids with cancer were ignored” for years, said University of Pittsburgh reproductive scientist Kyle Orwig. “Many of us dream of growing up and having our own families. We hope our research will help these young patients to do that.” Until now, boys hadn’t had a realistic option to preserve their fertility, but that may be changing.

The Dark Side Of Artificial Intelligence: Increased Efficiency Comes With Ominous Threat Of Vulnerability To Hackers

A report warns that artificial intelligence can be easily duped with tiny pieces of data. The authors say bad actors could hack into records and make it seem like there’s an illness there that isn’t. But more likely is that doctors, hospitals and other organizations could manipulate the A.I. in billing or insurance software in an effort to maximize the money coming their way. In other health technology news: a day of reckoning is coming for digital health, the FDA calls for tighter security of electronic health records following a KHN report, and data breaches from the states.

Even With Insurance, She Faced $227K In Medical Bills. What It Took To Get Answers.

The first surprise was the massive heart attack, which struck as Debbie Moehnke waited in a Vancouver, Wash., medical clinic last summer.

“She had an appointment because her feet were swollen real bad,” said Larry Moehnke, her husband. “But she got in there and it was like, ‘I can’t breathe, I can’t breathe!’”

Her life suddenly at risk, the 59-year-old was rushed by ambulance, first to a local hospital, where she was stabilized, and then, the next day, to Oregon Health & Science University across the river in Portland for urgent cardiac care.

That meant heart bypass surgery, replacement of one valve and repair of another. Just as she recovered from that, Debbie Moehnke developed a raging infection that required powerful IV antibiotics to treat. She spent a month in the hospital, some of it in intensive care, before she was discharged home.

That’s when she got the next surprise: Bills totaling more than $454,000 for the medical miracle that saved her life. Of that stunning amount, officials said, she owed nearly $227,000 after her health insurance paid its part.

“I wish I would have known. I would have said ‘no’ to life support,” said Debbie Moehnke, a former cocktail waitress who suffers from signs of early-onset dementia. “We’ll lose everything.”

Large “surprise bills” like the Moehnkes received have become a national epidemic outraging patients and politicians alike. Solutions have been elusive to date, even in a progressive state like Washington.

Lawmakers in Olympia this year are trying for the fourth time to pass legislation banning the practice that leaves consumers with huge out-of-pocket costs.

“Everybody agrees we’ve got to get the consumer out of being stuck in between,” said Mike Kreidler, the state insurance commissioner who has repeatedly backed the proposals.

While the protection would be beneficial to patients, there has been formidable and effective pushback from insurers, hospitals and doctors.

The central issue is money. Such surprise bills, or “balance bills,” typically occur when a patient’s insurer and a hospital or doctor not in its network don’t agree on what treatment is worth. The insurer — LifeWise Health Plan of Washington, in this case — pays what it judges to be fair. Providers then bill patients for the balance, which can easily tally tens if not hundreds of thousands of dollars.

As of December, 25 states had laws providing protection against balance bills, according to the Commonwealth Fund. Those laws take consumers out of the middle in billing disputes and force providers and insurers to negotiate directly for payment.

When an insurer and a provider disagree about how much a service is worth, who decides the legitimate charge? The proposed bills in Washington state use a “commercially reasonable” rate as the standard. But what does that mean in a country where medical prices are so variable?

“We need to make sure that any law that is enacted doesn’t tilt the scale toward one side or another,” said Chelene Whiteaker, senior vice president of government affairs for the Washington State Hospital Association.

The Washington state legislation borrows from a 2015 New York law that sends insurers and providers to baseball-style binding arbitration if they can’t come to an agreement about costs. Both parties remain cautious.

“I hope they will give up the idea that this is a chance to stick it to doctors,” said Dr. Nathan Schlicher of the Washington State Medical Association.

Leonard Sorrin, vice president of congressional and legislative affairs for Premera Blue Cross, which operates LifeWise, said in a statement that his organization is working for legislation that prevents balance billing, but also “maintains a contracting balance that allows health plans to build networks for members and pays the provider a fair rate.”

While patients can generally avoid balance billing by staying in-network, a life-or-death emergency such as Debbie Moehnke’s can make that impossible. Also, many in-network hospitals often use out-of-network doctors, leaving patients vulnerable to surprise charges.

So much money is at stake that, even when they exist, laws are filled with loopholes and offer only patchwork protection. For example, hospitals are not prohibited from sending balance bills; patients have to know they’re protected by law and go to considerable effort to contest them.

And about 60 percent of employer-based plans are governed by federal rather than state law. There is currently no federal prohibition against balance billing, although a bipartisan bill to end the practice was proposed last year.

Oregon, where Debbie Moehnke was treated, does have a law banning surprise bills, which took effect last year. But it applies only to out-of-network charges sent to a patient who received care at an in-network provider. And it covers only insurers regulated in the state, which excludes the Moehnkes’ plan, according to state insurance officials.

The proposed Washington legislation would ban balance billing for most of the state’s nearly 6 million insured consumers under age 65. But it could skip about 2 million people who get coverage through employers with self-funded plans. Those plans are regulated by a federal law, called ERISA, shorthand for the Employee Retirement Income Security Act of 1974, which doesn’t prohibit balance billing.

Self-insured employers would be allowed, but not required, to participate in provisions of the new law, if approved.

So far, however, change has come too slowly for families like the Moehnkes, who found themselves facing crushing bills, despite buying a well-subsidized plan on the state’s insurance exchange. In Debbie Moehnke’s case, the full bill from OHSU and affiliated providers was $454,550.54. Her insurance paid $227,959.19.

That left the Moehnkes with bills totaling $226,591.35.

“What do you think you’re going to do, squeeze blood out of a turnip?” said Larry Moehnke, 70, a big-rig truck driver.

Married 32 years, the Moehnkes and their two dogs, Coco and Belle, live in a 47-year-old mobile home in rural southwestern Washington. Larry Moehnke hasn’t been able to work since health problems of his own developed after his wife’s heart attack. They’re getting by on his Social Security income of $1,884 a month.

Charges for Debbie Moehnke’s emergency care totaled more than $454,000. Her health insurance plan agreed to pay about half the costs, leaving the couple responsible for the rest. With help from a patient advocate, the bill was eventually erased.(Michael Hanson for KHN)

LifeWise spokesman Bo Jungmayer said the insurer paid for her emergency care to the extent required under the Affordable Care Act.

Debbie Moehnke was hospitalized at OHSU from Aug. 14 to Sept. 12, 2018. She was initially admitted for her emergency heart treatment. While there, she developed an unidentified infection that required two additional weeks of care.

Only later did the couple learn that she could have been transferred to an in-network hospital, potentially saving tens of thousands of dollars.

“They never said anything about not being ‘in network’ or anything,” Larry Moehnke said.

Debra Tomsen, OHSU’s director of hospital billing and coding, said LifeWise officials should have notified the Moehnkes after receiving bills for nearly $250,000 halfway through her stay.

“Insurance should tell them they’re incurring out-of-pocket costs,” she said.

Jungmayer, of LifeWise, said it was up to OHSU to let Debbie Moehnke know about the high bills — and about the option to transfer to another hospital.

“Typically we allow that conversation between the provider and the patient while they’re there,” he said. “I don’t know why OHSU didn’t ask them.”

Early this month, after repeated inquiries about Debbie Moehnke’s care — first from a reporter, then from a patient advocate alerted by the Washington state insurance commission — the couple’s outstanding bills were resolved.

With the help of Jared Walker, who runs Dollar for Portland, a nonprofit group, the couple applied for a medical charity care waiver, in itself a complicated process. OHSU officials granted the waiver, erasing the sky-high debt.

“Their balance is now zero,” OHSU spokeswoman Tamara Hargens-Bradley confirmed in an email.

The Moehnkes are relieved, but they said they resent that they endured the stress of mounting bills and collection calls for six months when there was a solution available.

“Nobody ever said anything about charity care,” said Larry Moehnke.

That’s not how the process should work, said Kreidler.

“It shouldn’t be one where the squeaky wheel gets help,” he said. “There should be fairness and equality in the system. You shouldn’t have to file a complaint. This should be ingrained into the system so that when you have a problem and you’re due relief, you get it.”

Aspiring Doctors Seek Advanced Training In Addiction Medicine

The U.S. Surgeon General’s office estimates that more than 20 million people have a substance use disorder. Meanwhile, the nation’s drug overdose crisis shows no sign of slowing.

Yet, by all accounts, there aren’t nearly enough physicians who specialize in treating addiction — doctors with extensive clinical training who are board-certified in addiction medicine.

The opioid epidemic has made this doctor deficit painfully apparent. And it’s spurring medical institutions around the country to create fellowships for aspiring doctors who want to treat substance use disorder with the same precision and science as other diseases.

Now numbering more than 60, these fellowship programs offer physicians a year or two of postgraduate training in clinics and hospitals where they learn evidence-based approaches for treating addiction.

Such programs are drawing a new, talented generation of idealistic doctors — idealists like Dr. Hillary Tamar.

Driven To Connect With Patients In Need

Tamar, now in the second year of a family medicine residency in Phoenix, wasn’t thinking about addiction medicine when she first started medical school in Chicago.

“As a medical student, honestly, you do your ER rotation, people label a patient as ‘pain-seeking,’ and it’s bad,” Tamar said. “And that’s all you do about it.”

But in her fourth year of med school, she happened to be assigned to a rotation at a rehab facility in southern Arizona.

“I was able to connect with people in a way that I haven’t been able to connect with them in another specialty,” the 28-year-old recalled.

Working with patients there transformed Tamar’s understanding of addiction, she said, and showed her the potential for doctors to change lives.

“They can go from spending all their time pursuing the acquisition of a substance to being brothers, sisters, daughters [and] fathers making breakfast for their kids again,” she said. “It’s really powerful.”

When Tamar finishes her residency, she plans to pursue a fellowship in addiction medicine. She sees addiction medicine, like primary care, as a way to build lasting relationships with patients — and a way to focus on more than a single diagnosis.

“I love when I see addiction patients on my schedule, even if they’re pregnant and on meth,” she said. “More room to do good — it’s exciting.”

Build A Program And They Will Come

Doctors with Tamar’s enthusiasm are sorely needed, said Dr. Anna Lembke, medical director of Addiction Medicine at Stanford University School of Medicine and a longtime researcher in the field.

“Even 10 years ago,” Lembke said, “I couldn’t find a medical student or resident interested in learning about addiction medicine if I looked under a rock. They were just not out there.”

But Lembke sees a change in the upcoming generation of doctors drawn to the field because they care about social justice.

“I now have medical students and residents knocking on my door, emailing me; they all want to learn more about addiction,” Lembke said.

Historically, the path to addiction medicine was through psychiatry. That model started to change in 2015, when the American Board of Medical Specialties — considered the gold standard in physician certification in the U.S. — recognized addiction medicine as a bona fide subspecialty and opened up the training to physicians from other medical fields.

Until then, Lembke said, there had been no way to get addiction fellowships approved through the nationally recognized Accreditation Council for Graduate Medical Education. And that made recruiting young talent — and securing funding for their fellowships — difficult.

Last year, ACGME began accrediting its first batch of addiction medicine fellowship programs.

“We have got an enormous gap between the need and the doctors available to provide that treatment,” Lembke said.

“At least the medical community has begun to wake up to consider not only their role in triggering this opioid epidemic, but also the ways they need to step up to solve the problem,” she said.

Laying The Foundation

When Dr. Luke Peterson finished his residency in family medicine in Phoenix in 2016, there were no addiction medicine fellowships in Arizona.

So he moved to Seattle to complete a year-long fellowship at Swedish Cherry Hill Family Medicine Residency. There he learned, among other things, how to treat pregnant women who are in recovery from drug use.

“I really needed to do a fellowship if I was going to make an impact and be able to teach others to make the same impact,” said Peterson, who went on to help found an addiction medicine fellowship program in Arizona. His program is based in Phoenix at the University of Arizona’s medical school and its teaching hospital, run by Banner Health and the Phoenix VA.

Arizona’s two addiction medicine fellowships received ACGME accreditation last year — a stamp of approval that made the programs desirable choices for up-and-coming physicians, Peterson said.

Not every doctor who plans to treat substance use disorder needs to do a fellowship, he said. In fact, his goal is to integrate addiction medicine into primary care settings.

But a specialist can serve as a referral center and resource hub for community doctors.

For example, physicians can learn from a specialist such as Peterson how to provide medication-assisted treatment like buprenorphine.

Public health leaders have been pushing to get more physicians trained in evidence-based treatment like buprenorphine, which has been shown to reduce the risk of death among people who have recovered from an opioid overdose.

“As we provide more education and more support to primary care physicians, they will feel more comfortable screening and treating for addiction,” Peterson said.

Peterson’s own journey into addiction medicine began during a rotation with a family doctor in rural Illinois.

“In moments that most doctors find uncomfortable — maybe a patient comes in to request pain medication and you’re seeing the negative side effects — he did not shy away from that situation,” Peterson said. “He addressed it head-on.”

It was a formative experience for Peterson — one he wants other young doctors to have. And he recognizes the urgency.

“In 20 or 30 years from now,” Peterson said, “those medical students are going to look back at my current generation of doctors, and we will be judged by how we responded to this epidemic,” in the same way he and his peers now look back at how doctors handled the HIV epidemic.

One of the first steps in stopping the epidemic, he said, is making sure there are enough doctors on the ground who know how to respond.

Many of today’s medical students, people like Michelle Peterson (no relation to Luke), say they feel the calling, too.

She’s in her first year at the University of Arizona College of Medicine and became interested in addiction after working at an outpatient treatment center.

She said she’s already learning about addiction in her classes, hearing from doctors in the field and seeing others classmates equally engaged.

“It’s definitely not just me,” she said. “There are quite a few people here really interested in addiction.”

It’s a trend she and her mentors hope will continue.

This story is part of a partnership that includes KJZZ, NPR and Kaiser Health News.

FDA Chief Calls For Stricter Scrutiny Of Electronic Health Records

Food and Drug Administration Commissioner Scott Gottlieb on Wednesday called for tighter scrutiny of electronic health records systems, which have prompted thousands of reports of patient injuries and other safety problems over the past decade.

“What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients,” Gottlieb said in an interview with Kaiser Health News.

Gottlieb was responding to “Botched Operation,” a report published this week by KHN and Fortune magazine. The investigation found that the federal government has spent more than $36 billion over the past 10 years to switch doctors and hospitals from paper to digital records systems. In that time, thousands of reports of deaths, injuries and near misses linked to EHRs have piled up in databases — including at least one run by the FDA.

Gottlieb said Congress would need to enact legislation to define when an electronic health record would require government oversight. He said that the digital records systems, which store a patient’s medical history, don’t fit neatly under the agency’s existing mandate to regulate items such as drugs and medical devices.

Gottlieb said the best approach might be to say that an EHR that has a certain capability becomes a medical device. He called EHRs a “unique tool,” noting that the risks posed by their use aren’t the same as for a traditional medical device implanted in a patient. “You need a much different regulatory scheme,” he said.

The 21st Century Cures Act of 2016 excludes the FDA from having oversight over electronic health records as a medical device.

Gottlieb said that health IT companies could add new functions that would improve EHRs, but they have been reluctant to do so because they didn’t want their products to fall under FDA jurisdiction. He added that he was “not calling” for FDA to take over such a duty, however, and suggested that any new approach could be years away. Proponents have long argued that widespread use of EHRs can make medicine safer by alerting doctors to potential medical errors, though critics counter that software glitches and user errors may cause new varieties of medical mistakes.

How closely the FDA should watch over the digital medical record revolution has been controversial for years. The agency’s interest in the issue perked up after Congress decided in February 2009 to spend billions of dollars on digital medical records as part of an economic stimulus program.

At the time, many industry groups argued that FDA regulation would “stifle innovation” and stall the national drive to bring medicine into the modern era. Federal officials responsible for doling out billions in subsidies to doctors and hospitals generally sympathized with that view and were skeptical of allowing the FDA to play a role.

The debate became public in February 2010, when Jeffrey Shuren, an FDA official, testified at a public hearing that the agency had tied six deaths and more than 200 injuries to health information technology. In all, the FDA said, it had logged 260 reports in the previous two years of “malfunctions with the potential for patient harm.”

The agency said the findings were based largely on reports voluntarily submitted to the FDA and suggested “significant clinical implications and public safety issues.” In one case cited, lab tests done in a hospital emergency room were sent to the wrong patient’s file. Since then, several government and private repositories have associated thousands of injuries, near misses and deaths to EHR technology.

Shuren said in 2010 that the agency recognized that health information technology had great potential to improve patient care, but also needed oversight to “assure patient safety.”

While some safety proponents agree that EHRs offer tremendous benefits, they also see a greater opportunities to improve their safety.

Dean Sittig, a professor of bioinformatics and bioengineering at the University of Texas Health Science Center, said EHRs have improved safety within the health care system, but they have not eliminated errors to the extent that he would have expected. Federal officials were initially pushing for rapid adoption and “there wasn’t a lot of interest in talking about things that could go wrong,” Sittig told KHN and Fortune.

Earlier this month, Gottlieb announced his resignation from the FDA. His last day is scheduled to be April 5.

KHN correspondents Sarah Jane Tribble, Sydney Lupkin and Julie Rovner contributed to this report.

Podcast: KHN’s ‘What The Health’ Surprise! Fixing Surprise Medical Bills Is Harder Than it Looks

Surprise medical bills — when patients receive an unexpected bill from a health provider not in their insurance network — are among the few problems in health care just about everyone wants to solve. But it turns out that no one in the health industry wants to take responsibility for paying those bills. That could complicate efforts toward a legislative fix, despite bipartisan support.

And the 2020 presidential campaign is already in full swing, with candidates staking out some surprisingly diverse positions on how to expand access to health care.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Alice Miranda Ollstein of Politico.

Also, Rovner interviews Scott Gottlieb, the commissioner of the Food and Drug Administration, who is stepping down in early April.

Among the takeaways from this week’s podcast:

  • State and federal lawmakers of both parties and industry groups say they want to find a way to protect patients from getting surprise bills from out-of-network doctors and hospitals after treatment. But they can’t find agreement on a way to fix the system.
  • Efforts to end surprise bills generally fall into two categories: setting rates for out-of-network services (which might be based on some percentage of Medicare rates) or requiring patients and providers to go through an arbitration process (a technique some states are using).
  • Among Democratic candidates for president, the push for switching to a “Medicare-for-all” system appears to be moderating a bit as more centrists call for less sweeping changes in the health care system, hoping to avoid blowback from people who like their current insurance and a united opposition from industry groups.
  • The Trump administration’s budget proposal would put money behind the effort to stop the spread of HIV. But while medical advances have made HIV eradication possible, obstacles remain, including the difficulty of reaching many of the communities that need the support.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Fortune’s “Death by a Thousand Clicks: Where Electronic Health Records Went Wrong,” by Erika Fry and KHN’s Fred Schulte

Joanne Kenen: NBC’s “Surprise Medical Bills Lead to Liens on Homes and Crippling Debt,” by Lindsey Bomnin and Stephanie Gosk

Anna Edney: Stat News’ “The Astounding 19-Year Journey to a Sea Change for Heart Patients,” by Matthew Herper

Alice Miranda Ollstein: The New York Times’ “States Seek Financial Relief for Family Caregivers,” by KHN’s Samantha Young

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Adolescents Treated With Some ADHD Drugs Like Adderall May Be At Higher Risk Of Having Psychotic Event

The risk is “low enough that you can’t say, ‘just don’t prescribe Adderall,’” said Dr. Lauren Moran, the study’s lead author. “But from a public health perspective, there’s so many millions of people being prescribed these medications that it actually leads to thousands of people at increased risk of psychosis.” In other public health news: Zika, sugary drinks, depression and more.