Listen: A Sudden Freeze On ACA Payouts And What It Means For You
Over the weekend, Seema Verma, administrator for the federal Centers for Medicare & Medicaid Services, said she was suspending $10 billion in “risk adjustment” payments that helped stabilize the insurance markets created under the health law. Julie Rovner, chief Washington correspondent and host of KHN’s What The Health podcast, explains the national picture on the Takeaway for WNYC: Can’t see the audio player? Click here to download. Chad Terhune, senior correspondent, explains the effects of this development in California and other states for South California Public Radio: Can’t see the audio player? Click here to download. They examine what health insurers and Covered California officials have described as another curveball from the Trump administration meant to weaken the Affordable Care Act. Verma said the “risk-adjustment” payments and collections had to be halted in response to a New Mexico court ruling in February that said elements of the program were flawed. Another court in Massachusetts had upheld the program in January. The risk-adjustment program was meant to stabilize the insurance exchanges by taking money made through low-risk consumers and shifting it to higher-risk pools. The federal government collects money from some insurers that enrolled healthier patients and then transfers money to other insurers who had sicker enrollees. Because the Affordable Care Act requires insurers to accept all people regardless of their medical history or preexisting conditions, architects of the law created the program to prevent insurance companies from cherry-picking the healthiest people. The Republican-led Congress failed last year to repeal and replace the ACA. However, Republican lawmakers and the Trump administration have made a series of moves intended to weaken the health law, such as halting subsidies that covered some consumers’ out-of-pocket costs and eliminating the penalty. This story originally appeared on Kaiser Health News (KHN) Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
More Nurse Practitioners Now Pursue Residency Programs To Hone Skills
By Michelle Andrews, Kaiser Health News contributing columnist The patient at the clinic was in his 40s and had lost both his legs to Type 1 diabetes. He had mental health and substance abuse problems and was taking large amounts of opioids to manage pain. He was assigned to Nichole Mitchell, who in 2014 was a newly minted nurse practitioner in her first week of a one-year postgraduate residency program at the Community Health Center clinic in Middletown, Conn. In a regular clinical appointment, “I would have been given 20 minutes with him, and would have been without the support or knowledge of how to treat pain or Type 1 diabetes,” she said. But her residency program gives the nurse practitioners extra time to assess patients, allowing her to come up with a plan for the man’s care, she said, with a doctor at her side to whom she could put all her questions. A few years later, Mitchell is still at that clinic and now mentors nurse practitioner residents. She has developed a specialty in caring for patients with HIV and hepatitis C, as well as transgender health care. The residency program “gives you the space to explore things you’re interested in in family practice,” Mitchell said. “There’s no way I could have gotten that training without the residency.” Mitchell is part of a growing cadre of nurse practitioners — typically, registered nurses who have completed a master’s degree in nursing — who tack on up to a year of clinical and other training, often in primary care. Residencies may be at federally qualified health centers, Veterans Affairs medical centers or private practices and hospital systems. Patients run the gamut, but many are low-income and have complicated needs. Proponents say the programs help prepare new nurse practitioners to deal with the growing number of patients with complex health issues. But detractors say that a standard training program already provides adequate preparation to handle patients with serious health care needs. Nurse practitioners who choose not to do a residency, as the vast majority of the 23,000 who graduate each year do not, are well qualified to provide good patient care, they say. As many communities, especially rural ones, struggle to attract medical providers, it’s increasingly likely that patients will see a nurse practitioner rather than a medical doctor when they need care. In 2016, nurse practitioners made up a quarter of primary care providers in rural areas and 23 percent in non-rural areas, up from 17.6 and 15.9 percent, respectively, in 2008, according to a study in the June issue of Health Affairs. Depending on the state, they may practice independently of physicians or with varying degrees of oversight. Research has shown that nurse practitioners generally provide care that’s comparable to that of doctors in terms of quality, safety and effectiveness. But their training differs. Unlike the three-year residency programs that doctors must generally complete after medical school in order to practice medicine, nurse practitioner residency programs, sometimes called fellowships, are completely voluntary. Like medical school residents, though, the nurse practitioner residents work for a fraction of what they would make at a regular job, typically about half to three-quarters of a normal salary. Advocates say it’s worth it. “It’s a very difficult transition to go from excellent nurse practitioner training to full scope-of-practice provider,” said Margaret Flinter, a nurse practitioner who is senior vice president and clinical director of Community Health Center, a network of community health centers in Connecticut. “My experience was that too often, too many junior NPs found it a difficult transition, and we lost people, maybe forever, based on the intensity and readiness for seeing people” at our centers. Flinter started the first nurse practitioner residency program in 2007. There are now more than 50 postgraduate primary care residency programs nationwide, she said. Mentored clinical training is a key part of the programs, but they typically also include formal lectures and clinical rotations in other specialties. Not everyone is as gung-ho about the need for nurse practitioner residency programs, though. “There’s a lot of debate within the community,” said Joyce Knestrick, president of the American Association of Nurse Practitioners. Knestrick practices in Wheeling, W.Va., a rural area about an hour’s drive from Pittsburgh. She said that there could be a benefit if a nurse practitioner wanted to switch from primary care to work in a cardiology practice, for example. But otherwise she’s not sold on the idea. A position statement from the Nurse Practitioner Roundtable, a group of professional organizations of which AANP is a member, offered this assessment: “Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high quality, competent care. Additional post-graduate preparation is not required or necessary for entry into practice.” “We already have good outcomes to show that our current educational system has been effective,” Knestrick said. “So I’m not really sure what the benefit is for residencies.” This story originally appeared on Kaiser Health News (KHN) and NPR. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Outsiders Swoop In Vowing To Rescue Rural Hospitals Short On Hope — And Money
Barbara Feder Ostrov, Kaiser Health News Photos by Heidi de Marco (@heidi_demarco) CEDARVILLE, Calif. — Beau Gertz faced a crowd of worried locals at this town’s senior center, hoping to sell them on his vision for their long-beloved — but now bankrupt — hospital. In worn blue jeans and an untucked shirt, the bearded entrepreneur from Denver pledged at this town hall meeting in March to revive the Surprise Valley Community Hospital — a place many in the audience counted on to set their broken bones, stitch up cattle-tagging cuts and tend to aging loved ones. Gertz said that if they vote June 5 to let him buy their tiny public hospital, he will retain such vital services. Better still, he said, he’d like to open a “wellness center” to attract well-heeled outsiders — one that would offer telehealth, addiction treatment, physical therapy, genetic testing, intravenous vitamin infusions, even massage. Cedarville’s failing hospital, now at least $4 million in debt, would not just bounce back but thrive, he said. Gertz, 34, a former weightlifter who runs clinical-lab and nutraceutical companies, unveiled his plan to pay for it: He’d use the 26-bed hospital to bill insurers for lab tests regardless of where patients lived. Through telemedicine technology, doctors working for Surprise Valley could order tests for people who’d never set foot there. To some of the 100 or so people at the meeting that night, Gertz’s plan offered hope. To others, it sounded suspiciously familiar: Just months before, another out-of-towner had proposed a similar deal — only to disappear. Outsiders “come in and promise the moon,” said Jeanne Goldman, 72, a retired businesswoman. “The [hospital’s] board is just so desperate with all the debt, and they pray this angel’s going to come along and fix it. If this was a shoe store in Surprise Valley, I could care less, but it’s a hospital.” Looking For Salvation The woes of Surprise Valley Community Hospital reflect an increasingly brutal environment for America’s rural hospitals, which are disappearing by the dozens amid declining populations, economic troubles, corporate consolidation and, sometimes, self-inflicted wounds. Nationwide, 83 of 2,375 rural hospitals have closed since 2010, according to the North Carolina Rural Health Research Program. These often-remote hospitals — some with 10, 15, 25 beds — have been targeted by management companies or potential buyers who promise much but often deliver little while lining their own pockets, according to allegations in court cases, a Missouri state audit and media reports. Enticed by such outsiders, some struggling rural hospitals around the country have embraced lab billing for faraway patients as a rescue plan. That’s because Medicare and commercial insurers tend to pay more for tests to sustain endangered rural hospitals compared with urban hospitals and especially outpatient labs. In general, this kind of remote billing is controversial and legally murky, and it recently has resulted in allegations of fraud in several states, according to government documents and media reports. Rural hospital boards, however, tend not to have expertise in the health care business. The president of Surprise Valley Community’s board, for instance, is a rancher. Another board member owns a local motel; a third, a construction company. That lack of experience “leaves them vulnerable in many cases,” said Terry Hill of the nonprofit National Rural Health Resource Center, based in Duluth, Minn. Seeking to distinguish himself from other would-be rescuers who ran into legal trouble, Gertz described his proposal to residents as perfectly legal — a legitimate use of telemedicine, essentially remote treatment via electronic communication such as video. “If you do it correctly,” he said in an interview with Kaiser Health News, “there is a nice profit margin. There [are] extra visits you can get from telemedicine but … it has to be billed correctly and it can’t be abused.” Gertz runs several companies — founded within the last four years —including two labs, SeroDynamics and Cadira Labs, as well as a wellness company called CadiraMD. He pledged in court documents to buy the bankrupt hospital for $4 million and cover its debts, saying he had lined up a $4 billion New York company as a financial backer. Kaiser Health News was unable to locate the company under the name Gertz cited, Next Genesis Development Group. He did not respond to emails seeking clarification on the issue. Gertz, who acknowledged that he had never before run a hospital, was asked at the same gathering whether he had disclosed his “financials” to the hospital board. “As a private entity, I don’t have to show my financials and I have not provided my financials to the board,” he replied. It was not clear whether board members had ever asked. Surprise Valley Health Care District board President John Erquiaga declined to comment. A Sad Decline Surrounded by the Warner and Modoc mountains and forests in California’s northeastern corner, Surprise Valley is home to four small communities. The largest is Cedarville, population 514, at last count. The valley, covered in sagebrush and greasewood, is part of Modoc County, one of California’s poorest, with a median income of about $30,000. The closest hospital with an emergency room is roughly 25 miles away, over a mountain pass. One of hundreds of rural hospitals built with help from the 1946 federal Hill-Burton Act, the Surprise Valley hospital opened in 1952 to serve a thriving ranching community. But it has struggled since, closing in 1981, reopening as a health clinic in 1985, then reconverting to a hospital in 1986. A county grand jury report in 2014-15 found that “mismanagement of the [hospital district] has been evident for at least the past five years.” By last summer, those in charge didn’t seem up to the task of running a modern hospital. By then, it was hardly a hospital at all. Crushed by debt, it primarily offered nursing home care, an emergency room, a volunteer ambulance service and just one acute care bed, with three others available if needed. When state inspectors arrived last June, they found chaos.
For The Babies Of The Opioid Crisis, The Best Care May Be Mom’s Recovery
Sarah Jane Tribble, Kaiser Health News CARRBORO, N.C. — The halls at UNC Horizons daycare are quiet at 5 p.m. Amanda Williammee pauses at the toddler classroom window to watch 2-year-old daughter Taycee. “I like to peek in on her and see what she’s doing before she sees me,” Williammee nearly whispers. “I love watching her, it’s too funny.” There’s a dance party in progress and then Taycee spots her mom, screams and comes running to the door. “Did you dance?” Williammee says, leaning down to her daughter. It seems a typical preschool pickup, but it’s not. The University of North Carolina Horizons Program is a residential substance use disorder treatment center where mothers can bring their children. The kids attend school or daycare while mothers take classes and go to therapy sessions. Williammee, 25, has struggled with addiction since she was a 19-year-old college student. She injected opioids during both of her pregnancies, and her babies were born with neonatal abstinence syndrome, which includes withdrawal symptoms like tremors, irritability, sleep problems and high-pitched crying. She remembers that withdrawals were harder for toddler Taycee than they’ve been for 6-month-old Jayde. “It wasn’t just like we had this two-week period at the hospital of her being sick. Like, it went on for months because she did not sleep,” Williammee said, recalling that Taycee would sleep only for 20-minute stretches and needed constant swaddling. Sometimes, Williammee ran a warm bath for the baby to calm her. “She’d wake up and just be miserable,” Williammee said. On average, a baby is born every 15 minutes in the U.S. withdrawing from opioids, according to recent research. That staggering statistic raises concerns among doctors, social workers and mothers like Williammee who worry about how drug abuse while pregnant affects a baby’s health. Today, both Taycee and Jayde are developing normally. Still, Williammee wonders, how did the drugs affect their tiny bodies and brains? Research is just beginning to point toward the answers. A recent international multisite study tracked nearly 100 children and their mothers, who were in medically assisted treatment during their pregnancy, for 36 months. Hendrée Jones is executive director at UNC Horizons and co-authored the study. She offered reasons to be optimistic. “The children through time tended to score within the normal range of the tests that we had,” Jones said. Dr. Stephanie Merhar, a neonatologist at Cincinnati Children’s Hospital, released a separate study after growing increasingly worried the past few years as she treated children coming in for checkups. Her team reviewed the two-year charts of 87 infants who had been diagnosed with neonatal abstinence syndrome at birth. Each child had been given a standard test for 2-year-olds that evaluated cognitive, language and motor skills — the same assessment used in Jones’ study. What Merhar found was a call to action, she said. “Most of these children do well and they do within the normal range,” Merhar said. “But it’s important to know that there is a risk for some delays and that these children are monitored closely.” Still, exposure to opioids in utero does not appear to be as damaging as some other addictive substances. “It’s not like the fetal alcohol syndrome problem, where it really affects the brain,” Merhar said. “[Children with fetal alcohol syndrome] are at high risk of mental retardation and there’s significant developmental delays.” Merhar’s analysis found that about 8 percent of the children had been treated for strabismus, or lazy eye, by age 3. A number of the children that Merhar studied also scored at least one standard deviation below the mean in cognitive, language and motor abilities. The reason for those delays is unclear, though. Even more, the long-term outlook for the children is unknown, Merhar said. National experts like Dr. Jonathan Davis, who chaired a Neonatal Advisory Committee for the Food and Drug Administration, said the current research is reassuring but the essential long-term research isn’t being done yet. Davis, who is also chief of newborn medicine at Floating Hospital for Children at Tufts Medical Center, has passionately advocated for a national registry for babies exposed to drugs while in the womb. While current research doesn’t reveal any major motor, language, or cognitive delays, he said, it cannot answer questions like “How are these children going to function when they get to school? How are these children going to speak, socialize and interact?” Researchers are quick to point out that fear spread nationwide about the children of the crack cocaine epidemic of the 1980s and early ’90s. Dire predictions of developmental delays turned out to be grossly exaggerated, according to the National Institutes of Health. Dr. Lauren Jansson, director of pediatrics at the Center for Addiction and Pregnancy at Johns Hopkins Medicine, has treated mothers and babies since the early 1990s. When asked about how the babies will develop, she said, “The one solid thing we can say about children who are exposed to substances prenatally is that their mothers need treatment.” The children, she said, are more likely to have optimal development if the mothers receive treatment. UNC Horizons opened its program in 1993 because of the cocaine epidemic. Since then, Jones said, it has become clear that the lives of people with substance use disorders — whether involving cocaine or opioids — can be very chaotic, and that can affect children, too. “It’s incredibly difficult to make a simple linear cause and effect between there was a prenatal exposure to opiates and therefore, because of that exposure to opiates … we see this particular poor birth outcome,” Jones said. Most of the mothers at UNC Horizons took multiple substances when pregnant and also experienced trauma, abuse or neglect in their own childhoods. And, Jones said, that can be hard to overcome. “There’s oftentimes an unrealistic expectation by society. They’re supposed to automatically know how to quote, unquote … be good mothers, how to be nurturing mothers,” Jones said. “That’s like trying to teach somebody algebra when they’ve never even had