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When Opioid Prescribers Are Arrested, What Happens To Their Patients? : Shots – Health News

Gail Gray suffers from degenerative disk disease and takes daily painkillers. Her pharmacist was arrested in a recent federal justice department sting.

Blake Farmer/WPLN

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Blake Farmer/WPLN

Gail Gray suffers from degenerative disk disease and takes daily painkillers. Her pharmacist was arrested in a recent federal justice department sting.

Blake Farmer/WPLN

A pharmacist in Celina, Tenn., was one of 60 people indicted on charges of opioid-related crimes this week, in a multistate sting. John Polston was charged with 21 counts of filling medically unnecessary narcotic prescriptions.

He was also Gail Gray’s pharmacist and the person she relied on to regularly fill her opioid prescriptions.

“I take pain medicine first thing in the morning. I’m usually up most of the night with pain,” she says. “I hurt all the time.”

Living in a mountainous community on the Tennessee-Kentucky line, Gray has coped with a degenerative disk disease for more than 15 years, requiring multiple back surgeries. She says the chronic pain is totally debilitating without powerful opioids.

But with her druggist shut down, her high-dose prescriptions have been questioned by the other pharmacy in town.

“They wouldn’t take me because I was red-flagged on my dose,” she says.

The dozens of indictments across Appalachia this week left thousands of patients who are dependent on opioids to function on a daily basis scrambling, from Ohio to Alabama. Over 50 of those indicted were doctors, nurses or other medical professionals. So as agents were in the field making arrests, the Justice Department also coordinated with local agencies to deploy health workers to look for desperate patients.

U.S. Assistant Attorney General Brian Benczkowski says the enforcement was coordinated with health agencies and addiction treatment providers.

“That plan is designed to ensure that affected patients have continued access to care and are, at the same time, directed to legitimate medical professionals in the area,” he said at a press conference in Cincinnati on Wednesday.

Amid an ongoing crackdown on overprescribing doctors in Appalachia announced in October, patient advocates have been increasingly concerned for pain patients and those abusing prescription drugs. Being suddenly cut off from medications they depend on can be dangerous. Patients could become so desperate from withdrawals that they may resort to street drugs and could overdose.

But this time, in Tennessee, the health department is working to connect people who need pain treatment to legitimate pain clinics. And the substance abuse department began plastering messages online just as the indictments were unsealed, giving patients a hotline to call.

“This is the first time that we have had this type of heads-up,” says Marie Williams, who oversees Tennessee’s substance abuse agency.

With previous stings that resulted in the closure of pain clinics, Williams says, her staffers have gotten maybe one day to prepare. This time, it was nearly a month.

Overdose prevention specialists have been deployed to train families on how to use reversal drugs like Narcan. They’ve also been taping up flyers on shuttered clinic doors.

Williams says she hopes many who may have become addicted to painkillers will see the loss of their opioid supplier as a turning point.

“This is an opportunity to really change your life and get to be the person that you really want to be,” she says.

One of medical practices shuttered by the federal takedown is in the small town of Carthage, Tenn. Dr. Bowdoin Smith is charged with prescribing controlled substances without a legitimate medical purpose.

Suzanne Angel is a state-funded outreach nurse in the area who is helping contact patients in wake of the crackdown. She has been warning local hospital and emergency responders to be on alert for patients who may act out of desperation to find addictive narcotics or who may even be suicidal. This month, the Food and Drug Administration has acknowledged the risk of serious harm for patients who are abruptly taken off opioids and issued new guidance to prescribers for how to safely taper patients off high dosages of opioids.

“I’m sure that they feel depression, despair, maybe anger and fear about ‘who is going to take care of me?’ and ‘is there going to be any support or services out there for me?’ ” Angel says. “I don’t want them to feel alone.”

Angel says there are now more alternatives to opioids, and it’s possible patients could find another pain clinic.

Because of the current legal focus on opioids, it can be much harder to obtain heavy dosages. And among the thousands of patients getting their medication through questionable providers, many have very legitimate needs.

“I’ve tried therapies. I’ve tried injections. I’ve tried several different things,” says Gail Gray. “We didn’t just start off taking opiates.”

Gray found a new pharmacy, though it means driving to the next county. She expects it won’t be long before she’s shopping for help again.

“We’re being punished for people that do abuse drugs,” she says. “The chronic pain patients are being punished for it.”

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As syphilis invades rural America, a fraying health safety net is failing to stop it

When Karolyn Schrage first heard about the “dominoes gang” in the health clinic she runs in Joplin, Mo., she assumed it had to do with pizza.

Turns out it was a group of men in their 60s and 70s who held a standing game night — which included sex with one another. They showed up at her clinic infected with syphilis.

That has become Schrage’s new normal. Pregnant women, young men and teens are all part of the rapidly growing number of syphilis patients coming to the Choices Medical Services clinic in the rural southwestern corner of the state. She can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves.

Public health officials say rural counties across the Midwest and West are becoming the new battleground. While syphilis is still concentrated in cities such as San Francisco, Atlanta and Las Vegas, its continued spread into places like Missouri, Iowa, Kansas and Oklahoma creates a new set of challenges. Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views toward homosexuality and nonmarital sex.

In Missouri, the total number of syphilis patients has more than quadrupled since 2012 — jumping from 425 to 1,896 cases last year — according to a Kaiser Health News analysis of new state health data. Almost half of those are outside the major population centers and typical STD hot spots of Kansas City, St. Louis and its adjacent county. Syphilis cases surged at least eightfold during that period in the rest of the state.

At Choices Medical Services, Schrage has watched the caseload grow from five cases to 32 in the first quarter of 2019 alone compared with the same period last year. “I’ve not seen anything like it in my history of doing sexual health care,” she said.

Back in 1999, the Centers for Disease Control and Prevention had a plan to eradicate the sexually transmitted disease that totaled over 35,000 cases nationwide that year. While syphilis can cause permanent neurological damage, blindness or even death, it is both treatable and curable. By focusing on the epicenters clustered primarily throughout the South, California and in major urban areas, the plan seemed within reach.

Instead, U.S. cases topped 101,500 in 2017 and are continuing to rise along with other sexually transmitted diseases. Syphilis is back in part because of increasing drug use, but health officials are losing the fight because of a combination of cuts in national and state health funding and crumbling public health infrastructure.

“It really is astounding to me that in the modern Western world we are dealing with the epidemic that was almost eradicated,” said Schrage.

Grappling With The Jump

Craig Highfill, who directs Missouri’s field prevention efforts for the Bureau of HIV, STD and Hepatitis, has horror stories about how syphilis can be misunderstood.

“Oh, no, honey, only hookers get syphilis,” he said one rural doctor told a patient who asked if she had the STD after spotting a lesion.

In small towns, younger patients fear that their local doctor — who may also be their Sunday school teacher or basketball coach — may call their parents. Others don’t want to risk the receptionist at their doctor’s office gossiping about their diagnosis.

Involuntary Commitment For Addiction Treatment Raises Troubling Questions : Shots – Health News

The Massachusetts Alcohol and Substance Abuse Center in Plymouth houses men for court-mandated addiction treatment.

Robin Lubbock/WBUR

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Robin Lubbock/WBUR

The Massachusetts Alcohol and Substance Abuse Center in Plymouth houses men for court-mandated addiction treatment.

Robin Lubbock/WBUR

Robin Wallace thought her years of working as a counselor in addiction treatment gave her a decent understanding of the system. She has worked in private and state programs in Massachusetts and with people who were involuntarily committed to treatment.

So in 2017, as her 33-year-old son, Sean Wallace, continued to struggle with heroin use — after years of coping with mental health issues and substance use — she thought she was making the right choice in forcing him into treatment.

Without Medical Support, DIY Detox Often Fails

“His behavior was erratic,” Robin says. “I think he had some mental health issues that were worsened by his use.”

Now she worries that her decision contributed to Sean’s taking his own life.

The law known as Section 35

Robin had become one of several thousand Massachusetts residents each year who ask the courts to force a loved one into addiction treatment under a state law known as Section 35.

The law allows a family member, physician or police officer to ask the courts to involuntarily commit someone to substance use treatment. Dozens of states have civil commitment laws, but Massachusetts is believed to use it more aggressively than most states.

In the last fiscal year, more than 6,500 Massachusetts residents were ordered into treatment this way.

After a court clinician in Hyannis, Mass., reviewed Robin’s request, a judge agreed that Sean’s substance use was dangerous and ordered him committed to up to 90 days of residential treatment.

Sean had begged his mother in court that day not to go that route. He was being sent to a program, he told her, where he would be locked up and not allowed to continue taking the medication that was helping him with his addiction — methadone.

Home-Based Drug Treatment Program Costs Less And Works

“I thought he misunderstood,” says Robin. “Because I couldn’t conceive that there would be an opioid treatment program that would not provide medication-assisted treatment.”

It turns out Sean was right. Although many providers say medication is the gold standard in addiction treatment, Sean was sent to a program in a state prison in Plymouth, Mass., that does not provide the medicine.

When we spoke with Sean in 2017 — shortly after he’d spent about a month committed, he said that the conditions were inhumane and that he was often placed in segregation, or “the hole” — though he had not committed any crime.

“I was punished for not eating,” Sean told us. “That’s how I ended up in the hole. If you refuse your tray, they consider it a behavioral issue. I didn’t know that — I was just sick.”

He spiraled to suicide

Sean also said in that interview that he was having trouble adjusting to life after his time in the Plymouth prison.

“I just feel different,” he said. “I have a lot more anxiety. I feel scared. I feel like I’m going to wake up and be back there.”

Less than a year after that interview, Sean killed himself. His mother says that after that stint in civil commitment, Sean could no longer hold a job. He ended up in a psychiatric hospital and was later jailed on charges of trying to break into a house. Robin believes being locked up for addiction treatment contributed to his suicide.

“I think that his trauma was very much triggered by him being in the cell” at the local jail, she says. “And he just felt like he couldn’t take it anymore.”

The sheriff wouldn’t comment, but documents at the local jail confirm that Sean tried to take his own life there; he later died from those injuries.

Sean’s longtime partner, Heather McDermott, says he was never the same after his civil commitment.

“He was like a big, sad, depressed tumor that I was trying to bring back to life,” McDermott says. “We had a home. I can’t even believe we got here, and then — then he died.”

Massachusetts is one of a few states that use prisons and jails to involuntarily commit men to addiction treatment — and Massachusetts uses the approach more than most states do.

In an emailed statement, the Massachusetts Department of Correction said that its mission is to promote public safety by providing a secure treatment environment. And there is so much demand for involuntary treatment for addiction in Massachusetts that 100 more beds opened in another jail last year.

Hampden County Sheriff Nick Cocchi says that many traditional treatment centers aren’t willing to take patients who don’t want to be there and that, with a declining inmate population, jails have room for these men.

“This is a very dangerous, acutely sick and — I would say — not so well-behaved population,” Cocchi says.

Many states are going down the same road as Massachusetts — strengthening their civil commitment laws to hold people against their will so they will get treatment. And some researchers, such as Leo Beletsky of Northeastern University, say more families are choosing to have loved ones locked up because it’s the only way to get immediate help.

“Limiting someone’s civil rights should be the last resort and only reserved for those cases that are truly dire,” he says.

Denise Bohan believes involuntary commitment saved her 33-year-old son’s life. Families are desperate, she says, and can’t reason with a loved one in the throes of addiction.

“This is a last resort,” Bohan says. “It’s not something you do, like, just on a whim. This is a desperate act of just trying to save your child’s life.”

Aspiring Doctors Seek Advanced Training In Addiction Medicine

Several Massachusetts officials are signaling that the law may change so that correctional facilities will not be used for men committed to involuntary addiction treatment — primarily because addiction is now widely considered a disease that requires medical treatment.

Already, a class action lawsuit against the state has been filed, charging gender discrimination — because Massachusetts stopped sending involuntarily committed women to prisons in 2016, in response to a different lawsuit.

A longer version of this story originally appeared in WBUR’s CommonHealth. Deborah Becker is a senior correspondent and host at WBUR. Her reporting focuses on mental health, criminal justice and education.

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Kansas to let Farm Bureau health coverage avoid ACA rules


Kansas to let Farm Bureau health coverage avoid ACA rules

FILE - In this Wednesday, April 17, 2019 file photo, Kansas Gov. Laura Kelly speaks during a news conference at the Statehouse in Topeka, Kansas. The Democratic governor is urging the Republican-controlled Legislature to remain cautious in the wake of a new, slightly more optimistic forecast for state tax collections.

FILE – In this Wednesday, April 17, 2019 file photo, Kansas Gov. Laura Kelly speaks during a news conference at the Statehouse in Topeka, Kansas. The Democratic governor is urging the Republican-controlled Legislature to remain cautious in the wake of a new, slightly more optimistic forecast for state tax collections.

AP Photo

Kansas will allow its state Farm Bureau to offer health care coverage that doesn’t satisfy the Affordable Care Act after Democratic Gov. Laura Kelly on Friday declined to block a Republican-backed effort to circumvent former President Barack Obama’s signature health care law.

Kelly allowed an insurance bill to become law without her signature, and it includes provisions that will exempt the bureau from state insurance regulations in the health care coverage it offers to its members.

Kelly, in a statement, said that while she has “serious reservations” about the measure, she will allow it to become law “as a demonstration of my genuine commitment to compromise.”

Kansas Senate President Susan Wagle, a Wichita Republican, said in a statement that the measure helps “Kansans struggling to afford coverage find new, affordable options.”

Kelly’s fellow Democrats strongly opposed the measure, suggesting it would allow the nonprofit to sell skimpy health care coverage while offering false hope to consumers.

The proposal had overwhelming Republican support in the GOP-controlled Legislature. Kelly had not taken a position publicly before allowing the bill to become law.

The new law takes effect in July. It is patterned after one in place in Tennessee for decades and one enacted last year in Iowa.

Its enactment demonstrated the Farm Bureau’s political clout in Kansas, particularly in rural areas, where Republicans dominate politics. The bill also had the support of most urban and suburban GOP lawmakers who continue to oppose the 2010 federal health care overhaul.

Some Democrats argued that rural communities would be better served by expanding the state’s Medicaid health coverage for poor residents as outlined in the Affordable Care Act, as Kelly has proposed. The House passed a Medicaid expansion plan last month, but the Senate has yet to take it up.

“Unfortunately, leaders in the Kansas Senate continue to prioritize their own political ambitions over the health and security of Kansas families and hospitals,” Kelly said. “Despite the will of both their chamber and their state, these three Senate leaders remain devoutly committed to partisan obstructionism.”

Farm Bureau President Rich Felts said in a statement that Kelly’s action “paved the way for lawmakers to advance a comprehensive healthcare solution that will benefit our entire state.” He said the governor’s Medicaid expansion plan “to help rural hospitals, create new jobs, and expand affordable healthcare to non-KFB members remains a critical piece of that puzzle.”

Farm Bureau officials estimated that about 42,000 people would eventually take its coverage and promised lower rates than plans complying with federal mandates. They believed the takers would be individuals without coverage or struggling to pay for individual coverage.

Bureau officials said they pushed for permission to offer the coverage because the group’s members were asking for more choices. The Farm Bureau’s new coverage will avoid state regulation because the law simply declares that it’s not insurance.

Kansas has seen the number of individual coverage plans offered through the federal ACA marketplace decline to 23 for 2019 from 42 in 2016, according to the Kansas Insurance Department. While average rate increases for 2019 were smaller than in past years, they’ve sometimes previously topped 25 percent, according to annual reports from the department.

Republicans repeatedly have cited premium increases as a reason to repeal the ACA since President Donald Trump’s election in 2016, but a drive in Congress to do it stalled when they couldn’t agree on a replacement. Trump has deferred another push until after the 2020 election.

Critics of the Farm Bureau’s proposal said companies offering traditional health insurance coverage would face unfair competition.

They also focused on how the Farm Bureau would be able to set higher rates or reject coverage for people who have pre-existing medical conditions. They also suggested that coverage could be limited for large expenses, such as a pregnancy or cancer treatment.

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Orange County judge ruled for mental health patients from personal experience

By Taylor Knopf

On the first night of class, UNC law professor Pat DeVine tells her students that she has an agenda. She wants every student to graduate with more in mind than making six figures a year.

“I want you to have formed an opinion about how you can do some good and make a contribution,” she said. “If this doesn’t appeal to you, you can drop the class.”

She said no student ever has.

DeVine, now in her 70s, took a circuitous path into the legal profession, starting out as a nun. She grew up going to Catholic girls schools and said, “my whole life I loved the nuns.”

Her senior year of college, she entered the convent at St. Mary’s in Columbus, Ohio, and her undergraduate diploma reads “Sister Constance.”

“I liked the idea of being constant,” she said. “Although, of course, I was not. I flew the coop.”

After five years in the convent, she received a Christmas letter from her old college boyfriend. The two became pen pals and DeVine slowly realized that she wanted a family someday.

When she left the convent, three nuns in full habit drove Sister Constance from Columbus to her parents home in Cincinnati, where her mom had a room full of clothes for her. Her mother had prepared brunch for the group, but the meal was interrupted by a long-distance call from Chapel Hill. It was the boyfriend.

He asked her to come to North Carolina. Only a few weeks out of the convent, DeVine went to be with him in Chapel Hill. Two weeks later, they were engaged. The young couple soon had twins they named Timothy and Elizabeth.

No longer a nun, DeVine said she wanted to continue helping people, so she went to law school.

At 41 years old, DeVine graduated from UNC School of Law in 1983, and since then, she’s done it all. She was a public defender, assistant district attorney and retired from the bench as a judge in Orange and Chatham Counties.

Early in her career, DeVine began to notice quite a few people ended up in a courtroom when what they really needed was mental health treatment.

“Some people who commit crimes are not criminals,” she said. “They’re sick.”

Mental health benefits help line NC Dept of Insurance 855-408-1212

As a public defender, DeVine recalled watching a man who was acting difficult and belligerent stand before the judge without a lawyer. She said the judge was about to hold him in contempt and send him to jail.

She approached the bench and asked the judge for a few minutes with the man.

“I believe very strongly that he’s not well,” she recalled telling the judge.

She got the case continued and helped him find treatment for his mental illness. DeVine said she was familiar with the symptoms because she saw them so often in her clients.

When Chief District Court Judge Joe Buckner was looking for a judge to preside over North Carolina’s first mental health court, he chose DeVine.

Also, as the mother of a son with schizoaffective disorder, Buckner knew her lived experience would serve the court well.

“I watched her as a defense attorney, and she was probably as good at humanizing a person that had done some pretty bad things as any attorney I had ever seen,” Buckner said.

‘Walking wounded’

They called it “community resource court” because Buckner said they didn’t want the court to have a stigma about a person’s mental condition.

“And it really is about managing community resources to help that person to have a safe and happy life and maintain some stability,” Buckner said.

DeVine said she learned that every person who came before the court had a unique story, and she likes to say that everyone is “walking wounded.”

“We all have our issues, and we all have had our problems, but some people are afflicted with mental illness,” she said. “It’s not of their choosing. Some people get cancer or other diseases and some people get mental illness.”

She explained that presiding over a mental health court is a very different way to be a judge. In a typical court session, she would go in, hear the case, and decide what should be done.

“For this court, I’m a team player,” she said. “I sit there and listen to therapists, psychiatrists, social workers and so forth report to me about how the person is doing. As long as the person is cooperating, my job from the bench is to say, ‘You look great. I’m so glad that you’re still taking your meds. How are things going?’”

If the participant successfully completes the program, the case against them is dismissed.

white man in blue sweater sitting at a table
Tim Faherty, Pat DeVine’s son, was an artist and musician. He taught his mother a lot about living with a mental illness. Photo credit: courtesy of Pat DeVine

Certain kinds of crimes, such as violent felonies, are not eligible for mental health court. But Buckner said that’s not the usual crime people with mental illnesses are arrested for.

“We knew that we had a large population that we saw on almost a daily basis in our regular criminal courts that were not meeting our real criminal profile,” he said. “They were committing community nuisance crimes and neighborhood crimes.”

Buckner said the community resource court is the most successful court in his whole system. He said that probably fewer than 1 percent of the court’s participants spend any time in jail and that their compliance rates are extremely high. They take their medications, make their appointments and graduate the program.

He said there’s no better example than the story of DeVine’s son.

“Tim Faherty did not need to be in a jail ever,” Buckner said. “But he did need a place to be […] Everybody needs a bed, a buddy and a job.”

After an arrest, a couple of years in a mental health facility, and finding the right medications,  Faherty lived a fairly stable life. He had his own supervised apartment at a complex in Chapel Hill. He found purpose at Club Nova, a clubhouse for people with severe and persistent mental illnesses. And his buddy was his mother.

Mother and son

Faherty showed signs of having a mental illness in his 20s. DeVine said her son abused alcohol and marijuana and had trouble holding a job.

“If the inside of your head is turning into hell, and you’re hearing voices, and you think people are out to get you, substances can do a lot for a period of time to kind of block that out,” she said.

Then one day, Faherty snatched a lady’s purse on the steps of the courthouse. He was arrested and DeVine had her son involuntarily committed to a hospital in Butner.

“We’re going to keep you here,” she recalled telling her son. “You’re not a criminal, sweetie. You’re just a little crazy. We’re going to get you on the right meds and you’re going to be alright.

“And I said that with relief and love for him,” DeVine said.

After the hospital, Faherty moved into a group home for a time and then to his own apartment, where he got his own checking account and car. He was an artist, a cartoonist and a musician.

He took his medications consistently and was mostly stable, DeVine said.

Medications have side effects, and DeVine said her son was always worried to some degree.

The first time Faherty met his mother’s new neighbor, he said, “Hey, I’m Tim, Pat’s son. I have mental illness, but you don’t need to be afraid of me. I’m not going to hurt anybody.”

DeVine said that exchange was heartbreaking to her because he lived with the stigma associated with mental illness.

“He’s the best man I’ve ever known,” DeVine said. “He used to say to me, ‘Mom, you got to have compassion. Put yourself in the other person’s shoes.’”

An example to the end

Sadly, statistics show people with severe mental illness die 10-25 years earlier than the average in the population.

a flat tombstone with an engraved drawing of a man with a guitar and a quote by Buddha that reads: our basic nature is goodness.
Pat DeVine’s son passed away suddenly from a blood clot shortly before Christmas in 2015. The engraved image on his tombstone is one of his self portraits. Photo credit: courtesy of Pat DeVine

Shortly before Christmas 2015, Faherty fell to the floor in a Chapel Hill grocery store and died of a blood clot that traveled to his lungs. The emergency responder knew he was the son of a retired judge and notified Buckner who called one of DeVine’s closest friends, former judge and now state Rep. Marcia Morey (D-Durham).

Morey drove straight to DeVine’s home to deliver the news.

“I knocked on the door and she said, ‘Well, what do I have the pleasure of having you here today?’” Morey remembered. “And you kind of just take your last breath before you know her life is going to change forever.”

Although DeVine wishes she had the chance to say goodbye to her boy, she’s grateful that he didn’t suffer through the end of his life.

Morey said she had known Faherty well and described him as a “kind, thoughtful, conscientious and beautiful soul.” She would join the mother and son for dinner at a seafood place Faherty liked. She said their relationship was as much friendship as it was familial.

Faherty taught his mother a lot, Morey said. And DeVine was “in awe” of her son as she watched him struggle, develop and then succeed in living life on his own.

“Anyone that you talk to that knows Pat will say she’s one of the most caring, compassionate, former nuns, judges that you’ll ever meet,” Morey said.

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Listen: Syphilis Spreads Into Rural America
Can’t see the audio player? Click here to download.

Lauren Weber, one of Kaiser Health News’ new Midwest correspondents, joined St. Louis Public Radio reporter Jeremy Goodwin on “St. Louis on the Air” Friday to discuss how syphilis is making inroads into rural counties across the Midwest and West. In Missouri, the total number of syphilis patients has more than quadrupled since 2012, testing the weakened public health safety net in areas unfamiliar with the potentially deadly infection. Listen to the interview on the St. Louis Public Radio website.

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More than a medical school: health care giants Atrium Health and Wake Forest Baptist Health want to consolidate

By Yen Duong

Even after last year’s failure to merge with UNC Health Care, Atrium Health isn’t giving up on consolidations. Last week, Wake Forest University, Wake Forest Baptist Health and Atrium announced that by the end of the year, they would have a proposal for how to join forces.

While the prestige of a new medical school may appeal to Charlotteans, large mergers can end up hurting patients’ wallets, say health economists. And on top of negotiating their deal, the two health care giants need to prove to the attorney general and the Federal Trade Commission that they can combine without harming customers.

News of the proposed reorganization comes on the heels of Atrium’s January acquisition of Macon, Ga.-based Navicent Health and Wake Forest Baptist’s September 2018 purchase of High Point Regional from UNC Health Care.

Per state law, Atrium cannot expand more than 10 miles away from Mecklenburg County. That’s because Atrium is a hospital authority, a quasi-governmental public entity, rather than a private nonprofit corporation like Wake Forest Baptist.

Last summer, Atrium attempted and failed to remove the 10-mile limit through legislative action.

A map of a portion of North Carolina and some of South Carolina with icons for hospitals
Atrium services 34 counties, which includes five in South Carolina. Map credit: Atrium Health

The law, however, does not hold in Georgia, so Atrium was able to add Navicent’s seven hospitals to its roster along with the five hospitals it manages in South Carolina. In all, Atrium now owns 25 hospitals and manages 26 affiliated hospitals across the three states.

Last March, a proposed “virtual” merger between Atrium and UNC system fell apart. That deal would have created a third umbrella corporation to oversee both organizations and avoid the hospital authority law.

It’s unclear how Wake Forest Baptist, which reported a $7 million net operating loss in fiscal year 2018, will combine with Atrium, which reported $300 million in net operating income in 2018. Wake Forest Baptist is headquartered in Winston-Salem, as is Atrium’s rival Novant Health.

“[It] would be premature to comment on any specific models,” wrote an Atrium spokesperson in an email. “Obviously, we will structure any combined efforts so that they are in compliance with all applicable laws.”

‘Prices tend to go up and quality tends to get worse’

Last year, Atrium reported about $10.3 billion in revenue with over 62,000 employees, while Wake Forest reported $2.6 billion in revenue and over 19,000 employees for fiscal year 2018, according to financial reports.

“For patients, usually, large mergers are not good,” said Dr. Ashish Jha, a Harvard University health economist. “As competition goes down, prices tend to go up and quality tends to get worse.”

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For instance, Jha said that studies have shown people are more likely to die of a heart attack in markets with fewer competitors.

Consumers’ costs increase because larger hospital systems can negotiate higher rates with private insurers, said Dr. Kevin Schulman, a Stanford University professor of medicine. Consumers pay for those increased rates by way of higher insurance premiums and lower take-home pay.

Research by the non-profit Health Care Cost Institute showed that as prices for health care increase, people use fewer health care services. The effect on Charlotte’s inpatient hospital stays was stark: prices were 12 percent above the national average, but use was 20 percent below the national average.

“If [Atrium] merged with Wake Baptist, you basically would have one health care provider cutting across the state,” said Schulman, who previously worked at Duke University. “And whose interests would they be serving? Clearly, it would not be the patient’s interests.”

The organizations will work together to keep “care more accessible and affordable,” a spokesperson wrote on behalf of Atrium. For instance, they could expand CHESS, an organization majority-owned by Wake Forest Baptist which helps hospitals transition to “value-based care,” with reimbursements from patient outcomes rather than the traditional fee-for-service way of paying for care.

“CHESS has had noteworthy success in accelerating change to lower healthcare costs,” an Atrium spokesperson wrote. “This change translates to tens of millions of dollars savings annually to payers, and ultimately employers and patients/consumers.”

Potential legal challenges ahead

Combined, Atrium and Wake Forest Baptist were responsible for almost a third of patient interactions over the 19 North Carolina counties and five Virginia counties served by Wake Forest Baptist.

Across its 34 county-reach, Atrium held 39.2 percent of the market.

“Both [Atrium’s] footprint already and Wake Baptist’s footprint is probably already beyond the cut off [for violating anti-trust laws],” Schulman said. “The other interesting thing about the timing is Blue Cross […] has gotten a little more aggressive in terms of negotiating, pushing back on the hospitals, and holding them financially accountable and responsible for the care they’re providing.

“You can also see this as a way to undermine that effort.”

In November, Atrium settled an anti-trust complaint with the U.S. Department of Justice, which prohibited Atrium from telling insurers to preferentially refer patients to its own services versus competitors. That same month, a group of former employees filed suit against Atrium, claiming they had to pay too much for medical services under their health plan.

Atrium and Wake Forest already co-own MedCost, a for-profit company which administers their group health plans. Though a five-year federal investigation into a potential conflict of interest closed in 2016, the government could take legal action in the future.

A map of a corner of North Carolina with icons indicating health care provider locations
Wake Forest Baptist services 24 counties, which includes five in Virginia. Graphic credit: Wake Forest Baptist

“The law of our country is very straightforward that mergers that are anti-competitive [and] monopolies that have the potential to harm consumers are generally not allowable,” Jha said. “If there is a good, compelling clinical reason to do it, it makes sense. But often, hospitals do it just so that they have more market power and can negotiate higher prices with insurers.”

Any proposed plan would have to be approved by the Federal Trade Commission before going through, and the N.C. Attorney General’s office would also examine it, Schulman said.

“We actually don’t have a great mechanism in North Carolina for reviewing these mergers,” Schulman said. “[The Attorney General’s office] is really the only agency at the state level that can examine these kinds of combinations, and they’re tremendously under-resourced.”

Earlier this year, N.C. Attorney General Josh Stein conditionally approved HCA’s purchase of Mission Health, after taking into consideration concerns from local leaders and residents.

What about Charlotte’s medical school?

Just last month, Philip Dubois, the chancellor of UNC Charlotte, and Wesley Burks, the dean of UNC School of Medicine, wrote an op-ed in the Charlotte Observer advocating against building a new medical school in the Queen City.

“[At] least for the foreseeable future, there are overwhelming financial, political and practical obstacles to establishing a four-year medical school in Charlotte,” Dubois and Burks wrote.

The op-ed referenced a 2017 report from the UNC Sheps Center for Health Services Research, which reported that by 2035, Charlotte will face a shortage of 343 primary care doctors. Like Dubois and Burks, the report concluded that a new medical school would not solve that problem.

Supply and demand for doctors in Charlotte and North Carolina

According to data from the Sheps Center report, demand for doctors in Charlotte will grow more than the rest of North Carolina. But supply will shrink or grow slowly. Graph credit: Yen Duong

Only 18 percent of North Carolina medical students end up working as primary care physicians in state five years after graduation, said health policy researcher Erin Fraher of the Sheps Center, a co-author of the report.

Instead of building a new “top 20” medical school, Fraher said Atrium and Wake Forest, which has a medical school ranked 50th in the nation, would better serve the community with a residency program such as UNC’s FIRST program. FIRST speeds medical students through three years each of medical school, residency and service in rural or underserved North Carolina communities.

“When I look at it from a data perspective, that to me makes more sense,” Fraher said.

An infographic breaking down how 20 internal medicine residents result in six primary care doctors in Charlotte
Data from UNC Sheps Center. Infographic credit: Yen Duong

Though a medical school would bring more prestige, research dollars and jobs to the area, an Atrium spokesperson  focused on Charlotte’s increasing demand for more doctors. She also said Atrium’s post-graduate program for nurse practitioners and physician assistants, the largest in the country, can help ease Charlotte’s growing pains.

“As the need for clinicians grows, we stand poised to help fill this need,” Atrium’s spokesperson wrote. “[The new school and programs] will provide critical experience for medical student education through an integrated academic health system.”

‘There’s still a lot to be worked out’

Since 2010, Atrium’s flagship hospital, Carolinas Medical Center, has been designated the Charlotte campus of the UNC School of Medicine. That means that CMC hosts 25 students per year for the clinical half of medical school.

In contrast, Wake Forest Medical School accepts about 140 new medical students each year, and teaches about 1,900 students and fellows across all of its programs.

“There’s still a lot to be worked out,” wrote an Atrium spokesperson when asked about the future of the existing program for third and fourth-year medical students. “[We] will be working through the details in a way that is appropriate and respectful for all involved.”

Though the new medical school was highlighted in the announcement, many prestigious medical schools, such as Harvard, don’t own hospitals, said health economist Jha. Those schools set up affiliate agreements with local hospitals for student rotations.

“It’s not really clear to me why two hospital systems need to merge, in order to open up a medical school,” Jha said. “If Wake Forest wants to open up a medical school in Charlotte, they can.”

Correction: This story has been changed to reflect that only 18 percent of medical students will end up working as primary care doctors in N.C.

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Podcast: KHN’s ‘What The Health?’ You Have Questions, We Have Answers

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were what might happen to parts of the Affordable Care Act if a lawsuit now working its way through the courts succeeds in declaring the health law unconstitutional, and how Medicare and Medicaid deal with surprise medical bills from out-of-network providers.

This week’s panelists are Julie Rovner of Kaiser Health News, Jennifer Haberkorn of the Los Angeles Times, Joanne Kenen of Politico and Kimberly Leonard of the Washington Examiner.

The panel addressed questions including the following:

What would happen to the Medicare Part D “doughnut hole” if the entire ACA is struck down, and would newer bills, such as the Bipartisan Budget Act, which helped close the coverage gap for brand-name drugs one year early, prevent this feature of the ACA from being eliminated?
Will the Health Insurance Portability and Accountability Act (HIPAA) of 1996 remain if the ACA is completely overturned?
Since surprise medical bills aren’t allowed in Medicare and Medicaid, what happens when an anesthesiologist or contract emergency room doctor who doesn’t accept Medicare or Medicaid treats an enrolled patient? Do they take a lower rate? Does the hospital make up the difference? Why can’t this be applied to all out-of-network arrangements?
Statistics show that approximately 5% to 10% of the population accounts for about 50% of total health care spending. Who makes up this population? Are there any reasonable proposals to address the health of this population and perhaps reduce spending while improving outcomes?

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

Julie Rovner: Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care,” by Melissa Bailey and JoNel Aleccia

Jennifer Haberkorn: The New York Times’ “Insurers Want to Know How Many Steps You Took Today,” by Sarah Jeong

Joanne Kenen:’s “Walmart’s $25 Insulin Can’t Fix the Diabetes Drug Price Crisis,” by Julia Belluz

Kimberly Leonard: The [Columbia, S.C.] State’s “SC Inmate’s Baby Died in Toilet: Lawsuits Allege Rampant Medical Neglect in Prisons,” by Emily Bohatch

And, The Atlanta Journal-Constitution’s “For Some in Ga. Prisons and Jails, Diabetes Has Meant a Death Sentence,” by Danny Robbins

To hear all our podcasts, click here.

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

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.

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Thursday, April 18, 2019

State Highlights: Connecticut House Passes Bill Protecting Pre-Existing Conditions; Judge Orders Chicago Hospital To Restore Services

Media outlets report on news from Connecticut, Illinois, Massachusetts, Wisconsin, Alaska, California, Pennsylvania, North Carolina, Maryland, Georgia, Kansas, Washington and Minnesota.

The CT Mirror:
Legislation Shielding People With Pre-Existing Conditions Clears House

Lawmakers in Connecticut’s House of Representatives passed a measure Wednesday to safeguard people with pre-existing conditions who are on short-term health insurance policies, sometimes called temporary health insurance. They could not say how many people the bill would protect, but pointed to data compiled by the Kaiser Family Foundation showing that as many as 522,000 people younger than 65 in Connecticut have pre-existing conditions such as cancer or heart disease. (Carlesso, 4/17)

Modern Healthcare:
Suburban Chicago Hospital Owner Must Restore Services: Judge

A Cook County Circuit Court judge found Pipeline Health in contempt of court and required it to restore most services offered at Westlake Hospital in Melrose Park, Ill. The judge, Moshe Jocobius, ordered Pipeline to restore services like behavioral health and obstetrics by Thursday morning or face daily fines of $200,000. He allowed Pipeline to stop offering weight-loss services (bariatrics) and accepting incoming ambulance traffic, which the hospital already had been allowed to do through a previous order. A written order to be made available will provide more detail about the specific sevices the 230-bed hospital will have to continue providing. (Goldberg, 4/17)

Boston Globe:
How To Find A Therapist When You Need One

Ask anyone who’s been in this position: Finding a therapist in the Boston area for a pressing mental health concern, especially for a teen or child, can feel overwhelming. When you need a kind and understanding person who can parachute in to help avert a crisis, if only by listening, sometimes the search feels like a never-ending scavenger hunt while the sun is swiftly sinking. (Baker, 4/17)

The Washington Post:
Tick, Tick, Tick: Alaska Braces For Invading Parasites

Health and wildlife officials are taking steps to prepare for potentially dangerous parasites that could gain a foothold because of Alaska’s warming climate. Non-native ticks represent a threat to wildlife and people because they can carry and transmit pathogens, said Micah Hahn, an assistant professor of environmental health with the Institute for Circumpolar Health Studies at the University of Alaska Anchorage. (Joling, 4/17)

The Associated Press:
Legionnaires’ Disease Found In Adjacent California Prisons

Legionnaires’ disease bacteria that killed one inmate and sickened another is more widespread than expected in a California state prison, officials said Wednesday, citing new test results. Preliminary results found the bacteria in the water supply at a prison medical facility in Stockton and at two neighboring youth correctional facilities, Corrections Department spokeswoman Vicky Waters said. (4/17)

Sacramento Bee:
Legionella Bacteria Widespread In Stockton Prison Water

Water tests discovered legionella throughout a state prison in Stockton, showing the bacteria found in a dead inmate last month is more widespread than was previously known, according to a California Department of Corrections and Rehabilitation email sent to staff Tuesday. The inmate, whom the department hasn’t identified, died the first week of March after being transported to an outside hospital from California Health Care Facility. (Venteicher, 4/17)

North Carolina Health News:
More Than A Medical School: Health Care Giants Atrium Health And Wake Forest Baptist Health Want To Consolidate

Even after last year’s failure to merge with UNC Health Care, Atrium Health isn’t giving up on consolidations. Last week, Wake Forest University, Wake Forest Baptist Health and Atrium announced that by the end of the year, they would have a proposal for how to join forces. While the prestige of a new medical school may appeal to Charlotteans, large mergers can end up hurting patients’ wallets, say health economists. And on top of negotiating their deal, the two health care giants need to prove to the attorney general and the Federal Trade Commission that they can combine without harming customers. (Duong, 4/18)

Modern Healthcare:
KPC Group Closes In On Purchase Of Four Verity Health Hospitals

The KPC Group moved a step closer to acquiring four Southern California hospitals owned by Verity Health with approval from a federal bankruptcy court Wednesday. The KPC Group, which is the parent company of KPC Health that operates seven hospitals in Southern California, secured the winning bid at $610 million for St. Francis Medical Center in Lynwood, St. Vincent Medical Center in downtown Los Angeles, Seton Medical Center in Daly City and Seton Coastside in Moss Beach as well as St. Vincent Dialysis Center in downtown Los Angeles. California Attorney General Xavier Becerra must approve the acquisition. (Kacik, 4/17)

The Associated Press:
Police: Maryland Man Spread HIV To 4 Women He Met Online

Police say a Maryland man knowingly spread HIV to four women after meeting them on dating sites and apps. The Frederick News-Post reported Tuesday that 34-year-old Rudolph Jericho Smith has been charged with first-degree assault and reckless endangerment. He also faces counts of knowingly transferring or attempting to transfer HIV to another person. The charge is a misdemeanor under Maryland’s general health law. (4/17)

Sacramento Bee:
10,000 Workers Weigh Strike After UC Imposes Contract Terms

The union representing 10,000 research and technical workers at the University of California on Wednesday denounced the UC’s decision to unilaterally impose wage increases of 3 percent annually over the next four years. UPTE-CWA 9119 leaders said in a news release that they are weighing their options, up to and including a strike. Members of the union have joined in four strikes over the past 12 months. (Anderson, 4/17)

Atlanta Journal-Constitution:
Best And Worst States For Child Health Care: Georgia Among Worst

When it comes to the best and worst states for children’s health care, Georgia doesn’t fare very well, according to a new report. In fact, the Peach State ranked among the bottom of the pack in WalletHub’s latest analysis based on kids’ health and access to health care; kids’ nutrition, physical activity and obesity and, last but not least, kids’ oral health. (Priani, 4/17)

Overland Park Psychiatrist Accused Of Having Sex With A Patient Loses His License 

An Overland Park psychiatrist has lost his medical license after state regulators alleged he had sex with a patient, exploited a patient relationship for financial gain and continued to practice after his license was suspended in 2018. Under a consent order entered Tuesday, Brian Patrick Lahey waived his right to a contested hearing and agreed to an indefinite suspension of his Kansas license. (Margolies, 4/17)

The Associated Press:
For-Profit Jail, Family Settle Arkansas Inmate Death Lawsuit

Lawyers reached an undisclosed settlement Tuesday in a federal lawsuit in which the family of an Arkansas man alleged employees of a for-profit jail left the man to die in his cell as his health deteriorated. Representatives for Michael Sabbie’s family and LaSalle Corrections, which runs the Bi-State Justice Center in Texarkana, Texas, said they would not comment on the terms of the settlement stemming from Sabbie’s 2015 death, according to the Texarkana Gazette. (4/17)

The Star Tribune:
Racial, Income Gaps In Medical Care In Minn. Are Closing, But Modestly 

Poor and minority patients in Minnesota are starting to receive better primary care, but they continue to have worse overall health outcomes and more difficulty managing chronic illnesses such as diabetes. In a sign of progress against the state’s longstanding health disparities, a new report shows that Minnesota clinics are doing a better job of screening low-income and minority adults for colon cancer and checking minority teenagers for depression — two of the medical indicators tracked in the annual review. (Olson, 4/17)

Minnesota Health Disparities Narrowing But Still A Concern

Minnesota Community Measurement said people covered through state-run health coverage — Medical Assistance and MinnesotaCare — continue to have significantly worse health measures than Minnesotans with private health insurance or Medicare. The health outcome tracking organization’s president, Julie Sonier, said those disparities have been shrinking over time for several measures. (Zdechlik, 4/17)

Chicago Tribune:
Day After Rebuke From Judge, Owners Of Westlake Hospital Offer To Give It To Melrose Park 

A day after a judge rebuked the owner of Westlake Hospital, its owner is offering to give it to the village of Melrose Park — a pitch the village is calling a “stunt.” “If Melrose Park truly values Westlake Hospital and is so sure it can do a better job of either running this antiquated facility or finding a buyer, they should take us up on this offer,” said Los Angeles-based Pipeline, which owns Westlake, in a statement Wednesday. Pipeline said it would give the 230-bed hospital to Melrose Park at no cost. (Schencker, 4/17)

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Abortion survivors bill heads to Gov. Cooper’s desk

By Rose Hoban

Legislators approved final passage of a bill Tuesday evening that would criminalize physicians who fail to provide life-saving care to fetuses that survive an unsuccessful abortion procedure and are subsequently born alive.

Despite objections from Democrats, the Born Alive Abortion Survivors Protection Act now goes to Gov. Roy Cooper for his signature or potentially his veto.

The Senate passed the bill Monday evening, sending it to the House, wrapping up a quick trip through the General Assembly. During debate on the House floor Tuesday, Rep. Pat McElraft (R-Emerald Isle) had an emotional moment as she recounted her experiences as a young phlebotomist in the 1970s at Onslow Memorial Hospital in Jacksonville, where she said she witnessed the remains of babies born alive but allowed to die.

“I was on a break and went in to visit with the pathologist in the pathology lab and I asked him, I said, ‘What are all these little pigs doing in these buckets?’ He told me, ‘Pat, look again,’ and I did. They were perfectly formed little human babies in those buckets,” she said, her voice cracking.

She also claimed that at the time, there was a doctor at the hospital that would drown babies born alive during unsuccessful abortions in saline.

“Who would have ever thought that the governor of Virginia would advocate for infanticide?” McElraft asked, pointing to recent legislation in Virginia which would have loosened some restrictions on abortions performed after the point of viability, generally recognized to be about 22 weeks gestation.

Opponents of the bill pushed back that the bill was unnecessary.

“Infanticide is already illegal in North Carolina and under federal law,” said Rep. Carla Cunningham (D-Charlotte).

Mental health benefits help line NC Dept of Insurance 855-408-1212

Under the bill physicians could be charged with a Class D felony, which also includes voluntary manslaughter, in addition to a $250,000 fine, as well as civil charges. Women giving birth would be immune from prosecution.

Cunningham and fellow Democrat Susan Fisher (D-Asheville) both pointed out current statutes criminalizing the killing of a child born alive, and laws against causing the death of an unborn child.

“Do any of you really think that infanticide is legal today in North Carolina?” Fisher asked. “If you think that then why on earth didn’t you do something to stop it in the decade that you have had in the supermajority?”

Changed milieu

During the debate, McElraft cited a 1981 interview in the Philadelphia Inquirer with the former chief of abortion surveillance at the then-Centers for Disease Control who said there were hundreds such births nationwide annually.

But there’s little evidence of such practices currently. A 2016 CDC review of fetuses born alive after abortion attempts over the period spanning 2003 to 2014 found 143 instances where a newborn survived an abortion attempt, out of 49 million births during that time. Of those, two-thirds involved “maternal complications or, one or more congenital anomalies,” where the newborn died within hours.

And, since the 1970s, the overall landscape of abortion has changed dramatically in the U.S. and in North Carolina.

In North Carolina, the abortion rate has steadily declined over time, down from 23 per thousand pregnancies in 1990 to 11.2 per thousand pregnancies in 2017, the most recent year for statistics.

Nationally, abortion rates have also fallen, from 27.4 per thousand pregnancies in 1990 to 11.8 per thousand pregnancies in 2015, the last year for national data compiled at the CDC.

Since the 1990s, North Carolina has restricted abortions by requiring longer waiting periods, limiting which insurance policies can cover abortions, and having a long-standing ban on procedures taking place after 20 weeks’ gestation.

According to the CDC, more than 90 percent of abortions nationally take place before 13 weeks gestation, with about only 1.3 percent occurring after 21 weeks.

North Carolina sees parallel trends, with 87.2 percent of procedures occurring before 13 weeks, and all but 40 out of 22,677 abortions in 2017 occurring before 21 weeks gestation.

During the floor debate, Cunningham pointed to existing laws that sanction unprofessional conduct and neglect on the part of health care practitioners. “The penalties that are in the bill are very necessary if your goal is to discourage physicians and health care providers from performing women’s health services.”

The statistics seem to indicate that’s already happening.

In 2015, the state enacted a law requiring physicians performing any abortions after 16 weeks to submit information about the procedure and tightened training standards for physicians who perform abortions, as well as lengthening the wait time for a procedure to three days.

Since that time, the number of abortions recorded as occurring after 21 weeks has dropped. In North Carolina in 2017, statistics record only one abortion of a fetus that was more than 21 weeks’ gestation being performed in-state. The other 39 instances were for women who went out of state to have the procedure.

If Cooper were to sign the bill, North Carolina would join other states that have passed such “abortion survivor” laws. But the governor’s signature may not be forthcoming.

“This unnecessary legislation would criminalize doctors for a practice that simply does not exist,” wrote Ford Porter, Gov. Cooper’s spokesman in response to a request for comment. “Laws already exist to protect newborn babies and legislators should instead be focused on other issues like expanding access to health care to help children thrive.”

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