Anthem expands its policy of punishing patients for ‘inappropriate’ ER visits

Over the last few months, Anthem, the nation’s biggest health insurer, has informed customers in several states that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their ER claim won’t be paid.

The policy has generated protests from numerous physician groups, including ER doctors, as well as pointed questions on Capitol Hill and among state regulators. So Anthem has taken the obvious next step: This year, it’s rolling out the policy in three additional states. Prior to Jan. 1, the policy was in effect in Georgia, Missouri and Kentucky. This year, it’s adding New Hampshire, Indiana and Ohio. More states may follow.

Medical experts say the policy places an insupportable responsibility on ordinary customers to diagnose themselves before turning to the ER for treatment.

Patients are not physicians.

Some are also concerned that patients who have experienced claim rejections in the past might be discouraged from returning to the ER for a recurrent condition or a new one, a decision that could have life-threatening implications.

 “Patients are not physicians,” Sen. Claire McCaskill (D-Mo.) lectured Anthem CEO Joseph R. Swedish in a Dec. 20 letter seeking documentation of how the company arrived at its policy and how it is being applied. “Anthem’s policies are discouraging individuals from receiving needed care and treatment out of fear they may personally be fully financially responsible,” McCaskill wrote, “even though they have insurance.” McCaskill asked for the material to be submitted by Jan. 19.
Anthem refused to say how it has responded to the letter, and McCaskill’s office didn’t respond to a question about whether the company met the deadline.

Anthem says its policy is designed to save money by reducing unnecessary ER care. The goal, it says, is “to reduce the trend in recent years of inappropriate use of ERs for non-emergencies.”

A spokeswoman for Anthem’s Georgia program told me last year that the policy wouldn’t apply when the patient is 14 or younger, an urgent care clinic isn’t located within 15 miles, or the visit occurs on a Sunday or holiday. She said it’s aimed at manifestly minor ailments — “If you had cold symptoms; if you have a sore throat,” she said. “Symptoms of potentially more serious conditions, such as chest pains, could be seen at the ER even if they turn out to be indigestion.”

But that doesn’t fit well with a policy that threatens patients with a big bill if they guess wrong. And many patients may not be aware of the exemptions for weekend visits, for younger patients, or for those not located near an urgent care clinic. They could be discouraged from visiting the ER, too.

What’s especially unclear is how Anthem’s policy is supposed to correspond to two important legal safeguards for patients. One is the Emergency Medical Treatment and Labor Act of 1986. EMTALA, as the act is known, requires emergency departments to screen, stabilize or treat anyone showing up at the ER, regardless of their ability to pay.

EMTALA was designed as an anti-dumping law to prevent for-profit hospitals from fobbing off indigent patients to public hospitals without treating them first. The rule imposes costs for care on hospitals that treat uninsured patients; hospitals justifiably are concerned that Anthem’s policy could impose costs for insured patients, too.

“Anthem expects us to screen their patients in the ER,” says Jonathan W. Heidt, an emergency physician in Columbia, Mo., and president of the state chapter of the American College of Emergency Physicians, “but won’t guarantee they’ll pay for the treatment.”

The second safeguard is the “prudent layperson” rule, which requires insurers to cover ER visits made by a member who resorts to the ER for a condition that the average person would consider a possible emergency.

Anthem told me in an emailed statement that a company medical director will review suspect ER claims by applying the prudent layperson standard to “claim information and medical records” submitted by the hospital, but that leaves a lot of room for dickering, in a process in which the patient, facing an unpaid charge that could be thousands of dollars, is almost certain to be at a disadvantage.

In Missouri, according to Heidt, judgments on ER claims appear to be made by Anthem nurses or other medical professionals based on the diagnostic codes entered on claims documents. But that’s insufficient to show whether an ER visit was appropriate. In one case Heidt reviewed for his medical group, a patient was hit by a car, transported by paramedics to the ER on a backboard and with a neck brace, given a CAT scan and X-rays, and eventually found not to have suffered a serious injury. The patient was discharged with a diagnosis of bruises and abrasions. Anthem denied the claim.

A list of conditions that Anthem warned Indiana hospitals might warrant claims rejections numbered more than 120, including bronchitis, contusions, sprains and low back pain, any of which might herald more serious conditions; a more detailed list reportedly obtained for Missouri by physicians in that state ran to more than 1,900 conditions, including sprains and injuries of limbs, bone and muscles.

Medical experts have found that ER discharge diagnoses can be virtually useless in determining whether an ER visit was made for a “non-emergency” reason. A 2013 study of nearly 35,000 ER visits found that the vast majority of patients appeared with complaints that could have warranted an ER examination.

“Patients present to the [emergency department] with … complaints, symptoms and signs,” observed the authors, “but usually not with diagnoses.” They found that those relying on final diagnoses are “unable to accurately identify ‘non-emergency’ ED visits.”

That doesn’t surprise Heidt. He says that in studying claims denied by Anthem for his ER medical group, he concluded that more than half of the visits were reasonable, about 45% “were in the gray zone,” and fewer than 5% could have been treated outside the ER. “I’m a board-certified trained doctor of emergency medicine,” he told me, “and I have trouble looking at the ER note and knowing what the patient was thinking at 3 o’clock in the morning, let alone trying to figure it out from a claim form.”

None of these concerns has yet stayed Anthem from expanding a manifestly anti-consumer policy. Only state regulators can do that, and it’s time they stepped in.

Source: Anthem expands its policy of punishing patients for ‘inappropriate’ ER visits

In mediation, doctors reduce billed charges by millions – Houston Chronicle

Of $7 million in disputed surprise medical bills patients submitted to the state’s mediation process last year, insurers agreed to increase their overall payments by $1 million, new Texas Department of Insurance data show. That means physicians made the more dramatic concessions, reducing their demands by $6 million.

The who-pays-what argument is at the core of an ongoing state crisis over a confusing medical business practice called balance billing that costs patients millions of dollars each year. Under the system, a doctor who is outside a patient’s insurance network can charge more and then shift any or all of the “balance” not paid by the insurer onto patients.

Last year, Gov. Greg Abbott signed into law a revised version of the state’s mediation process designed to give such patients a chance for relief. Those who feel wronged by a balance bill of more than $500 can request that their insurer organize a telephone conference between the insurance company and the physician to see if a compromise can be reached. If not, the dispute goes to a full hearing.

The law, which went into effect Jan. 1, expands the scope of mediation to now also include bills from free-standing emergency centers.On Tuesday, the state Senate Committee on Business and Commerce met at the University of Houston for a status check on the process.

State Sen. Robert Nichols, R-Jacksonville, got to the heart of the matter quickly when questioning Insurance Department officials about the outcome of mediations.

“Who gives in?” he asked.

The answer appears to be the physicians. Less clear is why such a lopsided gap exists between two sides.

“It could be the bill was too high to begin with or that providers feel like that was the best they could get,” speculated Stacey Pogue, a senior policy analyst for the Center for Public Policy Priorities, who has studied balance billing in Texas for a decade.

Dr. Ray Callas, an anesthesiologist from Beaumont who testified Tuesday, said afterward in an emailed statement that he has not been through a mediation process and does not know why there is such a gap in the negotiation between parties.

“I can say that if the physicians and health-care providers did receive as much as $1 million through mediation, at least that is something. Without mediation they would not have received even that, despite having cared for the patients,” his statement said.

Pogue also saw value in the mediation process but from a different perspective. Without mediation, she said, that $7 million reduction in billed charges would have most likely been borne by patients.

“What it does show is people who don’t go to mediation are paying a lot more than they need to,” she said.



Last year, 2,064 Texans asked for mediation over a balance bill. Of those, 1,926 were settled in the phone conference. Only 124 were forwarded to a further hearing and 14 are still pending, the data show.

The disputed billed amount last year totaled $7,109,670 with insurers agreeing to pay an additional $1,101827. That means that physicians apparently agreed to not collect slightly more than $6 million. A small amount of that may have been paid by patients through co-pays and co-insurance.

While last year’s gap was the widest, there have been similarly disproportionate amounts in past years. In 2016, there were 1,504 mediation requests for a total of $4.2 million in billed charges. Again, the vast majority were settled by phone conference. And while insurers agreed to pay an additional $713,952 toward claims, physicians agreed to forgo more than $3.5 million in billed charges.

Consumer advocates say only a tiny fraction of Texans who might be eligible for mediation know about the option.

Callas insisted at the hearing that the entire problem of balance billing could be solved if insurers would negotiate in good faith. He said physicians want to be included in insurers’ networks but are often shut out or offered such low reimbursement rates they have no choice but to be out-of-network.

He also chided the Insurance Department for not holding insurers more responsible for letting consumers know who is in-network and for not enforcing existing rules on network adequacy.

Jason Baxter, director of government relations for the Texas Association of Health Plans, the state’s insurance trade association, countered that doctors – especially those in emergency room settings – may remain out of network intentionally so they can bill at higher rates.

“The evidence suggests this may not be an accident,” he testified.

A 2017 Houston Chronicle investigation into the financial forces behind balance billing showed that unsuspecting Texas patients receive thousands of dollars in balance bills from out-of-network emergency room physicians even if they go to an in-network hospital.

Source: In mediation, doctors reduce billed charges by millions – Houston Chronicle

Hospitals cut back on opioids to battle addiction epidemic – Chicago Tribune

Zulidany Cortez came to the emergency room at Amita Health Adventist Medical Center Bolingbrook when she could no longer take the pain from a wrist she hurt moving furniture.

In years past, doctors likely would have given the 32-year-old a prescription for an opioid painkiller to swiftly curb her suffering. But when Cortez met with Dr. Mark Livak, the subject didn’t even come up.

 “I think Tylenol should be OK,” Livak said. “We’re going to put you in a splint, a piece of moldable fiberglass that goes in an ACE wrap. I think that’s going to give you some pain relief just by not moving it.”

So it goes in the emergency rooms and surgical suites of many Chicago-area hospitals, where physicians are trying to overturn their profession’s longstanding dependence on opioids.

“The majority of overdoses come from (people who use opioids to treat) chronic pain, but that doesn’t tell you how their use began,” said Dr. Andrew Kolodny, a Brandeis University scientist who is executive director of Physicians for Responsible Opioid Prescribing.

“I can’t point to data, but I believe that for the vast majority of people who become stuck on opioids, their prescriptions began because of injury or surgery.”

But it’s not just patients who are in danger from excessive opioid prescribing. People who receive large doses often end up with leftover pills that are taken by others: More than half of Americans who misuse opioids report getting them from a friend or relative, according to the National Survey on Drug Use and Health.

Many hospitals are now moving to alternative methods of treating pain. Some doctors say less potent medications can handle pain equally well — and that patients are coming to share that view.

In the past six months, Rush University Medical Center has given post-surgical patients Tylenol, Motrin and gabapentin, a medication used for nerve pain. A mild opioid is used just for intermittent pain spikes.

Dr. Asokumar Buvanendran, a Rush pain specialist, said patients greeted the new protocol in a surprising way.

“We were concerned we would have a lot of complaints, but we have not seen any of that,” he said. “We have seen the reverse — patients are more satisfied.”

Second thoughts

Opioids, which encompass everything from codeine to heroin, block pain signals to the brain. That trait has made them a prized analgesic for thousands of years, but experts say their use exploded in the 1990s as doctors — swayed by shifting attitudes about treating pain and aggressive pharmaceutical company marketing — became more generous about prescribing them.

While most of the pills went to patients with chronic conditions, Kolodny said they also became the first choice for people visiting an emergency room or recovering from surgery.

“There’s a notion that the drug can’t cause addiction, that the abusers are the ones at fault,” he said. “(Doctors) don’t think they’re creating abusers. They don’t quite get that the drugs themselves are causing addiction.”

But as overdoses spiked and stories emerged of habits that began with a broken bone or a pill filched from a relative’s medicine cabinet, medical professionals began to rethink their use of the drugs.

The U.S. Centers for Disease Control and Prevention called for physicians to prescribe no more than three to seven days’ worth of take-home opioids for acute pain. Numerous professional groups also called for restraint.

“We were probably too liberal when we were responding to all this pressure (to prescribe the drugs), but that’s really tightened up,” said Dr. Mark Reiter, past president of the American Academy of Emergency Medicine.

The same reckoning has happened in operating rooms. At Northwestern Medicine’s hospitals, surgeons try to prescribe no more than a small amount of opioids after a procedure, though they don’t stick to a specific amount.

“The reality of treating acute pain is we’re often guessing how many pills a patient will need,” said Dr. Jonah Stulberg, a Northwestern surgeon who has led its opioid reforms. “Some people’s pain gets much better in 24 hours; others have significant pain for three to five days. We probably will never be able to exactly match the number of pills a patient needs with their pain.”

Instead, Northwestern tutors patients about the potential dangers of opioids and asks them to bring unused medication to follow-up meetings with their surgeons, where the drugs can be disposed of properly.

Lynn Adler, who recently underwent gastrointestinal surgery at Northwestern, said she appreciated that policy.

“I had never been asked that before,” said Adler, 70, who returned a bottle of tramadol. “I loved it because I had filled the prescription but never took any. I didn’t know what to do with them, so I was really happy when they told me to bring them in.”

Pre-emptive measures

Some hospitals are focusing on what happens before an operation to lessen the need for post-op pills.

NorthShore University HealthSystem tries to set patient expectations at a realistic level in advance. And for some procedures, doctors inject localized pain blockers prior to surgery to keep the area numb after the person wakes up.

Dr. Rebecca Blumenthal, a NorthShore anesthesiologist, said before the organization adopted this protocol in 2016, every patient who underwent these procedures received opioid prescriptions. Now only half do, she said, and most get just a few pills.

“It’s amazing,” she said. “Our patients are having these very large surgeries, and half of them require very low opiates.”

Pablo Michalewicz, a 61-year-old biology instructor at Triton College who suffers from diverticulitis, was given a local pain blocker before having a section of his colon removed at NorthShore Evanston Hospital earlier this month.

He said he felt little pain when he awoke and declined the offer of a take-home opioid, using only Tylenol, ibuprofen and gabapentin.

“I wasn’t even close to needing (opioids),” he said. “The first five or six days I was waiting — like, when is the pain coming? It never did.”

Hospitals are also taking extra measures to foil people who might be seeking narcotic drugs. All doctors in Illinois are required to sign up for a state database that monitors opioid prescriptions, and some hospitals have also developed in-house systems.

At Cook County’s Stroger Hospital, that information is now automatically included in a patient’s electronic medical records, allowing doctors to make better decisions, said emergency medicine physician Dr. Steven Aks.

He said he and his colleagues are prescribing fewer opioids, and to his surprise, patients who once demanded the drugs are accepting alternatives.

“Honestly, I’m not sure what it is,” he said. “Five years ago, there was a lot more resistance. I think people are getting it.”

Dramatic changes

Back in Bolingbrook, Cortez said she was glad opioids would not be not part of her care.

“I’m very familiar with (the opioid epidemic),” she said. “I don’t want anything to do with that.”

Amita recently outfitted its emergency rooms with large posters outlining its opioid policies. They state that doctors do not prescribe long-acting painkillers such as OxyContin, which are especially prone to abuse, and do not refill lost or stolen prescriptions.

The hospitals also have moved away from a potent opioid called Dilaudid, once the first choice for patients who suffered traumatic injuries.

Dr. Carlos Martinez, an emergency room physician, said it can have a euphoric effect when given through an IV, a quality that appeals to drug-seekers. So for most cases, the hospitals now stick with morphine, a more prosaic opioid.

Since the policy began about six months ago, Martinez said, Dilaudid use at some Amita hospitals has dropped by more than half. But as dramatic as that result might be, he said, it shouldn’t lead anyone to expect a swift end to the opioid crisis.

“It will make a difference, but emergency departments across the United States will not solve this problem by themselves,” he said. “It’s not going to make a huge dent unless everyone does their part together.”

Source: Hospitals cut back on opioids to battle addiction epidemic – Chicago Tribune

New state guidelines issued for how doctors should treat acute pain- Indiana

Chronic pain physicians had them. So did emergency room doctors. Now outpatient physicians have clear guidelines for managing acute pain without quickly resorting to opioids.

The Indiana Hospital Association, Indiana State Medical Association and the Indiana State Department of Health collaborated to produce the guidelines that aim to discourage the overuse of prescription pain pills considered responsible for driving the opioid crisis.

“I believe these guidelines are a critical tool for both healthcare providers and for patients and will allow them to work together to identify the safest and most effective tools to treat their acute pain,” said Dr. Kristina Box, Indiana State Health Commissioner.

The new guidelines recommend that for patients with acute pain — pain defined as being related to damaged tissue and that will resolve with healing in a matter of days and weeks — doctors first consider non-pharmacologic treatment, such as ice, acupuncture, chiropracty and massage. If those are not strong enough, doctors should then consider non-opioid pharmacologic treatment, the guidelines say.

Only the most severe injuries warrant opioids, the guidelines say. In those instances, doctors should take several steps to ensure that the drugs are not misused, using opioids only in concert with other therapies, putting patients on the lowest dose possible and offering no refills.

An Indiana law that went into effect in July prohibits doctors from prescribing more than a seven-day supply to patients under 18 or to adults for whom that is their first prescription from that provider. Within the first few months of the law going into effect, there were 100,000 fewer prescriptions written, said Dr. John McGoff, president of the Indiana State Medical Association.

While many doctors shy away from practicing what McGoff called “cookbook medicine,” he added that the guidelines aim to raise awareness among doctors about the problem and serve as a document that doctors can consult for best practices on how to address a patient’s acute pain.

The stunning statistics associated with the opioid epidemic prompted the experts to devise ways to decrease doctors’ reliance on opioids. Excessive prescribing in the early part of this century helped stoke the epidemic, many experts believe.

Since 1999, Indiana has seen death by drug overdose increase by 500 percent.

Nationally accidents have become the third leading cause of death in the United States for the first time ever, according to the National Safety Council.

In 2016, preventable deaths increased by 10 percent over the previous year, largely due to a rise in deaths due to drug overdoses and motor vehicle crashes. Previously chronic respiratory diseases were responsible for the most deaths after heart disease and cancer, according to the Centers for Disease Control and Prevention.

While the experts who wrote the guidelines hope doctors find them useful, the final decision of whether to prescribe an opioid still rests with the doctor, said Julie Reed, executive vice president of the Indiana State Medical Association of the guidelines. Doctors will be able to tailor their decisions to fit their patients’ needs.

“They don’t stand to replace professional judgment or clinical judgment,” said Julie Reed, executive vice president of the Indiana State Medical Association of the guidelines. “That’s really an important thing that needs to be balanced, that is to make sure that the needs and unique characteristics and judgment that healthcare providers have learned through their training over the years can really serve to complement these guidelines.”

IndyStar’s “State of Addiction: Confronting Indiana’s Opioid Crisis” series is made possible through the support of the Richard M. Fairbanks Foundation, a nonprofit foundation working to advance the vitality of Indianapolis and the well-being of its people.

Source: New state guidelines issued for how doctors should treat acute pain

Could A Co-Pay Curb Emergency Room Abuse? « CBS Dallas / Fort Worth

A U.S. Representative is weighing in on the idea of charging a co-pay to Medicaid patients who go to North Texas hospital emergency rooms for non-emergency reasons.

Rep. Michael Burgess is also a doctor. The Republican Congressman says part of the issue can be traced back to the implementation of Obamacare. “When the Affordable Care Act passed, there was concern that it would drive overutilization of emergency rooms… and it turns out that was the case.”

Last week’s Consumer Justice investigation found millions of taxpayer dollars being spent to treat acne, constipation, bunions and other health issues deemed “non-emergency” in nature by the Texas Health and Human Services Commission.

“Talk to any emergency room doctor and they will tell you a better part of their day is spent tending to things that could be very easily taken care of at a doctor’s office or an urgent care center where the overhead is much, much lower,” said Rep. Burgess.

Right now Medicaid patients are treated for free at hospital emergency rooms. Experts say that means there is no incentive for them to avoid the ER, but a co-pay could make them think twice.

The State of Texas could submit a waiver to the federal government to charge some Medicaid patients a co-pay for emergency room treatment in the event their medical situation is deemed non-emergency. “The dollar amount is fairly small, I think it’s $8 by statute,” said Burgess. “But there are populations that cannot be charged a co-pay. Pregnant women, for example, children, for example.”

Submitting a waiver would not require legislative action, but State Sen. Kelly Hancock says he’s interested in studying the issue before the next session. Hancock says he’s putting together a “working group” to look into the effects any type of co-pay would have on Medicaid patients.

Rep. Burgess says it’s especially important right now to not misuse the emergency room, with so many ERs overwhelmed with flu cases. Still, critics say the emergency room may be the only choice for some, since fewer doctors are accepting Medicaid patients.

Even so, Rep. Burgess says everyone should have a primary care doctor. “It’s continuity of care — someone who’s going to pay attention as to whether or not you’ve had your flu shot for example, or whether or not you’ve had screening tests that you should have at various points of your life.”

Source: Could A Co-Pay Curb Emergency Room Abuse? « CBS Dallas / Fort Worth

Non-Emergency Visits Costing North Texas Taxpayers Millions « CBS Dallas / Fort Worth

Acne, bad breath and ingrown nails: all seem like relatively minor health issues. But a Consumer Justice investigation found millions of taxpayer dollars paying for Medicaid patients to use the emergency room for non-emergency medical attention.Data from the Texas Health and Human Services Commission showed Medicaid patients using ERs in Collin, Dallas, Denton and Tarrant County emergency rooms for just about any health problem.Thousands of people checked in for routine issues like seasonal allergies, birth control, pregnancy tests, immunizations — even prescription refills and cavities. There were the common illnesses, like bronchitis, strep throat and coughs, along with unusual afflictions, like excessive crying or nightmares.It all adds up. Emergency rooms billed $750,000 to treat acid reflux and heartburn, and $3.2 million to treat headaches (not migraines). Another $3.8 million went to treat constipation and excessive gas. Upper respiratory infections alone cost taxpayers almost $9.2 million.“There’s a high number of emergency room visits that are not for emergencies,” said Dr. John Carlo, president of the Dallas County Medical Society. “It’s a huge drain of resources, absolutely.”Dr. Carlo says there are a few reasons why Medicaid patients choose the ER over a primary care physician or walk-in clinic. “After-hours visits. People that might have a job during the day and cannot take time off,” said Carlo. “People are choosing ERs because they’re easier to get to,” he added, “Keep in mind these centers are well-located on public transportation routes.”State Senator Kelly Hancock agrees.“There is no incentive to keep people out of the emergency room,” said Sen. Hancock.He pointed to a federal law that requires ERs to treat patients no matter the issue.“It’s great in theory, it’s just working out to where it’s very costly to the taxpayer and it’s really creating a lot of logjams in the emergency rooms.”According to the Texas Association of Health Plans, the state can submit a waiver to the federal government to implement a co-pay for Medicaid patients who use the emergency room for non-emergency reasons. Supporters say while this wouldn’t stop emergency room abuse, it could curb it.Hancock says he is interested in studying the issue. “We’ll have a very large working group together and we’ll be working on this from here till [the legislative] session starts to try to come up with something.”Still, he warns against a “one size fits all” policy that could hurt people that need the care most. Hancock worries that even a relatively small co-pay could be too much for people on Medicaid.“We want emergency rooms to treat emergencies. But at the same time, we gotta make sure that we parse out the details and we’re not harming the individuals we’re trying to help,” said Sen. Hancock.

Source: Non-Emergency Visits Costing North Texas Taxpayers Millions « CBS Dallas / Fort Worth

Emergency Room Charges and What to Do About Them

Washington, DCA study into medical bills, treatment costs at hospitals and emergency room charges undertaken last year and published in May by the Johns Hopkins University School of Medicine confirmed what we already know: charges for medical care can be excessive when compared to what Medicare and Medicaid interprets as the true value for services.

What we didn’t know was by how much – but we do now. The study revealed that in emergency rooms in the US, patients are billed on average as much as 340 percent more than what Medicare pays for the same service. The study also found that minorities and the uninsured bear the brunt of most of those charges.

How can they get away with that?

The Emergency Medical Treatment & Labor Act (EMTALA) passed in 1986ensures that no one requiring treatment from a hospital emergency room will be turned away due to an inability to pay. However, there are essentially two tiers of uninsured Americans: those who can’t afford health insurance and can ill afford to pay for treatment themselves: and those who choose not to have insurance or don’t qualify for same, but nonetheless have the means to foot the bill.

The challenges for the uninsured are numerous

The uninsured with means can be a hospital’s best customer, in that charges can be inflated and patients hounded for payment without the capacity for an insurer to negotiate lower fees. Even when health insurance is involved, hospitals can inflate the cost of a service with full knowledge they’ll be hounded for a reduction by the health insurer. Fees are then reduced somewhat as both sides arrive at a compromise. But the end result is a basket of fees that is still higher than the value Medicare places on the services rendered.

The uninsured lacks that buffer, and thus feels the full weight of the billing department on their shoulders for emergency room cost. And lest one suspects that inflating a charge for treatment just because a patient carries no insurance is a fallacy, USA TODAY (07/13/17) makes that very point, suggesting in the report that “the bill they send will be higher than for an insured patient because there’s no carrier to negotiate lower prices.”

USA TODAY also references a study published in 2016 by the National Bureau of Economic Research that determined an uninsured patient reporting to a hospital for treatment faces a heightened risk for bankruptcy within four years of that hospital visit. The study suggests the risk for bankruptcy for the uninsured is doubled when compared against insured patients, or those with the means to absorb the costs with reasonable comfort.

The issue of inflated emergency room fees, over which some plaintiffs launch an ER bill lawsuit, is further complicated with the general inability of a patient – in the midst of a real emergency – to choose where he or she is taken and whether or not, for the insured the hospital or emergency room staff fall within their approved healthcare network. As more hospitals begin to outsource emergency room service, it’s almost impossible to know whether, or not the individual(s) treating the patient falls within their approved service network as required to qualify for reimbursement by their insurance provider.

State governments should be prepared to help

Writing in (09/06/17) contributor Robert Pearl, MD advocates for patients to have the right to know in advance what prices are for service: “…when a hospital intends to charge $15 for a Tylenol caplet or $100 to turn on the overhead light in an operating room.” This would be especially helpful for the uninsured that may have to foot the bill themselves – with the emergency room bill likely far, far higher than what Medicare views as the true value of service.

Conversely, when an insured patient in emergency distress is transported by ambulance to an emergency room that falls outside of their approved network for reimbursement, Pearl advocates that there is a role to play for state government to help tame unexpected costs for the patient.

To that end, the writer notes that as of September of last year 23 states had either passed, or had under consideration hospital fair-pricing laws that would help to limit the financial burden for out-of-network emergency care.

Pearl cites New York as an example of a state that has passed legislation (in 2015) helping to shield insured patients from burdensome fees. Patients, according to the legislation, “do not have to pay non-participating provider charges for emergency services…that are more than your in-network co-payment, coinsurance or deductible.”

Regardless as to whether, or not a patient receives care from an in-network or out-of-network facility – and regardless of whether, or not a patient is insured or uninsured – we come back to the Johns Hopkins study that suggests hospitals overcharge by up to 340 percent above the true value a service is worth.

No wonder people dispute a medical bill – often with an ER charges attorney in tow.

Source: Emergency Room Charges and What to Do About Them

No Differences Seen Between Opioids, OTC Pain Drugs for Extremity Pain in ED – Pain Medicine News

Lead author Andrew Chang, MD, vice chair of research and academic affairs and an endowed professor of emergency medicine at Albany Medical College, in New York, travels to many international pain conferences to learn how other countries manage pain. “It is really eye-opening to see conditions where in the United States a physician would not hesitate to prescribe opioids, but physicians in other countries manage that same condition with nonopioids,” he said.

Dr. Chang singled out New Zealand, where he came across a product that combines ibuprofen and acetaminophen into a single pill. “That seems like such an obvious combination, yet I have never seen it anywhere else. These experiences and the worsening U.S. opioid epidemic inspired me to see if I could do something to help mitigate the epidemic’s devastating effects on communities.”

The results of the trial did not surprise Dr. Chang. “It intuitively makes sense that if you took two over-the-counter analgesics that work differently, used higher doses and combined them, then perhaps they would provide analgesia on par with that of opioids,” he said.

The investigators did not think ibuprofen alone or acetaminophen alone would provide the same level of pain relief, although they believed the additive effects of the two combined would do so.

A subanalysis of the study patients who had fractures on X-ray and/or had the maximum baseline pain score of 10 also revealed there were no differences in effectiveness of the four combinations of analgesics. “I think some physicians may reflexively prescribe opioids for fractures, but this study lends evidence that opioids are not always necessary, even in the presence of fractures,” Dr. Chang said.

He emphasized that the study’s lack of a difference among the four treatments is an average. Hence, any individual patient might obtain better pain relief with a particular analgesic or for a particular fracture pattern, such as one that is displaced or broken in multiple places.

Because the study was conducted in the setting of an ER, the authors are unable to generalize the findings to patients being discharged home or patients being seen in other settings. “Still, it is not a huge leap of logic to think that the same regimen would probably work when patients are discharged home,” Dr. Chang said. The trial did not examine adverse events.

By administering a combination of nonopioids to patients while they are in the ER, and showing them—as well as the treating physician—that such a regimen provides pain relief comparable to opioids, “the patient will likely be more accepting of a nonopioid upon discharge, and the physician may feel less pressure to prescribe an opioid,” Dr. Chang said. “So by preventing patients from being exposed to opioids in the first place, perhaps this will help contain the ongoing opioid epidemic.”

But there are challenges in instituting such a regimen. “You cannot just tell physicians to suddenly stop prescribing opioids, without first providing them a high level of evidence that nonopioid treatments both exist and are effective,” Dr. Chang said. Nonetheless, he believes there are many ED physicians who would like to administer fewer opioids to their patients and who will adopt this strategy.

Dr. Chang hoped that at minimum, the study will make physicians reflect about whether nonopioids can manage certain types of pain. “Our results could also serve as future evidence toward guidelines for pain treatment prescribing.” He plans on obtaining funding to continue his research and track patients after their discharge from the ED.

‘Significant Impact’

Yvonne D’Arcy, MS, ARNP-C, CNS, FAANP, a nurse practitioner and pain management consultant from Ponte Vedra Beach, Fla. and a Pain Medicine Newseditorial advisory board member, said the new study has “significant impact on the practice of pain management in the ER because the medications that were chosen for comparison are those that are commonly used by ERs for pain relief.”

Ms. D’Arcy knows the value of a nonopioid medication from routinely administering IV acetaminophen for postoperative pain. “Many patients were reluctant to use a nonopioid medication for additive pain relief, thinking it was not strong enough. But after experiencing the improved pain relief, patients felt they had underestimated the value of a nonopioid.”

Because there was no significant difference in pain relief among the four medication regimens, “clinicians should consider using a nonopioid as a first choice,” Ms. D’Arcy said. “If the patient does not receive adequate pain relief, there is always the opportunity to offer an opioid.”

She pointed out that one very real advantage of a nonopioid is the reduction in side effects. “Patients on a nonopioid pain regimen should experience less nausea, vomiting and pruritus. Using fewer opioids will also make ERs less of a target for patients seeking opioids, once this pattern is identified by the community.”

One issue that Ms. D’Arcy has faced when incorporating nonopioids into treatment is a patient perception that these medications are not strong enough. “Asking how the patient has taken nonopioids in the past will often reveal that they were used inconsistently. By scheduling the nonopioid medication for a period of 24 to 48 hours, clinicians should be able to determine the efficacy of the nonopioids.”

Ms. D’Arcy said the short assessment time of the study (two hours) was not long enough to determine the full efficacy of repeated dosing with any of the medications. She also said the study lacked definition of the type of extremity pain. “Were these burn patients, trauma or fractures? For future studies, there should be particular patient types to compare the drugs again.”

Source: No Differences Seen Between Opioids, OTC Pain Drugs for Extremity Pain in ED – Pain Medicine News

To understand why America’s opioid epidemic keeps getting worse, just look at this map

America’s opioid epidemic keeps getting worse, with the latest data showing that drug overdose deaths in the US climbed by roughly 21 percent between 2015 and 2016 — from a record high of more than 52,000 to a new record of nearly 64,000. About two-thirds of those overdoses were linked to opioids.

To understand how this crisis keeps growing, take a look at an insightful map by amfAR, an advocacy group dedicated to the fight against HIV/AIDS. The map shows three things: the availability of facilities that treat drug addiction, the facilities that provide at least one medication for opioid addiction (marked as MAT, or medication-assisted treatment, on the map), and the facilities that provide all three kinds of medications for opioid addiction.

A map of drug addiction treatment facilities across the country that provide medications for opioid addiction.

Clearly, there are a lot of gaps in coverage. In a post on Health Affairs, Austin Jones, Brian Honermann, Alana Sharp, and Gregorio Millett of amfAR looked at 2016 data from the Substance Abuse and Mental Health Services Administration and found that only 41.2 percent of the more than 12,000 drug addiction treatment facilities in the US offered at least one kind of medication for opioid addiction. Only 2.7 percent offered all three.

These medications are widely considered by experts to be the gold standard in opioid addiction care. Studies, including systematic reviews of the research, have found that opioid addiction medications in general cut all-cause mortality among opioid addiction patients by half or more. The Centers for Disease Control and PreventionNational Institute on Drug Abuse, and World Health Organization acknowledge their medical value. That doesn’t mean these medications are for everyone (they’re not), but there’s a lot of good evidence for their general efficacy.

So it is pretty bad that a majority of addiction treatment facilities don’t provide access to any of these medications. It is similarly bad that even more of these facilities don’t offer access to more than one kind of medication; the individual types of medications don’t work for everyone — nothing in addiction treatment does — so it’s important to provide multiple options.

We are, as a country, nowhere close to that goal.

If the US isn’t making good use of even the bare minimum of evidence-based treatment, it’s no wonder the opioid crisis keeps getting worse.

One caveat: The map likely understates the amount of addiction treatment that is available in some parts of the US. For one, physicians can gain the ability to prescribe buprenorphine through a special waiver, but those kinds of practices wouldn’t appear in a map solely dedicated to drug addiction treatment facilities. Still, other data collected by amfAR shows that there are big swathes of the country without doctors who can prescribe buprenorphine.

There’s also other data that exposes America’s big gaps in addiction treatment. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country lacking affordable options for any treatment — which can lead to waiting periods of weeks or even months.

The map exposes America’s inaction in the opioid epidemic

More than showing the specific counties and states that don’t have access to some kinds of treatment and medications, amfAR’s map shows that America isn’t truly serious about dealing with its opioid epidemic.

Given that we know these medications are highly effective for opioid addiction, providing access to them should be the low-hanging fruit for dealing with a drug overdose epidemic fueled by opioids. Coverage remains sparse, and there’s been little attention to changing that.

A major reason for that is stigma. These medications are often characterized as “replacing one drug with another” — say, replacing heroin use with methadone use.

This fundamentally misunderstands how addiction works. The problem is not drug use per se; most Americans, after all, use caffeine, alcohol, and medications without major problems. The problem is when drug use becomes a personal or social burden — for example, putting someone at risk of overdose or leading someone to commit crimes to obtain drugs.

Medications for opioid addiction, by staving opioid withdrawal and cravings without leading to a significant risk of overdose, mitigate or outright eliminate those problems — treating the core concerns with addiction.

Another reason for the treatment gap is a lack of federal attention. In the past few years, for example, the only new federal effort to dedicate a serious amount of money to the opioid crisis was the Cures Act, which committed $1 billion over two years.

Even that sum fell woefully short of the tens of billions annually that experts argue is necessary to deal with the opioid epidemic. For reference, a 2016 study estimated the total economic burden of prescription opioid overdose, misuse, and addiction at $78.5 billion in 2013, about a third of which was due to higher health care and addiction treatment costs. So even an investment of tens of billions could save money in the long run by preventing even more in costs.

As Stanford drug policy expert Keith Humphreys previously told me, “Crises in a nation of 300 million people don’t go away for $1 billion. This is the biggest public health epidemic of a generation. Maybe it’s going to be worse than AIDS. So we need to go big.”

America has not gone big, at least yet. So the opioid epidemic continues, killing tens of thousands of people in the process every single year.

Source: To understand why America’s opioid epidemic keeps getting worse, just look at this map – Vox

New Plan to Fight the Opioid Epidemic: Sue the Hell Out of Big Pharma Like Big Tobacco

In the next two years, the opioid epidemic is estimated to cost the United States a trillion dollars and kill almost 100,000 Americans. President Donald Trump declared it a public health crisis this year but has not asked Congress for additional money to fight the scourge.

That leaves states, counties, and cities to bear much of the cost—and they want Big Pharma to pay.

“We kept seeing our crime problems and overdose deaths going up every year, and we got no response for anyone with the federal government,” Mayor Paul Billups of Ceredo, West Virginia, told The Daily Beast. “They didn’t have a plan, so we decided to come up with a plan. We decided caring for people is more important than marketing and profits.”

Ceredo is one of about 250 states, counties, and cities that have filed lawsuits against multiple pharmaceutical companies and distributors of opioid prescription pills that are blamed for turning pain patients into heroin addicts.

Richie Webber is one such victim. A star high-school track and football athlete 10 years ago, Webber got injured, got on pain pills, and got hooked. It led to heroin use and two nearly fatal overdoses. Webber has been clean for about three years and works with a community group in his native Ohio to help people like him get treatment.

“I find it really odd when the pharmaceutical companies that make pills like OxyContin claim they are nonaddictive and just help people with pain,” he said. “Well, let’s look at it from my perspective. We’ve helped more than 300 people get into rehab this year, and 90 percent of them started with prescription pain pills. That’s nonaddictive?”

That is the thrust of most of the lawsuits: Those who make and distribute opioid pain pills have to clean up the drug addiction mess, and that mess was created by deceptive marketing and claims that these pain meds were nonaddictive. Communities want the companies they’re suing to help pay for “significant harm and damages, including, but not limited to, the breakdown of families, increased health insurance costs, increased police and fire usage, increased usage of the criminal justice system and other significant harms,” as a recent lawsuit filed Columbus, Ohio, put it.

These lawsuits are being filed all over the country, from Seattle, Washington, to Bangor, Maine. The Cherokee Nation has filed one as well.

“All we are looking for is a little justice in all this,” Pete Orput, the Washington County attorney in Minnesota told The Daily Beast on why his county joined other counties in the state filing suit. “We just want some payback. For years we have heard [the pharmaceutical companies] tell us they have nothing to do with the addiction. I resent what they have told us, and I resent what they have done in our community.”

The defendant named in most lawsuits is Purdue Pharma, which introduced OxyContin in 1996. The drug is a pain medicine based on a morphine-like derivative that Purdue promised was nonaddictive thanks to its time-release formula. Originally, it was prescribed for acute pain, like broken bones, terminal cancer, or post-surgical recovery. By the 2000s though, it was doled out by doctors to treat chronic and even minor pain.

“What happened was compassion became conflated with opioid prescribing, so a doctor who wasn’t willing to prescribe opioids was seen as withholding and sadistic,” said Anna Lembke, a professor of psychiatry and behavioral sciences and author of Drug Dealer MD: How Doctors Were Duped, Patients Got Hooked and Why It’s So Hard to Stop.

In a statement, Purdue Pharma said: “We are deeply troubled by the prescription and illicit opioid abuse crisis, and are dedicated to being part of the solution. As a company grounded in science, we must balance patient access to FDA-approved medicines, while working collaboratively to solve this public health challenge… We vigorously deny these allegations and look forward to the opportunity to present our defense.”

Opioid prescriptions tripled between 1999 and 2016 and so too did overdose deaths. In 2016, 42,249 people in the U.S. died of opioid-caused overdoses, according to the Centers for Disease Control and Prevention—more than deaths from breast cancer that same year. The White House Council of Economic Advisers (CEA) last November estimated the cost from the opioid crisis was about $500 billion in 2015.

Back to Big Tobacco

Supporters and critics of the opioid lawsuits point to the lawsuits by states against tobacco companies in the 1990s for the cigarette-makers responsibility for health problems like lung cancer. That was settled in 1998 for $246 billion, and the tobacco companies will pay their yearly allowance of that settlement through 2025.

“The model for this is still tobacco,” said David Kessler, who led the Food and Drug Administration from 1990 to 1997 and pushed hard for the FDA to regulate cigarettes. “Those who sell or distribute these highly addictive products need to have systems in place that they adhere to so we can control this epidemic.

“It is accepted and there is little doubt that too many of these drugs were put into the marketplace and sold beyond their legitimate needs,” Kessler told The Daily Beast. “The vast majority of people get addicted because of prescriptions, and we need to tighten the distribution and make the manufacturers of these drugs more responsible for what they have placed in the market.

“This is a public health issue, and we need to get better control on how much of the drug is placed in the market. These lawsuits may call better attention to those goals.”

Pharmaceutical companies in the past have settled lawsuits like these (including Purdue Pharma) and treat their fines as a cost of doing business. In this case, however, the settlement might be very big. “There is power in numbers,” says Orput. “You can pay one or two of us off, but you can’t pay all of us off.”

If Big Pharma is forced to pay, the question is to whom and how many. Treatment services? Increased foster care for children of addicts? Compensation to the addicts themselves?

Just the amount of funding that might go to the families of the deceased could be huge. From 1999 to 2015, more than 183,000 people have died in the U.S. from overdoses related to prescription opioids. If the court valued those lives at $50,000 each (to pick a random number), that would be $9 billion just in death payments.

Kenneth Feinberg, the attorney who oversaw the Sept. 11 victim’s fund dispersal, as well as similar appointed jobs with the BP offshore oil cleanup and the Boston Marathon bombing, said any settlement would need to be combined with congressionally approved funding to “have a better idea of who to and how much is distributed.”

“But getting anything through Congress is a chore,” Feinberg said. “If Congress enacted and appropriated enough money to deal with this crisis, a lot of these lawsuits would disappear.”

Wayne Campbell of Pickerington, Ohio, has been hearing the calls from other parents for the federal government to do something since his son, Tyler, died from a heroin overdose in 2011 after he was prescribed pain medication for a football injury.

“We constructed a timeline of his death, and it was just 18 months from precipitation drugs like OxyContin to heroin to rehab treatment to overdose and death,” he says of his son.

Campbell now runs a nonprofit group called Tyler’s Light, which tries to raise awareness about drug abuse and addiction for Ohio schoolchildren.

“If you see dead fish floating in the river, the best thing to do is to go upstream and find out why the fish are being killed. I think these lawsuits might have a role in us as a society doing that.”

Source: New Plan to Fight the Opioid Epidemic: Sue the Hell Out of Big Pharma Like Big Tobacco