by C.K. - The Economist - September 27, 2018
FEARRINGTON in North Carolina is a planned community modelled on an English village. It was built on the site of a former dairy farm. Stilwell, Oklahoma, also has agrarian roots: it advertises itself as the strawberry capital of the world. But a recent analysis by researchers at the National Centre for Health Statistics suggests the two communities are otherwise very different. Fearrington is home to some of America’s healthiest people, with an average life expectancy only two-and-a-half years short of a century. In Stilwell, newborns should expect to live to the age of 56. Stilwell has the same estimated average life expectancy as Somalia; Fearrington’s is 13 years higher than the average in Japan, the world’s most long-lived country.
The researchers estimated life expectancies across every one of America’s 65,662 census tracts: geographical divisions containing a few thousand people each that cover the entire country and are used for census data collection. The median estimated life expectancy across all tracts in America is 78.5 years. But 1,656 tracts see life expectancy below 70 years, and 2,511 have expectancy above 85—a 15-year gap. At the extremes there are 64 census tracts where life expectancy is estimated to be above 90, while seven see expectancies more than 30 years lower than that.
Census data points to some of the factors that lie behind this inequality. Median household income in the Fearrington tract is $81,900. The 4,630 people of Stilwell have a median household income of $25,000, less than half the national average. None of Fearrington’s children are reported to live in households below the poverty. That compares to more than half of children in Stilwell. A history of discrimination also plays a role: Chatham County, where Fearrington is located, is 96% white. Most people in Stilwell are native Americans—part of the Cherokee Nation that was forcibly relocated to the territory in 1830. The analysis suggests the bottom quarter of census tracts nationwide in terms of median household income account for 61% of the bottom quarter of tracts measured by life expectancy. The richest quarter of census tracts include 57% of the longest-lived tracts. Low life-expectancy is concentrated in the South and in tracts with a high share of minority populations.
Previous analyses of the inequality of life expectancy in America have also pointed to the huge role played by poverty in cutting American lives short. Raj Chetty, an economist at Stanford University, has studied the variation of health outcomes by income and across regions of America using tax and census data. His research suggests that the poorest 1% of women die an average of ten years earlier than the richest 1%. The richest-poorest life expectancy gap for men is 15 years.
Researchers at the Institute for Health Metrics and Evaluation also found that poverty and education were strongly linked to life expectancy at the county level. Their work suggests that low income and limited schooling were related to behavioural and metabolic risk factors including obesity, limited exercise, smoking, hypertension, and diabetes. In turn, these risk factors shortened lives.
There is a regional component to those risk factors as well. Mr Chetty found life expectancy amongst the poorest quarter of Americans differed across regions by four years for women and five for men. Once again, longer-lived regions saw lower average rates of obesity and smoking along with higher rates of exercise. Low-income individuals lived healthier and longer in affluent cities with highly educated populations and high levels of government expenditures, perhaps reflecting policies such as smoking bans or greater funding for public services.
Mr Chetty’s study argued that regional differences in life expectancy for poorer people were not significantly related to the proportion of people insured in those regions or measures of preventive health care. And health outcomes for that group did not notably improve when they become eligible for government-backed Medicare coverage at the age of 65. But the data still suggests that healthy living in the United States is a luxury good.
In These Red States, the Health of More Than 450,000 People Is on the Ballot
by Zoe Carpenter - The Nation - September 26, 2108
For years, more than 334,000 people in Nebraska, Utah, and Idaho have been locked out of Medicaid, the health-insurance program for low-income Americans, by state leaders who refused to expand their programs under Obamacare. But in November, voters have a chance to change that. Measures to expand Medicaid are on the ballot in those three states, and also in Montana, where a temporary expansion passed in 2015 is about to expire.
If the measures succeed, “It will be an enormous leap forward in the health of working families in these states. By some measures it would be the single biggest leap forward since the original enactment of Medicaid,” said Luke Mayville, co-founder of Reclaim Idaho, the grassroots group that led the effort to put expansion on that state’s ballot.
The expansion of insurance coverage via Medicaid is one of the Affordable Care Act’s most obvious successes. While many states previously restricted Medicaid to the very poorest families, the ACA raised the threshold of eligibility for Medicaid to anyone making 138 percent of the federal poverty level, and provided billions of dollars to states to shoulder the bulk of the cost of doing so. More than 10 million people gained health insurance because of the expansion—millions who had a new chance of obtaining preventive care, addiction treatment, and life-saving procedures without bankrupting their families.
But in 2012 the Supreme Court ruled that states were not legally required to expand Medicaid. As of September 17 states, most of them under Republican leadership, still have not done so. That’s left some 2 million people in a coverage gap: They make too much to qualify for their states’ traditional Medicaid programs, but not enough to get insurance through Obamacare’s individual marketplace.
To circumvent the legislative roadblocks, health-care advocates have turned to ballot measures. Last year Maine voters overwhelmingly passed an expansion initiative, though Governor Paul LePage has refused to implement it, sparking an ongoing legal battle. This year, after months-long grassroots efforts, similar measures are on the ballot in some of the country’s most conservative states—in Idaho and Nebraska, where Republican leaders have repeatedly resisted expansion; in Utah, where the Republican governor signed a “partial” expansion law but has not received approvalfrom the Trump administration to implement it; and in Montana, where a temporary expansion is set to expire next year, potentially stripping insurance coverage from nearly 100,000 people.
Idaho has one of the strictest Medicaid eligibility thresholds in the country: A parent with one child must make less than $3,468 per year to qualify. In order to get expansion on the ballot there, volunteers with Reclaim Idaho traveled throughout the state for months, through cities and remote small towns, in a kelly-green camper van that became a sort of unofficial mascot, gathering the necessary signatures. “We started in the far-northern part of the state, a nine-hour drive away from Boise,” said Mayville. “I think we communicated from very early on that this really is a citizens’ initiative and this isn’t just another round of partisan fighting. There are new voices coming into the debate and those voices are coming from ordinary people who care enough about this to do something about it.”
Though the Idaho Republican Party reaffirmed its opposition to expansion earlier this year, support for the measure isn’t limited to Democrats. State Representative Christy Perry, a four-term Republican, is the co-chair of the campaign backing the ballot measure. She argues that Medicaid expansion is the “most effective and efficient way of delivering health care, and fiscally responsible”—as well as the moral thing to do. That the issue made it onto the ballot is itself significant, Perry noted. Ballot measures are a tough vehicle for change in Idaho, in part because of stringent requirements for signature collection. “The fact that the public has stepped forward, I think that’s really very telling. Our communities have watched people play political football with the issue and they were having their friends and family and neighbors die for lack of health care, not only in Idaho but in a number of states,” said Perry. “It speaks of a frustration on the part of the public that their government was not able to come up with a solution.”
Although the states voting on Medicaid this year are among America’s most conservative, they also have high percentage of residents living in rural areas, which have been particularly hard-hit by the Medicaid gap. Rural communities generally tend to be sicker and face more barriers to accessing health care than urban populations. Rural hospitals have closed at a faster rate in states that have refused to accept expansion. Conversely, a new analysis from Georgetown University’s Center for Children and Families and University of North Carolina’s NC Rural Health Project found that in states that have expanded Medicaid, rural communities benefited the most. Overall, the percentage of rural residents without insurance has dropped from 35 to 19 percent in expansion states.
Polling on the ballot measures is limited, but surveys in Idaho and Utah show momentum on the side of expansion. Compared to the large, organized coalitions of health-care groups and citizen activists who did the legwork to get expansion on their states’ ballots, opposition has been muted. The measure in Nebraska survived a lawsuit seeking to block it. State chapters of Americans for Prosperity, the conservative group funded by the Koch brothers and which poured millions into persuading Republican legislatures to reject Medicaid expansion, are fighting the measures, but so far the group’s opposition has amounted mostly to op-eds placed in local newspapers and volunteer phone banks. Nevertheless, advocates are wary of last-minute infusions of conservative cash and negative-ad blitzes. Heather Williamson, the Utah director of AFP, recently told The New York Times that her group is “ramping up our efforts against the ballot initiative.”
Montana’s Medicaid initiative faces another deep-pocketed opponent: Big Tobacco. There, the expansion would be largely paid for by a tax on tobacco products. The parent corporations of Philip Morris and R.J. Reynolds—which manufacture Marlboros and Camels, respectively—have contributed more than $9 million to a political group opposing the ballot measure; the money has been used to launch a massive television, radio, and digital ad campaign across the state. Advocates for the ballot measure say the ads are deliberately misleading—for instance, the tobacco-backed group describes the measure as “a massive new tax increase,” though the taxes would only be paid by tobacco users.
“Big tobacco is again telling lies that put lives at risk,” said Jonathan Schleifer, executive director of the Fairness Project, a national group that is backing the four Medicaid ballot initiatives. “Voters in Montana will have a clear choice: Side with their neighbors who need access to health care or side with tobacco companies that have killed millions of people. You don’t need a poll to know health care is more popular than cancer.”
Medicaid expansion is also at play in states where it’s not explicitly on the ballot. In Florida, where more than half a million people fall into the coverage gap, the Democratic candidate for governor, Andrew Gillum, is running on a health-care platform that includes expanding Medicaid. In Georgia, Democratic gubernatorial candidate Stacey Abrams has said that the first thing she’d do if elected is expand Medicaid. (Gillum and Abrams’s Republican opponents oppose expansion.) “You’ll hear me talk about this ad nauseam because it’s the only answer to Georgia’s challenges,” Abrams said at a press conference earlier in September.
Back in Idaho, the coalition backing the ballot measure is aiming to talk with 100,000 voters before Election Day. “People in Idaho have been struggling with this Medicaid gap crisis for six years now, and they’ve seen over and over again their legislators fail to do anything about it,” said Mayville of Reclaim Idaho. “They see our campaign as a break from that pattern.” Still, he added, they’re not taking anything for granted.
Maine legal battle keeping Medicaid expansion in limbo to stretch into October
by Michael Shepherd - Bangor Daily News - September 28, 2018
PORTLAND, Maine — Advocates for Medicaid expansion withdrew a request in a Maine court on Friday to have a third party manage implementation of the voter-approved law given Gov. Paul LePage’s opposition to it, but their case will stretch far into fall.
Maine voters approved expanding Medicaid to 70,000 people under the federal Affordable Care Act last year, but the Republican governor hasn’t implemented it. A group representing Mainers who say they would be eligible for care under the long-gone July 2 deadline for coverage sued LePage over that delay in April.
Last month, the Maine Supreme Judicial Court ordered the state to submit an expansion plan to the federal government. While the Maine Department of Health and Human Services quickly filed one, the plan was accompanied by a LePage lettersaying it should be rejected.
At the same time, the high court sent unanswered, core legal questions back to Maine Superior Court Justice Michaela Murphy, who held two days of hearings in Portland on Thursday and Friday with lawyers for Maine Equal Justice Partners, the progressive group leading the suit, and the state.
Little was decided by the end of those proceedings, but on Friday, expansion proponents withdrew a motion asking Murphy to hold the state in contempt of the high court’s order, which was originally filed because of LePage’s letter asking the federal government to reject the plan.
They were assuaged after the department filed a letter with the federal Centers for Medicare and Medicaid Services noting that the effective date of coverage under the law is being disputed in court — which could preserve coverage for thousands of people who have sought it since July.
Murphy will likely have to rule on that and the key legal question in the case — whether the LePage administration can implement a law without dedicated funding from the Legislature. The governor successfully vetoed a start-up funding plan from the Legislature earlier this year.
Advocates have argued that existing funds could be used to pay for expansion, while private lawyers for the LePage administration have said that a dedicated appropriation is required. Both sides looked to bolster those cases in questioning of witnesses this week.
But Murphy issued no decisions, and the sides agreed to submit legal briefs on core issues in the case by mid-October. The sides will likely present arguments to the lower-court judge before she her ruling, and any ruling is likely to go back to the high court later this year.
At elegant McLean psychiatric outpost, $2,150 a day, and insurance is not welcome
Liz Kowalczyk - The Boston Globe - S
CAMDEN, Maine — In elegant rooms with sparkling views of Penobscot Bay, some of Harvard’s most skilled psychiatrists treat patients from across the United States — football players referred by the NFL, lawyers sent by their firms, a school janitor with a wealthy brother.
What they have in common is the means to pay $2,150 a day for a minimum of 30 days of treatment at Borden Cottage, a remote outpost of McLean Hospital, perhaps the country’s best-known psychiatric facility. Credit cards are welcome. Health insurance is not.
In return, patients have access to a heated outdoor pool, a movie theater with reclining leather seats, a vintage bowling alley, and, most importantly, gold-standard residential addiction and psychiatric treatment for as long as they need it — and can afford to pay the bill.
McLean’s steady expansion into the realm of private-pay care, which now accounts for 40 percent of its residential beds and several outpatient programs, exposes a tension in mental health care: Options for the upper middle class and wealthy are growing at a time when many other patients say they can’t get their insurers to pay for adequate treatment.
The phenomenon threatens to create a two-tier system “where high-quality care is only accessible to those with enough resources to afford care out of their own pocket,’’ said Brian Rosman, policy director at Health Care for All, a Boston-based patient advocacy group. Rosman blamed in part “unreasonable’’ restrictions by health insurers for the problem.
But Dr. Scott Rauch, president of McLean, said its growing array of private-pay programs — not all of them luxurious like Borden Cottage, but all providing highly specialized care — serve an important purpose that helps all patients. They subsidize the hospital’s money-losing insurance-based residential programs and allow them to expand.
“Hopefully it’s understandable to all why that’s a good thing,’’ he said.
Insurers will typically cover three to seven days of inpatient care for many psychiatric patients in crisis — long enough to stabilize a patient with medication.
While many patients then go on to outpatient therapy, others need residential treatment, which insurers are not required to cover under Massachusetts law — and often do not.
“Some insurance companies won’t pay without a fight, and most won’t pay without considerable work to document need,’’ said Danna Mauch, president of the Massachusetts Association for Mental Health, an advocacy organization.
Those who win the battle can typically expect coverage for a couple of weeks of treatment. And while private-pay programs such as Borden provide one-on-one therapy to patients daily, most insurance-based programs rely on group therapy, which requires fewer staff.
Patients such as Shellye Echeverria need more.
A week into her sophomore year at Boston University in 2012, Echeverria reached a breaking point after years of struggling with anxiety and depression. When she revealed her suicidal feelings to her parents in a text, her mother drove from their home in the New York area, and they headed for McLean. Echeverria was admitted to an inpatient unit and diagnosed with borderline personality disorder, a complex condition characterized by intense, overwhelming emotions and unstable relationships.
Fortunately, McLean had a specialized program, 3East, for teen girls and young women with just this diagnosis. The 10-year-old unit is considered one of the best in the world. It is also private-pay. It is not at all plush like Borden, but it’s still pricey — $1,435 a day for intensive specialized care. McLean opened a self-pay unit for teenage boys and young men at the same price last year.
“The only thing we had to do was figure out how to pay for all this,’’ said Henry Echeverria, her father.
She spent six weeks in the program, learning to calm “hot” emotions by chewing ice or dunking her head in cold water — part of a proven approach called dialectical behavior therapy. It aims to build coping skills such as mindfulness and emotion regulation to help patients get through crises without harming themselves. Cold water automatically slows heart rate and respiration, which reduces feelings of distress.
A relative paid for Shellye Echeverria’s first month there. Her parents dug into retirement funds and relied on credit cards to pay the rest —a decision her father said saved Echeverria’s life. Other families he met on the unit were either wealthy or took out second mortgages and home equity loans to cover the cost, he said.
After Echeverria was discharged from McLean’s 3East, Henry Echeverria, who works as an insurance consultant, sought to persuade his health insurer to reimburse him for her care. He mailed off the necessary paperwork to Cigna, but the company refused, he said. A representative told him McLean did not include the proper diagnosis and treatment codes in the medical record, he said. A Cigna spokesman said he could not comment on her situation because of patient privacy laws.
Still, Henry Echeverria has no doubt the cost was worth it. “I am a completely different person,’’ agreed Shellye Echeverria, 25, who recently completed college and is now working as a nanny.
Theresa Nguyen, vice president of policy and programs at Mental Health America, a nonprofit organization based in Virginia, said the family’s experience is typical. “Only in America do we have insurance [that] doesn’t cover what we need and then we pay extra,’’ she said.
Some insurance companies, however, have started paying for the sickest teens to stay on 3East on a case-by-case basis, said Dr. Joseph Gold, McLean’s chief medical officer. McLean runs two insurance-based programs for teens that include some dialectical behavior therapy, which is sufficient for most adolescents, he said.
But insurers said residential care is usually not medically necessary, except for a few exceptions, like those for eating disorders and obsessive compulsive disorder. In these cases, an overnight program is necessary because staff need to monitor binge eating and excessive handwashing around-the-clock.
“A lot of these therapies can be done in the community on an outpatient basis,’’ said Lora Pellegrini, president of the Massachusetts Association of Health Plans. “There is no evidence that these residential programs are producing better outcomes for patients.’’
Psychiatric hospitals with private-pay patients, including McLean, the Menninger Clinic in Houston, and Sheppard Pratt Health System in Baltimore, acknowledge that they have not studied whether patients in these programs achieve better results than those in insurance-based programs. Comparisons are difficult, in part because the industry does not agree on what to measure, or even what constitutes success.
But some differences are obvious. At 3East, when Echeverria became severely anxious at night, a doctorate-level clinician coached her through the episode. She was able to practice the skills repeatedly for weeks under supervision, and staff carefully planned her long-term therapy.
“There is no way to pull that off’’ with programs covered by insurance, said Bonnie Katz, senior vice president of strategy and business development at Sheppard Pratt, which has also expanded its self-pay program.
There also may be more subtle advantages to these expensive self-pay programs. Susan Fendell, an attorney with the Boston-based nonprofit Mental Health Legal Advisors, said “patients are treated as guests and clients. This is less stigmatizing to patients, and that could improve outcomes.’’
Cheri Andes, executive director of the National Alliance on Mental Illness in Massachusetts, said this type of gold-standard care should be available to everyone.
“Think about how a cancer patient is greeted at the door of Dana-Farber [Cancer Institute]. How they are wrapped in concern and enveloped in reassurance and how they are shepherded through their illness,’’ Andes said. “That is what we want for everybody. We want the Dana-Farber experience.’’
More than half of all the patients at McLean, once a refuge for the wealthy and elite, are now covered by private insurance. It has a far lower percentage of poor patients than most other Massachusetts psychiatric hospitals.
About 17 percent of its patients are on Medicaid, compared with a 48 percent average statewide, according to data from the Center for Health Information and Analysis in Boston. This is in part because many patients are referred directly by psychiatrists or by colleges, leaving less space for those waiting in hospital emergency rooms.
But while McLean said it loses about $4 million a year on insurance-based residential programs, its overall profit is about 2 percent.
Its most profitable programs are those for which patients must reach into their wallets. There’s Fernside in Princeton, Mass., at $1,985 a day for addiction and psychiatric treatment; Appleton in Belmont at $700 a day for chronic mental illness; and the Pavilion in Belmont — $55,300 for 14 days of treatment for anxiety, depression, and psychosis.
And there’s Borden, hidden at the end of a winding tree-lined driveway. Camden residents initially opposed Borden when it opened in 2015 but have since embraced it. In June, town voters approved an expansion from eight beds to 12.
The 14-acre property was originally owned as a private retreat by businessman Charles Cawley, a founder of the bank MBNA. Cawley built many of the amenities McLean patients now use. They have limited time for recreation, however; they are scheduled for individual and group therapy from 8 a.m. to 8 p.m.
During a July tour, staff members were careful to keep a reporter away from patients. They have included executives, lawyers, doctors, and a man who had traveled from abroad and who had been so addicted to alcohol and sedatives that he was unable to get out of bed.
On this particular morning, the eight men and women were said to be gathered in a cognitive behavioral therapy group in a large living room and then were scheduled for a trainer-led fitness group in the gym. They meet one-on-one with a psychiatrist or therapist two to three times a day, often in plush chairs overlooking the island-studded bay.
Clinicians said they are treating patients who may not get help otherwise, either because they would not tolerate conditions in a standard facility or because they require absolute privacy.
“Some folks are their brand, and if folks knew they were struggling, it would affect a lot of people who work for them,’’ said Catherine Milliken, program director for Borden. “We don’t have paparazzi in the bushes.’’
The Hospital That Held a City Hostage
by Branko Narcetic - Jacobin - September 30, 2018
A funny thing happened in July as the Pittsburgh City Council prepared to vote on approval for a planned $2 billion expansion by the University of Pittsburgh Medical Center (UPMC).
Just weeks earlier, the Council had declined to approve the controversial expansion, fiercely opposed by community groups, local activists, and unions, until a community benefits agreement (CBA) was signed. Now they had gotten their wish.
Except the CBA that councilman R. Daniel Lavelle held up on July 31 dealt with none of the demands locals had made at the earlier meeting. In fact, it appeared to have been negotiated overnight, and without community input; some activists only learned about it from the media. Worse, the agreement was just two pages of bullet points attached to a letter from UPMC referencing an earlier agreement. The pages weren’t even signed.
“What I have here is two pieces of paper with bullet points,” councilwoman Deb Gross said at the time. “And there’s no evidence that this is what UPMC is agreeing to.”
Then Lavelle made a curious speech. Referencing the traumatic closure of UPMC’s Braddock Hospital in 2010 and the havoc it had wreaked on the local community, Lavelle warned that another UPMC facility, Mercy Hospital, was “in a conversation of potential closing.”
“Understanding the devastation that happened in Braddock, I decided I could not afford to let that hospital close and that I would need to do whatever was necessary for that hospital to stay open,” he said. He and all but two other council members then voted to let the expansion go ahead as the assembled crowd made its displeasure known.
For many activists, what had happened was clear: UPMC had threatened behind closed doors to shutter the facility if they didn’t get their way, and had produced a scant, non-committal CBA to placate the community. Such suspicions appeared to receive further credence the next day when Pittsburgh mayor Bill Peduto blamedopponents for “putting the existence of Mercy Hospital in jeopardy.”
Whether or not UPMC would have made good on this alleged threat is another story. Shannon Brownlee, senior vice president of the progressive health care think tank Lown Institute, calls the idea “laughable.” Deb Gross, one of the two council members who voted against the approval, says she was “not aware of any concrete plans to close Mercy,” though she “would certainly not put it past UPMC to threaten hospital closures.”
Yet disingenuous or not, such threats work. After the Seattle City Council introduceda new “head tax” on big firms’ employees to deal with the city’s homelessness crisis, Amazon — the largest local non-government employer — protested by ceasing construction on a seventeen-story office tower and threatening to send thousands of jobs elsewhere. The mayor and council quickly repealed the tax.
So when UPMC CEO Jeffrey Romoff declared last year that the health care network “desires to become the Amazon of health care,” those words would come to represent a far more ominous portent than he likely intended.
A Charity Like No Other
The row over the expansion is the latest in a litany of longstanding local grievances against UPMC, an economic juggernaut in the city and state. Its 656 acres and $1.6 billion in total real-estate holdings make it the largest property owner in Allegheny County, the southwestern Pennsylvania county that houses the city of Pittsburgh. With 85,000 employees, UPMC is not only Pennsylvania’s largest healthcare provider, but its largest employer aside from the government (a decade ago, it was Walmart).
UPMC’s 2018 revenue is a projected $20 billion, while in 2016 its CEO, Jeffrey Romoff, earned $6.1 million, just one of the organization’s two-dozen executives who earn at least $1 million and travel on its $51 million corporate jet. The kicker? UPMC is a officially a nonprofit, which means it avoids paying most property taxes, depriving the city of much-needed funds, particularly for its schools.
There are other factors that make UPMC a curious example of a nonprofit. It spends only around 2 percent of its revenues on charity care, for one. There are also few nonprofits that would describe themselves as an “integrated global health enterprise,” running an international network of for-profit health care facilities in places as far afield as Italy and Kazakhstan.
And few nonprofits have expanded as ruthlessly as UPMC has through the decades. Over the course of its first twenty-three years under Romoff, UPMC went from being a federation of six hospitals with fewer than 600 employees to nineteen hospitals with 40,000 employees. Today, it owns forty hospitals.
“That status should not come for free,” says Jennifer Rafanan Kennedy, acting executive director of Pittsburgh United, a labor-aligned activist coalition. “UPMC has not held up their part of the bargain.”
UPMC initially justified its expansion partly on the grounds that increasing its size would give it a stronger bargaining position with health insurers — that is, it would put the hospital in a stronger position to raise prices for its services. In response to the 1995 merger of insurance giants Blue Cross and Pennsylvania Blue Shield, which produced an insurance colossus covering twenty million people in four states and Washington, D.C, UPMC merged with a number of specialty and community hospitals to create the Tri-State Health System, before absorbing five more hospitals in 1996, quickly dominating the Pittsburgh healthcare industry.
But UPMC was also heading off a rival in the Allegheny Health Education and Research Foundation (AHERF), then the largest healthcare provider in Pennsylvania, and one jockeying with UPMC over Pittsburgh’s last remaining city and suburban hospitals. UPMC won out, with AHERF going bankrupt in 1998 in what was then the biggest failure of a nonprofit in US history (AHERF, it turned out, had overstated its assets by $127 million two years earlier).
UPMC was granted a near-monopolistic grip over the city’s health care, with unsurprising results. A 2006 report found that UPMC’s Presbyterian and Shadyside hospitals charged patients far more — between 37 and 92 percent more in the latter case — than did Mercy, which UPMC had yet to absorb at the time. The following year, it got in hot water for charging insurers $135 per flu shot. Nearly a decade later, UPMC would build a hospital less than a mile from one owned by Allegheny Health Network (AHN), a remnant of the collapsed AHERF, receiving criticism for doubling up on services for the sake of squeezing out another rival.
Adding to the sting was that UPMC had been closing hospitals vital for both the care and the economies of local communities, often in poorer neighborhoods. In 2010, it closed its hospital in the low-income community of Braddock, citing annual losses and residents increasingly traveling to other facilities. In one fell swoop, UPMC snatched away both Braddock’s biggest employer and its only dedicated emergency room. It was this closure that councilman Lavelle would cite last July to justify approving UPMC’s expansion without a CBA.
Such a cold-blooded, profit-driven business decision clashed with UPMC’s status as a charitable organization. And as the Pittsburgh Tribune-Review pointed out at the time, the hospital’s annual $4.5 million loss was the same amount as the salary of UPMC’s chief executive alone. Money worries also didn’t stop UPMC from paying$95 million that year for a two-thirds stake in Dublin’s Beacon Hospital, losing more than that amount when it sold the clinic four years later.
UPMC also stepped up its feud with Highmark, with residents caught in the middle of the tug of war between the two corporate giants. Frustrated with what it said was Highmark’s low reimbursement rates, UPMC had started its own health plan back 1997. In 2011, Highmark, in response to a significant rate increase from UPMC, acquired its own hospital system in the form of the AHN.
In turn, UPMC decided to let its contract with Highmark expire, forcing residents to switch insurers if they wanted to continue using UPMC’s now-ubiquitous medical facilities, a move that attracted bipartisan criticism. Ads were taken out. Lawsuits ensued. Multiple attempts at mediation kept the brittle partnership together over the years, but as of today, Highmark enrollees are due to lose their access to the UPMC hospital network by the end of July next year.
All the while, UPMC has carved out a solid reputation as one of the country’s most labor-unfriendly employers. At the same time it was paying dozens of executives more than $1 million each, or about half its yearly charity care, it paid workers poverty wages, pushing them into part-time work and food pantries to survive. According to a 2014 Pittsburgh Post-Gazette report, it paid ordinary workers between 8 and 30 percent less than what they needed for basic expenses like rent and groceries.
Efforts to fight these practices have been resisted by the nonprofit. UPMC has been the subject of several National Labor Relations Board (NLRB) cases, including a 2013 NLRB complaint alleging 80 charges of unfair labor practices revolving around its anti-union efforts, which included firing workers for their unionization efforts. Only a month ago, the NLRB determined that UPMC had broken federal law by barring workers from discussing unionizing in a hospital cafeteria. Just this August, the NLRB issued two rulings about UPMC’s intimidation efforts against union organizers.
At one point, UPMC tried to dodge a legal challenge to its treatment of workers by claiming it was simply a “holding company” that didn’t employ anyone. At the same time, its website proudly touted the large number of people it employed.
By contrast, employees at hospitals belonging to the AHN, UPMC’s longtime rival, have unionized with little trouble.
Four Hours of Fury
It was this tumultuous history that helped turn UPMC’s $2 billion expansion plans into a flashpoint this year.
The opposition, made up of the state’s SEIU Healthcare branch and a coalition of the city’s community organizations, viewed the planned expansion as yet another case of UPMC neglecting local communities in the pursuit of profit. The argued that the new facilities — including what one councilwoman called a “luxury eye-care hospital” — would mostly be used by wealthy patients outside the city, and called for UPMC to invest in treatment for mental health, diabetes, and opioid addiction (Allegheny County’s rate of fatal overdose due to heroin and prescribed opioids is double the national rate).
They also wanted the city to use UPMC’s request for expansion to extract key concessions from the health care behemoth. These included investment in local communities, a higher minimum wage, and an end to union-busting efforts.
The anger boiled over at a four-hour council meeting on July 17, for which 160 speakers registered to attend, mostly to air grievance after grievance with UPMC. One speaker charged that there was nowhere for people to get psychological care in Pittsburgh. Another cited an incident where an undocumented man taking his child to UPMC Children’s Hospital of Pittsburgh was delivered to ICE by the facility’s security.
One man who had retrained as a medical professional following the steel industry’s collapse recounted how he had lost his job at Shady Side Hospital due to UPMC’s cost-cutting. “That pattern continued at almost every hospital that UPMC swallowed up,” he said, calling UPMC a “great white shark that has never met another health care facility it doesn’t want to eat or destroy.”
Low wages were a theme. “The majority of us are paid too little to enjoy the good life in Pittsburgh,” said one speaker, who criticized UPMC’s promise to raise wages to $15 by 2021 — reluctantly agreed to by the health care titan in 2016 after a lengthy fight with the SEIU — because “by the time that happens, the $15 won’t be what it is today.” A Second World War veteran (himself locked out of UPMC because his union health insurance was issued by Highmark) recalled how a UPMC nurse’s aide, upon hearing of imminent food stamp cuts, remarked that she wouldn’t be able to feed her kids.
Another theme was the Highmark situation, as speaker after speaker recounted how UPMC’s decision to sever ties with the insurer had thrown them into sometimes mortal crisis. One speaker explained that his twenty-nine-year-old wife, who had beaten back a rare and very aggressive form of uterine cancer — a “death sentence,” in her words — was now barred from seeing the highly skilled and specialized oncologists who had saved her life unless she paid an extravagant amount, despite an 85 percent chance the cancer would come back within the first two years after treatment. His wife, speaking through tears, explained that “I have no fight left without those UPMC doctors.”
Speakers pressed the council to use its leverage over UPMC. “UPMC needs your approval,” one speaker told council members. “I urge the council to play hardball, and say to UPMC, ‘You are gonna have to give us something we want in order for you to get what you want.’” “It’s gonna be up to council to say, ‘Do we get the deal first,’” said another.
The onslaught seemed to work. The council adjourned the meeting with no vote, a majority of council members refusing to support the expansion without a CBA in place.
“We are employed by you,” said council president Bruce Kraus, as he moved to end the meeting. “Our charge, our call, our duty here is to work in the best interest of you.”
Yet only two weeks later, these hopes were dashed. Councilman Lavelle held up the two unsigned pages of bullet points that would stand in for a real CBA, and alluded to the vague threat of UPMC Mercy closing. All but two of the council members — Deb Gross and Darlene Harris — voted to approve the expansion as the crowd jeered. Lavelle’s statement that he “look[ed] forward to standing with you tomorrow” was met with derisive laughter.
“Amazon is watching”
While UPMC has faced fierce opposition over the years from local activists and even elected officials, it has rarely been held to account.
Locals had vigorously protested UPMC’s decision to close its Braddock hospital back in 2009-10, with hundreds turning up to protest the decision in wet weather. Residents even took UPMC to court as it started demolition, though a county judge threw the suit out.
When UPMC requested that the Allegheny County Council issue more than $1 billion in low-interest bonds on its behalf, protesters had urged the council to use the request as leverage to prevent the hospital closure. The council instead approved it 11-1. And while a local government complaint to the US Department of Health and Human Services succeeded in winning an agreement for UPMC to continue providing health services for the area, that didn’t include a fully operational emergency room, the chief demand made by locals.
In 2013, then-Pittsburgh Mayor Luke Ravenstahl challengedUPMC’s nonprofit status in court, attempting to force it to pay local payroll and property taxes. It was a U-turn from six years earlier, when Ravenstahl had pressured the city council to shield UPMC from a potential change to state law allowing nonprofits to be taxed. UPMC counter-sued, claiming the challenge violated the Fourteenth Amendment’s clauses for due process and equal protection.
A year later, however, the city’s suit was dropped by the new mayor, Bill Peduto, who argued that he would use more diplomatic means to get concessions from UPMC.
“They have, to date, resulted in no improvements of corporate accountability,” says Erin Kramer, a former SEIU organizer and executive director of One Pennsylvania.
As the council mulled whether to approve UPMC’s expansion this year, Peduto issued a statement of support for the project while insisting he was a “longtime and proven supporter of union and worker rights.” After the council approved the expansion, he accused SEIU Healthcare and other protesters of “holding a hospital hostage that is going to cure the blind,” charging that the union had “burned that bridge to the ground between themselves and UPMC.”
“It seems UPMC doesn’t suffer much political pressure,” says councilwoman Gross.
Amazon’s shadow looms over this ongoing conflict. Peduto began courting the corporate juggernaut after it set off gladiatorial competition between the nation’s cities for the privilege of hosting its second headquarters, praising Amazon’s ethos and its supposed compatibility with Pittsburgh. While the details of Pittsburgh’s bid continue to be kept under wraps, in March the city made Amazon’s list of twenty finalists. When the Pittsburgh Federation of Teachers voted to strike in February, Peduto complained that “the image of Pittsburgh would be set back … while we’re in competition with Amazon.” Local activists suspect Peduto’s soft treatment of Amazon is related.
“I think right now that’s the mode he’s in — ‘Amazon is watching,’” says Moshe Marvit, a local labor and civil rights attorney, and fellow at the Century Foundation, a progressive think tank. “They have to know there’s an open-door policy.”
“Accommodation to no one”
The battle between UPMC and Pittsburgh residents is more than the story of one bad actor abusing its nonprofit status. It’s also a real-world case study of the havoc businesses can wreak on residents in their quest for monopoly power.
More starkly, it illustrates what happens when a business becomes so large and powerful that it can push around local communities and elected officials — the product of “not just a desire for unchecked growth, but an expectation for unchecked growth with accommodation to no one,” as Allegheny County controller Chelsea Wagner put it at July’s four-hour hearing.
For many Pittsburgh residents, an unelected entity in the form of UPMC wields a large degree of power over some of the most intimate aspects of their existence, from their employment prospects and how much money they make, to where and whether they can get health treatment.
“I have the right to choose who I wanna vote for, I have the right to choose who I wanna be in my life,” the twenty-nine-year old cancer survivor facing a loss of access to UPMC doctors had told the city council. “But I don’t have the right to choose what hospital or what treatment I wanna get done.”
Shannon Brownlee says such power and unaccountability is particularly typical of hospitals. They’re usually seen as the “good guys” who save lives, are often major employers in a region, and their financial practices and investment decisions are hidden from public view, including how much they assist needy patients and their decisions to build new wings or hospitals.
“All have an impact on the cost and quality of care, and yet these decisions are rarely questioned by the communities that ultimately underwrite them,” she says.
It also has implications for the burgeoning struggle for single-payer health care. Vikas Saini, president of the Lown Institute, says what’s happened in Pittsburgh is a familiar story.
“Hospital consolidation is underway all over the US,” he says. “This has been increasing the pricing power of the hospital sector in their bargaining with insurers, who have also been consolidating.”
Saini says that unless the market model driving hospital behavior right now is replaced with something else, any single-payer plan — including the current version of Bernie Sanders’ Medicare For All bill — risks eventual defeat.
“Without a clear articulation of a path for the hospital sector, political conflict will rise, the affordability of hospital care will be strained, and the political credibility of solutions like Medicare for All will be under threat,” he says.
Meanwhile, local activists are refusing to give up the fight. One activist, Alisa Grishman, plans to challenge Lavelle come 2021, and urges others to run for office.
“The only way to reduce UPMC’s power is to reduce their access to power,” she says.
And if nothing else, UPMC’s actions appear to have galvanized an entire local movement that will outlive this temporary defeat.
“This fight has brought a strong and thriving coalition of Pittsburghers together,” says Rafanan Kennedy. “We are going to continue to let elected leaders, UPMC, and anybody else know that Pittsburgh belongs to our communities, not UPMC.”
Insulin prices could be much lower and drug makers would still make healthy profits
by Ed Silverman - STAT - September 25, 2018
As prices for diabetes treatments continue to roil consumers, a new study suggests that manufacturers could make both human and analog insulins at low costs and still pocket a profit.
After analyzing expenses for ingredients, production, and delivery, among other things, the researchers contend that the price for a year’s supply of human insulin could be $48 to $71 a person and between $78 and $133 for analog insulins, which are genetically altered forms that are known as rapid or long-acting treatments. Examples of analog insulins include Humalog, Lantus, and Novolog.
Put another way, the study estimated the cost of production for a vial of human insulin is between $2.28 and $3.42, while the production cost for a vial of most analog insulins is between $3.69 and $6.16, according to the study in BMJ Global Health.
Meanwhile, the median prices paid by more than two dozen countries for human insulin were 1.2 to 1.8 times greater than estimated prices. Median prices for other types of insulin were also higher: Lantus, which is sold by Sanofi (SNY), was 5.6 to 7.8 times higher; Humalog, which is sold by Eli Lilly (LLY), were at 2.7 to 3.7 times higher; and Novolog, a Novo Nordisk (NVO) treatment, was 2.6 to 3.5 times greater.
The study authors, who cited a 2016 study that examined government procurement prices paid and other data, argued their findings suggest greater competition would lead to sizable savings in most countries. They also maintain that existing insulin makers could set “significantly lower prices while still making a profit,” but they concede more companies would have to enter the market for this to occur.
“Anyone with Type 1 diabetes should be able to buy insulin for under $100 per year, including the long-acting forms,” said Andrew Hill, a study co-author and senior visiting research fellow at the University of Liverpool. “Pharmaceutical companies cannot justify charging governments $532 per person per year in the U.K. and $1,251 in the U.S., let alone similar amounts in low- and middle-income countries.”
There were some limitations to the study, though. For instance, biosimilar manufacturing expenses were not individually considered, such as capital expenditures, quality assurance and control, registration costs, and costs for adhering to manufacturing regulations. But the authors insisted they made a conservative assumption for the total costs of bringing a biosimilar to market.
A Sanofi spokeswoman wrote us that the drug maker “shares concerns about the affordability of medicines and is focused on ensuring people who can benefit from our medicines have access to them. As the authors noted, there were several limitations to the analysis, including a large number of assumptions which makes it challenging to draw any conclusions.”
[UPDATE: A Novo Nordisk spokesman sent us this: “We recognize that there are those who are having difficulty affording their medicine, including those made by us. We also appreciate the different perspectives across many stakeholders. The affordability of insulin for patients depends on health systems, regardless of country. Globally, We have preferential pricing for low income countries but we’re aware that sometimes our medicines don’t reach patients because of inefficiencies and supply chains. In the U.S., we offer human insulin through several channels for approximately $25/vial.
“This study presents only one facet of the cost of medicines – the manufacturing process. It’s important to see the big picture and take a more holistic view including how the sales of the medicines fund broader R&D efforts for the next generation of medicines along with our manufacturing investments (such as our $2 billion expansion in the U.S.) when assessing cost.”]
We asked Lilly for comment and will update you accordingly.
The findings come amid ongoing controversy over the cost of diabetes treatments, which make an attractive target, given soaring prices.
A 2016 study in the Journal of the American Medical Association found the price for a milliliter of insulin climbed 197 percent from $4.34 per to $12.92 between 2002 and 2013. Two Washington lawmakers subsequently accused the three largest insulin makers — Lilly, Sanofi, and Novo Nordisk — of price collusion. The companies later publicly committed to limiting price hikes on their medicines.
Meanwhile, Nevada legislators made diabetes medicines the specific target of a transparency law that requires drug makers to report pricing histories, disclose costs, and notify state officials and insurers in advance of price hikes above inflation. The move was prompted by data showing high disease rates and the subsequent medical and economic costs to many states.
The study is likely to further embolden advocacy groups that have been trying to pressure drug makers to lower prices. In the U.S., T1 International and People of Faith for Access to Medicines are staging another demonstration this coming Sunday at Lilly headquarters in Indianapolis to protest insulin prices.
“It is unacceptable that governments and people are paying so much more than the cost of production for insulin. Estimating the cost of production for hepatitis C treatment was instrumental in getting dramatic price cuts. This needs to happen now for insulin,” said Dr. Margaret Ewen, global pricing coordinator for Health Action International, a nonprofit advocacy group that backed the study.
Indeed, the same researchers have conducted similar studies suggesting that production costs for other types of medicines were sufficiently low enough that manufacturers could slash prices and still make reasonable profits to satisfy financial goals. This work was regularly cited by patient advocates who sought to pressure drug makers to lower their prices in order to widen access to treatment, especially in low-income countries.
In reaching their conclusions, the researchers used pricing data for active pharmaceutical ingredients exported from India and price quotes from insulin makers. When API pricing could not be obtained, prices were estimated based on comparison of similarity, in terms of manufacturing process, with APIs for which prices were available. Potential biosimilar prices were estimated by adding costs of excipients, formulation, transport, development and regulatory costs, and a profit margin.
Stabbed, punched, bitten: ER doctors face rising violence
by Liz Kowalcszyk - The Boston gone - October 2, 2018
Dr. Sundeep Shukla expected his patient would be upset to learn that he was stuck in the emergency room. The man was waiting for a bed in a psychiatric facility, but they were all full. But Shukla did not predict what happened next.
The patient leapt off his gurney and punched Shukla, hard, in the right jaw. Pain shot down his neck. He had little time to pause: Another ambulance arrived, and the doctor rushed off to treat a stroke patient.
Angry and distraught patients and family members have scratched, spit at, bitten, hit, and stabbed doctors and nurses working in hospital emergency rooms. One Massachusetts caregiver was so badly cut in an assault that she required eight hours of life-saving surgery. Nearly everyone has a story.
A new survey of more than 3,500 emergency physicians across the United States released Tuesday suggests this type of violence against hospital emergency room staff is growing worse. Assaults against nurses have been well-documented, but this is one of the largest surveys of physicians.
Nearly half of doctors said they have been physically assaulted on the job, while 71 percent said they have witnessed an assault, according to the data from the American College of Emergency Physicians, based in Texas. About one-quarter of doctors said they’d been injured in an attack at work.
The survey included 112 emergency physicians in Massachusetts, one of the top 10 participating states, and their responses were similar to those of doctors nationwide.
Debate here has intensified over whether hospital administrators are doing enough to prevent violence against employees, and a few hospitals have taken the unusual step of installing metal detectors. Some doctors and nurses argue that tough new laws are needed to force improvements and deter assaults. They say the violence hurts all patients seeking medical care, creating longer waits, anxiety, and distractions for staff.
Dr. David Brown
At Mass. General and many hospitals, patients with mental health diagnoses are increasingly stuck in the emergency room for hours and even days because of limited availability of psychiatric hospital beds and other treatment options.
“Patients are more anxious, and we’re more anxious.’’ said Brown, chair of emergency medicine at Mass. General.
Shukla said the patient who punched him several years ago was told by an outside therapist that if he checked into the emergency room, he would quickly be transferred to a psychiatric facility. “A lot of times, they get upset because they have nowhere to go,’’ Shukla said.
He has seen other patients lash out because a doctor would not prescribe painkillers.
“I have seen a colleague kicked in the face; I’ve seen a nurse kicked in the chest and have to get medical treatment. I’ve seen patients spit on people and throw urine across the room.’’
Health care workers face a rate of workplace violence that is four times higher than in private industry overall.
Of course, assaults can happen anywhere in a hospital. Three years ago, Brigham and Women’s Hospital surgeon Dr. Michael Davidson was shot to death in an exam room by the son of a deceased patient. But emergency rooms are especially risky.
According to the US Bureau of Labor Statistics, “intentional injury’’ by another person rose from 6.4 per 10,000 hospital workers in 2011 to 9.0 per 10,000 hospital workers in 2016, the most recent year of data. The rate across private industry is 1.7.
Dr. Terry Kowalenko, chairman of emergency medicine at William Beaumont School of Medicine in Michigan, believes one reason for the rise is that employees are reporting incidents to hospital administration more often, as computerized systems have made it easier. Many caregivers, though, said they still are reluctant to disclose incidents involving patients whose reactions they believe are unintentional, such as those with dementia.
Doctors who responded to the survey estimated that police arrested the patient who committed the assault in about 20 percent of cases.
Kowalenko, who has studied the issue for more than a decade, said he has been hit several times by patients, but the most frightening incident involved a threat from someone to whom he refused to prescribe narcotics.
He recalled the patient telling him, “ ‘I know what time your shift ends, and I know where the parking lot is, and I will wait for you.’ I was really scared,’’ said the physician, who was escorted to his car by a security officer.
Nurses generally provide more direct care to patients than doctors and are assaulted more often, Kowalenko said. According to a survey three years ago of 220 Massachusetts nurses by the Massachusetts Nurses Association, a labor union, 86 percent reported experiencing violence over the previous two years.
Elise Wilson, a longtime nurse at Harrington Hospital in Southbridge, was the victim of an especially vicious attack last year. A patient who had previously been treated for wrist injuries at the hospital was still in pain. He heard voices urging him to seek revenge, said Dr. James Sullivan, chief of emergency medicine.
When the patient arrived at the emergency department last June, Wilson was working triage. She led him into a small exam room to evaluate his condition. Suddenly, he pulled out a kitchen knife and repeatedly stabbed her in the neck and arm.
The attack on Wilson, who has not been able to return to work because of extensive nerve damage, was a wake-up call at the hospital. Harrington hired more security officers. Patients who verbally assault staff are now mailed letters warning that they will be escorted by security next time they come to the hospital.
Harrington installed metal detectors at emergency department entrances, and patients brought in on gurneys are searched using hand-held detectors. So far, the hospital has confiscated several guns and thousands of knives, Sullivan said.
The attack on Wilson also prompted nearby UMass Memorial Medical Center in Worcester to install metal detectors at its Memorial and University campuses for “an additional layer of protection,’’ spokesman Anthony Berry said.
Other hospitals, including Mass. General and those in the Baystate Health system in Springfield, are increasing training for emergency department employees on recognizing and defusing potentially volatile situations.
Shukla, the doctor who was punched and who now works at Baystate Franklin Medical Center in Greenfield, said he is taking simple measures to create more personal rapport with patients, such as sitting on a bedside stool during conversations, instead of standing over patients.
The Baystate system has decided against metal detectors, chief executive Dr. Mark Keroack said. Detectors are expensive, and most assaults don’t involve weapons.
In the American College survey, emergency physicians nationally cited 36 cases of staff being attacked with a knife or similar weapon, and four cases of gun violence. Massachusetts emergency doctors reported two knife attacks and no gun violence.
“Hospitals throughout the Commonwealth have well-established, stringent policies and procedures in place to address workplace violence,’’ said Pat Noga, vice president of clinical affairs for the Massachusetts Health & Hospital Association, in a statement. But, she said, “Hospitals cannot foresee absolutely every situation that might arise in a 24-hour-a-day publicly accessible setting.’’
Others say more should be done. Many Massachusetts emergency physicians support passing legislation that would make it a felony to assault a health care worker, similar to the penalties for assaulting police officers. The nurses union supports a bill that would require all health care facilities to annually assess the risk of violence, develop programs to minimize that risk, and allow employees who are victims of assault up to seven days’ paid leave.
Exceptionally informative and concern making articles. Between the incredibly pricy mental healthcare offered by Borden Cottage in Camden Maine, a McLain Hospital outpost, and the University of Pittsburgh Medical Center which basically "held the city hostage" financially, offers more proof that our current for-profit health care system is not getting the job done for millions of Americans. We need a fair, publicly funded universal system that covers everyone – no copays, no deductibles. It will cost less and is the right thing to do. It will be an economic boost to the nation and a great achievement in advancing human rights.
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