Kaiser Health News

If someone is well-educated, the odds are that he or she will marry someone with similar credentials, according to census data. And that trend has consequences when it comes to access to health care in rural areas.

Rural areas have for years been facing a doctor shortage. That means for the roughly 20 percent of Americans who live in those areas, it’s harder to get care when it’s needed. Policymakers have been trying to create programs that offer medical debt forgiveness and other incentives to doctors willing to set up shop away from the city. But a research letter published Tuesday in JAMA highlights how a key demographic change — the rise of power couples — is stacking the deck against these efforts.

According to the research letter, doctors are much more likely to marry people with advanced degrees than they used to be — 54 percent of married doctors in 2010 compared with less than 10 percent in 1960.

Part of that jump has been fueled by the surge in women physicians. Now, about one in three doctors in the country are women. In 1960, according to the researchers, only about 4 percent were. In addition, the researchers note that when female doctors marry, they’re more likely than men to marry someone with a graduate degree: 68 percent of them did so, compared with 48 percent of men.

These trends, the authors write, could further reduce the odds of these physicians working in rural areas. About 4 percent of power couples worked in underserved rural areas between 2005 and 2011, compared with about 7 percent of married doctors whose spouses weren’t as highly educated. That’s a small difference, but the researchers argue it’s still relatively significant. (They also qualify the finding, noting that its applicability is limited by the fact that, no matter what, the number of married doctors in rural areas is small.)

But for small towns, the challenge is real. The researchers suggest that physicians who have spouses who are doctors themselves — or lawyers, investment bankers or in other fields that are marked by graduate degrees — are also more likely to live and work in places where their partners can find jobs. More often, those places are cities. And, if a spouse has a high-paying job, the couple is more likely to consider it now than they previously would have.

This “wasn’t an issue 40 years ago and now is a major concern for physicians,” said Doug Staiger, a professor of economics at Dartmouth University who co-authored the study. “Anyone who’s tried to recruit in rural areas — [it’s] hard to overcome, given the lack of jobs.”

Rural communities often don’t have economies that support the power couples’ dual professional goals. “Money’s great,” Staiger added. “Being able to continue your career is probably most important to most couples.”

Then there’s the likelihood that city life is often a draw, where it might be easier to find a theater, an art gallery or trendy new restaurants. “There’s still a big discrepancy in educational, cultural and other areas … that make urban areas preferable,” said Andrew Bazemore, a D.C.-area family physician who directs the Robert Graham Center, which researches family medicine policy and is an outpost of the American Academy of Family Physicians.

So, Staiger suggested, if policymakers want people in rural areas to get better health care, they should consider other fixes that enlist telemedicine — through which patients conference with the doctor over technologies like Skype or FaceTime.

But not everyone agrees. Brock Slabach, senior vice president at the National Rural Health Association, argued such a solution would shortchange small-town patients. He thinks medicine — especially primary care — can’t effectively be given over a computer screen, because subtler kinds of communication will get lost.

The people who are underserved, he added, are the ones “who basically feed those other 78 percent of Americans that live in urban areas.”

“We need to be sure that individuals, no matter where they live, have access to high quality primary care,” he said.

Read original article – March 1, 2016
Medicine’s Power Couples: A Challenge In Recruiting Physicians To Rural Areas

A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, North Carolina, it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable. The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed.

Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.

“It was kind of scary for a while,” Murphy remembered. But with Murphy and two other family physicians trained in obstetrics as well as experienced nurses staffing the 25-bed hospital’s labor and delivery unit, the situation was manageable, and both mother and baby were fine.

Things are different now. Alleghany hospital — like a growing number of rural hospitals — has shuttered its labor and delivery unit, and pregnant women have to travel either to Winston-Salem or to Galax, Virginia, about 30 minutes away by car, weather permitting.

“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, said Murphy, who teaches at the Cabarrus Family Medicine Residency Program in Concord, North Carolina. (Although not essential, women typically see the physician they expect will handle their delivery for prenatal care.)

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

“The fact that closures continue happening — over time that means the nearest hospital gets further and further away,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who coauthored the study published in the January issue of Health Services Research.

There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

“A labor and delivery unit is functionally no different than an intensive care unit,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. Staffing levels are high in obstetrics, often one nurse for every patient, and the rooms are cluttered with monitors, infusion pumps and other equipment.

It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and rely instead on local family physicians, but it can be difficult to get enough to fully provide services for a hospital, too. Nurses with obstetrics experience also can be scarce.

Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be difficult because insurance payments are often low. Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, said Kozhimannil. Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she said.

Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.

Encouraging medical professionals to move to rural areas is key, they say. A bipartisan billintroduced in Congress last year, for example, would require the federal government to designate maternity care health professional shortage areas. Such designations exist for primary care, mental health and dental care. The National Health Services Corps awardsscholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage area. Once they get to a community and put down some roots, the hope is they’ll stay.

Expanding the use of midwives and birthing centers could be cost effective since they are generally less expensive than physicians and hospital obstetric units. Although birthing centers and home births are on the rise, more than 98 percent of the 4 million babies that were born in 2014 made their arrival at a hospital.

“You can deal with lower volume and still be sustainable,” said Shah.

“Finding strength in numbers, small rural hospitals are increasingly banding together to share resources, said Kozhimannil. For example, since it’s difficult to keep rural staff trained in rare complications, small rural hospitals sometimes pool resources to buy a mobile simulation unit to train people on handling postpartum hemorrhage, the leading cause of maternal mortality.

Kozhimannil sees great opportunity in the ongoing national dialogue about health reform but says much of the research to date has focused on reforming health care in urban settings.

“That’s why it’s crucial to have rural people at the table,” she said.

Read original article
As Rural Hospitals Struggle, Some Opt To Close Labor And Delivery Units

Ask David Ross to describe an average day on the job. He says it doesn’t exist.

Ross is a violence intervention specialist at the University of Maryland Medical Center. Though he isn’t a doctor, he’s been working at the hospital as part of its Violence Prevention Program for close to 10 years. His team works with patients who are victims of violent injuries — stabbings, gunshots or physical assaults — and who physicians flag as candidates for the program’s assistance.

His challenge is to figure out the factors in their lives that put them at risk of violence. The work he does is time-consuming, and the relationships he builds with these patients can last months and even years.

Do you feel safe at home? Do you have health insurance? A high school diploma? A stable job? Having health insurance or a diploma is no guarantee against violence, but Ross and his colleagues ask such questions to help the team connect patients with programs that might improve their lives and insulate them from the violence that put them in the hospital.

“Some days, it can be emotional. Or it can be gratifying,” Ross said. “I spoke to a patient the other day, and he almost had me crying.”

Sometimes that kind of emotion comes from the devastating things patients have seen, whether it’s the result of a dysfunctional living situation, substance abuse, poverty or other social ills. Other times, it’s because “you thought you made progress — and then there’s a setback.”

Maryland is a pioneer in this type of coordinated effort, having launched its anti-violence program in 1998. Now, about 30 hospitals across the country — from the Children’s Hospital of Philadelphia to the University of Rochester Medical Center in New York — have developed similar initiatives. They follow Maryland’s “wraparound” approach, which involves following up with patients after they leave the hospital, and providing medical and social support to keep them out of harm’s way — by, for example, getting them into drug rehab or education classes for people who have not finished high school. The hospitals are acting on the notion that keeping violent injury from recurring will ultimately reduce their expenses and improve people’s long-term health. In other words, they increasingly view violence prevention programs as both good medicine and good business.

On this particular day, Ross visited seven hospital patients who were being treated for violent injuries. Ross’s job isn’t just to identify the trouble spots in a patient’s life; it also involves moving with the person through the legal and medical systems, sometimes acting as an advocate. The day before, for instance, he had accompanied a mentally ill client to court to make sure the man’s condition was understood by authorities. On such days, he dresses in a suit instead of his hospital uniform: pink scrubs, an outfit that shows that while he doesn’t stitch wounds or prescribe pills, he’s part of a team dedicated to keeping patients healthy.

As experts increasingly view violence as a medical concern, hospitals see it as an opportunity. “There’s been a groundswell of professionals understanding that this is a public health issue,” said Rochelle Dicker, a trauma surgeon and professor at the University of California, San Francisco, who directs the UCSF Medical Center’s violence prevention program.

And the 2010 federal health law supports that interest. It says nonprofit hospitals have to work harder if they want to maintain their tax-exempt status: Among other requirements, they have to formally measure their surrounding community’s health needs at least every three years and implement a strategy to address them.

To this end, a growing number of hospitals, especially those located in areas with high rates of violent crime, are partnering with local organizations to try to reduce neighborhood violence, said Jonathan Purtle, an assistant professor at Drexel University who researches hospitals and violence prevention.

The Department of Justice has been supportive, too. In a 2012 report, it recommended that hospitals become more involved in violence prevention, through counseling patients directly or connecting them with education, gang diversion programs, substance abuse treatment and other social services.

Research shows that, if someone comes in suffering from a gunshot or stab wound and then, after leaving the hospital, returns to the same environment, there are good odds they will be back in the emergency department. In addition, trends and anecdotal evidence suggest people at higher risk for violent injury are likely to face issues such as domestic violence, mental illness or substance abuse. They also often deal with other stressors, like poverty or bad housing. These challenges can result in health problems including lead poisoning and poor nutrition, which the hospital can work to address. Even if they can’t change, for instance, a neighborhood’s crime rate or drug culture, they can help someone get into rehab or find somewhere new to live.

Much of the growth in such hospital interventions has happened in the past five years, Dicker said.

“It’s becoming a more established understanding that this kind of violence is preventable,” said Rebecca Cunningham, an emergency medicine professor at the University of Michigan and associate director of its youth violence prevention center. “And we can have programs that can prevent it, and the hospital and emergency department are really critical locations for this.”

Michigan’s center doesn’t do that same level of outreach and case management as Maryland’s. All patients between the ages of 14 and 20 and from neighborhoods where violence is more prevalent are approached for a counseling session — what Cunningham called a “preventive” intervention.

So far, there isn’t much research measuring these programs’ effectiveness. But the findings available show promise. UCSF found that people who had come to the hospital with a gunshot or stab wound and then participated in the intervention program were far less likely to get injured again after leaving. The number of patients returning with another violent injury dropped from 16 percent to 4.5 percent. And in a paper published last year, researchers estimated that program would save the hospital half a million dollars annually.

That’s crucial. “It’s very important to be able to talk about cost effectiveness” as hospitals look to curb unnecessary expenses, Dicker said.

The University of Maryland‘s statistics are similarly encouraging. Research found victims of violent injury who went through the program were 83 percent less likely to return because of another violent event when compared with those who didn’t participate, said Tara Reed Carlson, who directs the university’s Center for Injury Prevention and Policy. Those who had participated in the program were more likely to have a job and less likely to be involved in criminal activity.

Ross said the work he does — and the change he sees — underscores the value of intensive outreach. The before-and-after contrast is striking. “I’m talking about young guys who haven’t had any guidance,” he said. “That’s rewarding.”

Often, he said, patients stop by to visit, years after they’ve gone through the program. They share new successes, like buying a home or getting married.

“It makes you feel good,” he said. “You’re doing something that’s needed.”

Read original article – January 20, 2016
For Hospitals, Treating Violence Beyond The ER Is Good Medicine And Good Business

Butte is an old mining town tucked in the southwest corner of Montana with a population of about 34,000. Locals enjoy many things you can’t find elsewhere — campgrounds a quick drive from downtown and gorgeous mountain ranges nearby. But in Butte, as in much of rural America, advanced medical care is absent.

People in Butte who experience serious trauma or need specialty care rely on flights — air ambulances — to get them the help they need.

There were close to 3,000 air ambulance flights in Montana last year. And Amy Thomson of Butte was on one of them.

Last year, she was curled up among the medical bags in the back of a fixed-wing plane. Her 2-month-old daughter, Isla, had a failing heart, and the hospital that could help her was 600 miles away.

Thomson watched as Isla was placed in a small box strapped to a gurney inside the air ambulance.

“They did such wonderful care of her, and they tried to take great care of me, but in that moment I couldn’t let go,” Thomson said. “I was so afraid that if I closed my eyes, that would be my last vision of her.”

Seattle Children’s Hospital saved Isla’s life. Her family’s health insurance took care of all costs beyond her deductible — except for that critical air ambulance ride to Seattle.

The way the Thomsons read their insurance plan, they thought any emergency medical transportation was covered.

But it turns out, the air ambulance company was out of their network, and they got a bill for $56,000.

“Coming back and looking at that bill and thinking you’ve got to be kidding me,” Thomson said. “Here is the flight that ultimately saved Isla’s life by getting her to where she needs to be. And yet [it] is going to put us potentially in financial ruin. Or at least kill our future dreams as a family.”

When patients need an air ambulance, the first priority is getting them the care they need as fast as possible. So, patients don’t always know who is going to pick them up or if the ambulance is an in-network provider.

That can lead to surprise expenses if the companies ask patients to pay the bill or any balance left after the insurance plan’s out-of-network coverage is applied.

“Of all the complaints we have received in our office, not one person was uninsured,” said Jesse Laslovich, legal counsel for Montana’s insurance commissioner. “They’re all insured. And they are frustrated as heck that they’re still getting $50,000 balance bills.”

States can regulate some medical aspects of air ambulances, but federal laws prevent states from limiting aviation rates, routes and services.

The cost of an air ambulance bill is split into two main parts, according to a study completed by the Montana legislature. First, a liftoff fee, which ranges from $8,500 to $15,200 in Montana, and then a per-mile charge for the flight, which ranges from $26 to $133 a mile.

Some air ambulance companies offer membership programs as protection from big bills. For an annual fee of about $60 to $100, patients face no cost beyond what their health insurance pays if they use that company’s services.

But, Laslovich said that doesn’t always work because a patient can’t always know who is going to pick them up.

There is a lack of understanding about the actual costs of running an air ambulance business, said Rick Sherlock, the president of the Association of Air Medical Services. The costs include specialized labor, training, equipment and fuel.

“So those cost drivers are there and [it’s necessary] to maintain readiness to respond 24 hours a day, seven days a week, 365 days a year,” Sherlock said.

He says some air ambulance companies remain out of insurance networks because they can’t always reach in-network deals that allow them to stay profitable.

“I think what you also have to look at is that negotiations between [air ambulance] companies and insurance companies take place when there’s good negotiations on both sides,” Sherlock said. “In situations where there may be only one or two insurance options in an area, it’s harder and harder to negotiate on a level playing field.”

For Laslovich, it comes down to one thing: “You want to know what my personal opinion is about what the problem is? It’s money.”

There are three health insurance companies operating in Montana, and at least 14 air ambulance providers. At the time of Isla Thomson’s trip to Seattle Children’s Hospital, the Thomsons’ insurer, PacificSource, had no in-network agreements with any air ambulance company in the Thomsons’ area. (PacificSource did not return calls seeking comment.)

For people with insurance who think they’re protected against crippling health care bills, the cost of an air ambulance ride can be a shock.

Amy Thomson ended up not having to pay, but it took repeated appeals. According to Thomson, on the same day her family was arranging to meet with a lawyer, she was notified by her insurance company that it would pay an additional amount of about $30,000, on top of the $13,000 out-of-network fee, to the air ambulance company, and the air ambulance would waive the rest of the fee.

Isla Thomson turned 2 in November. She’s a healthy child with big blue eyes, but at times her mom still worries.

“Nobody takes a lifeflight for a joy ride. You’re not going on kayak.com and booking a lifeflight,” she said.

Thomson didn’t think the flight should be free, yet the huge bill felt wrong, too: “I ethically believe this is a part of healthcare. This is not some separate entity. There is something ethically wrong that these companies are profiteering off of people’s worst moments in their lives.”

A Montana interim legislative committee is investigating air ambulance companies’ wide range in pricing within the state. The state of Maryland has undertaken a similar investigation.

In North Dakota, an air ambulance is suing the state for adding regulations on the industry.

This story is part of a reporting partnership with Montana Public Radio, NPR and Kaiser Health News.

Read original article – January 21, 2016
A Lifesaving Flight, With A Price Tag Of $56,000

Prescription painkiller abuse is drawing national attention as states battle increasing abuse cases, presidential candidates offer possible solutions and even President Barack Obama includes the issue in his State of the Union address Tuesday night.

A new review article published Wednesday in the New England Journal of Medicine provides insights for policymakers on how to curb this deadly trend.

Almost 19,000 people died from overdoses of prescription painkillers — drugs like morphine and OxyContin — in 2014, the most recent year for which statistics are available, according to the Centers for Disease Control and Prevention. That same year, about 10,600 died from heroin overdoses — more than five times the number of fatalities from them in 2000.

Concern about the issue has grown in a number of states where heroin and painkiller addiction is particularly common. Vermont Gov. Peter Shumlin focused his entire 2014 state-of-the-state address on heroin addiction. Meanwhile, an increased focus in New England states on curbing painkiller abuse has resulted in the issue emerging as an area of national interest, with a number of presidential candidates discussing the problem as they campaign in New Hampshire. Last week, Republican presidential candidate Jeb Bushrolled out a set of proposals to fight drug addiction. That puts him in the company of GOP rivals like New Jersey Gov. Chris Christie, Kentucky Sen. Rand Paul, Carly Fiorina and Democrats Hillary Clinton and Vermont Sen. Bernie Sanders, all of whom have made addiction major campaign issues.

The review of recent studies examines the often cited link between abuse of prescription painkillers and heroin use. That consequence, the researchers say, fuels the need for better treatment and prevention of prescription drug abuse. They noted, however, that “although the majority of current heroin users report having used prescription opioids nonmedically before they initiated heroin use, heroin use among people who use prescription opioids for nonmedical reasons is rare, and the transition to heroin use appears to occur at a low rate.”

The correlation between painkillers and heroin, the authors suggest, could be in part because the drugs are chemically very similar. Heroin, meanwhile, has become much cheaper than it was 20 years ago, the review notes.

“Once someone has a significant habit or addiction to [prescription painkillers], heroin turned out to be cheaper and readily accessible,” said Wilson Compton, the first author on the review article and deputy director of the National Institutes of Health’s National Institute on Drug Abuse.

Policymakers have proposed a number of solutions: for instance promoting treatment for addicts, and preventing addiction by limiting the supply for painkillers to begin with. That could involve coming up with better prescription guidelines for doctors and cracking down on so-called “pill mills,” the purportedly corrupt physicians who may majorly overprescribe.

The CDC is currently finalizing new guidelines for doctors to help them better prescribe medication for pain, Compton said.

Meanwhile, cracking down on “pill mills” could address some of the problem but would hardly suffice, said Jonathan Chen, an instructor at the Stanford University School of Medicine who has researched painkiller abuse but is not associated with the review article. The top 10 percent of doctors prescribe about 57 percent of all painkillers, according to a study he co-authored that came out last December. That’s fairly concentrated but still consistent with other kinds of medications that aren’t abused — about 63 percent of all medications are prescribed by only 10 percent of physicians.

The NEJM article addresses another issue that’s been raised: whether efforts to curb inappropriate painkiller use will just drive more people to use heroin instead. On the whole, the article said that studies in a variety of states, including North Carolina, Wisconsin, Florida and New York, did not find a clear link between those efforts and increases in heroin deaths.

And even when there were more deaths from heroin, Chen noted, those were more than offset by the number of lives saved when people didn’t abuse prescription drugs.

“For an individual patient, when a doctor cuts them off [from painkillers], that may have been a strong motivation” to get heroin, Compton said. But on a larger basis, that isn’t generally the case, the review indicated.

To fully address painkiller abuse — and to curb heroin addiction — policymakers need to keep  people from getting started with drug abuse, but also to get treatment for those who need help, Compton said.

“When you turn a faucet down on a bathtub, you still have an awful lot of water before you drain it out,” he said. “We need to be thinking about intervention.”

Read original article – January 13, 2016
Research Gives Context To Addressing Nation’s Drug Abuse Crisis, Review Finds

Veteran Dave Manning served two combat deployments in Iraq and was the sole medical provider for more than 100 people on a Navy ship. But as he contemplated his post-military job prospects, he struggled.

“Nothing I’ve done really translates over [to civilian jobs] beyond basic EMT,” said Manning, who served 15 years in the Navy and five more in the Army. “Trying to find something in the medical field without any credentials, without any licensure is tough. There’s nothing out there.”

Manning is in the inaugural class of a physician assistant training program launched this month by the University of North Carolina at Chapel Hill and geared at recruiting non-traditional students — specifically, veterans, as the country seeks to improve health care by expanding the number of primary care providers. UNC staff worked with Army officials at Fort Bragg to figure out how to translate troops’ medical experience into jobs.

Manning’s story is becoming more common as the U.S. winds down wars in Iraq and Afghanistan, and it’s especially important for North Carolina which is home to eight military bases, including some of the country’s largest installations. Manning has experience that can’t be found in a classroom, and some in the UNC medical community wanted to capitalize on that.

“The medics and the corpsmen are often very skilled in acute medical care of younger people,” said Dr. Paul Chelminski, the director of UNC’s new Physician Assistant Program. “They’re extremely skilled in trauma care if they’ve been deployed.”

But Chelminski said there are some gaps in the veterans’ ability to diagnose and manage chronic illness, which is a large part of civilian health care. UNC’s program will fill in those gaps. The program will also accept some field experience in lieu of other, more standard, training.

Insurance company Blue Cross and Blue Shield of North Carolina is donating $1.2 million to help launch the training program and provide scholarships. North Carolina Blue Cross CEO Brad Wilson said the program will also help with a growing need for primary care providers in the state as more people get insurance through the Affordable Care Act.

“The customers who are accessing the health care system through the ACA are using more services than any other groups,” he said. “Many are in need of primary care, and the physician assistant plays a key role in delivering high quality, high value health care.”

Physician assistants work under the supervision of doctors but still diagnose and treat patients.

The first class is underway with 20 students, including nine veterans. The program is open to students of all backgrounds and takes two years to complete. Chelminski said this first class has an extraordinary amount of clinical experience compared to the national average. Its members are also a few years older than what is typical, with an average age of 33.

UNC research shows many troops with medical training are more interested in becoming a physician assistant than a doctor, and Manning, who is 43, said he is definitely in that camp.

“As I was coming out of the military in my early 40s, I didn’t want to spend a decade training and being in school,” he said. “I just wanted to get in and get out, and physician assistant is perfect for that.”

This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News.
Read original article – January 13, 2016
Making The Most Of Military Medics’ Field Experience