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CDC

Public Outrage Forces CDC To Restore Hospital Data On Website

Reprinted with permission from ProPublica

Hospitalizations for COVID-19 have been seen as a key metric of both the coronavirus's toll and the health care system's ability to deal with it. Recent federal actions may strike a blow to the public's ability to track them.

The U.S. Centers for Disease Control and Prevention removed from its website, and then restored, data on hospital capacity across the country to deal with the COVID-19 pandemic. But in a note, the agency indicated that the data may no longer be updated because of a change in federal reporting requirements to hospitals.

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hospital crisis

Crisis: Hospitals in Houston ‘Are Full” With New Covid-19 Patients

Reprinted with permission from ProPublica

HOUSTON — Houston hospitals have been forced to treat hundreds of COVID-19 patients in their emergency rooms — sometimes for several hours or multiple days — as they scramble to open additional intensive care beds for the wave of seriously ill people streaming through their doors, according to internal numbers shared with NBC News and ProPublica.

At the same time, the region's 12 busiest hospitals are increasingly telling emergency responders that they cannot safely accept new patients, at a rate nearly three times that of a year ago, according to data reviewed by reporters.

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Texas Medical Center

As Virus Overtakes Texas, Houston Hospitals Face Crisis

Reprinted with permission from ProPublica.

HOUSTON — At Lyndon B. Johnson Hospital on Sunday, the medical staff ran out of both space for new coronavirus patients and a key drug needed to treat them. With no open beds at the public hospital, a dozen COVID-19 patients who were in need of intensive care were stuck in the emergency room, awaiting transfers to other Houston area hospitals, according to a note sent to the staff and shared with reporters.

A day later, the top physician executive at the Houston Methodist hospital system wrote to staff members warning that its coronavirus caseload was surging: "It has become necessary to consider delaying more surgical services to create further capacity for COVID-19 patients," Dr. Robert Phillips said in the note, an abrupt turn from three days earlier, when the hospital system sent a note to thousands of patients, inviting them to keep their surgical appointments.

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State Coronavirus Data Debunk Trump’s False Testing Claims

State Coronavirus Data Debunk Trump’s False Testing Claims

Reprinted with permission from ProPublica.


President Donald Trump and Vice President Mike Pence have repeatedly attributed the increase in the coronavirus case count in the United States to an increase in testing.

“We're doing so much testing, so much more than any other country," Trump said in an interview with CBN News on Monday. “And to be honest with you, when you do more testing, you find more cases. And then they report our cases are through the roof."

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coronavirus, covid-19

How America’s Hospitals Survived The First Wave Of The Pandemic

Reprinted with permission from ProPublica.

The prediction from New York Gov. Andrew Cuomo was grim.

In late March, as the number of COVID-19 cases was growing exponentially in the state, Cuomo said New York hospitals might need twice as many beds as they normally have. Otherwise there could be no space to treat patients seriously ill with the new coronavirus.

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Here’s The Message You Need To Heed In This Crisis: Stay Home!

Here’s The Message You Need To Heed In This Crisis: Stay Home!

Reprinted with permission from ProPublica.

On Saturday afternoon, Sen. Ted Cruz took to Twitter to ask his followers to heed the advice of public health officials and politicians on the other side of the aisle:

“If you can stay home, stay home,” the Texas Republican wrote. “And wash your hands.”

Hours later, the Republican governor of Oklahoma tweeted from a packed restaurant in Oklahoma City showing that he is performatively not doing this. “Eating with my kids and all my fellow Oklahomans at the @CollectiveOKC. It’s packed tonight! #supportlocal #OklaProud”

He deleted the tweet an hour later.

On Sunday morning, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, told CBS’ “Face the Nation,” “Right now, personally, myself, I wouldn’t go to a restaurant.”

Meanwhile, Rep. Devin Nunes, a California Republican, spoke on Fox News and said, “If you’re healthy, you and your family, it’s a great time to just go out, go to a local restaurant, likely you can get in easy. Let’s not hurt the working people in this country … go to your local pub.”

Stay Home, Even if You Feel Fine

The discordant messages underscore the immense challenges conveying common messages during a public health crisis, one that has happened time and again as the novel coronavirus that causes COVID-19 has swept across the country.

“The most important thing is for people to change their daily routines and really reduce their social interactions,” said Dr. Joshua Sharfstein, a former federal and state health official who is now vice dean for public health practice and community engagement for the Bloomberg School of Public Health at Johns Hopkins University.

“I don’t think it is the consistent message from all health and political officials. If people are going to change the way they live their lives, they need to hear about the need to do that from every credible source of information they have because if they get mixed messages it’s easy to lapse back to not changing.”

From the availability of testing to the need to avoid handshakes, from where patients should go if they develop symptoms to whether to touch your face, the messages — and the actions by the public officials and even sometimes the doctors delivering those messages — have been contradictory.

Go to the ER; Don’t Go to the ER

One day last week, for example, a New York City allergy practice sent patients an email telling them what to do if they suspect they have symptoms consistent with infection with COVID-19.

“As you may be aware, there is a shockingly low number of available tests, and all testing now is done through local emergency departments in the area,” the note read.

Hours later, the advice was retracted: “It has been brought to our attention that the recommendation to visit the ED if one suspects COVID19 is incorrect. One should call their primary care provider to be screened and whether a visit to a lab or emergency department is necessary. … We are sorry for the confusion.”

While the government’s inability to get coronavirus tests in the hands of doctors and local health departments has been roundly criticized for preventing leaders from understanding how the virus is spreading, the mixed messages being given by leaders and others throughout this outbreak threatens to have a continuing effect.

“In some places, at least, there’s an advice vacuum and that leaves a lot of people trying to figure out what’s available and what to do,” Sharfstein said.

Conflicting Information Causes Real Harm

Accurate information is the coin of the realm in public health emergencies such as this one. Setting expectations and sharing accurate information is vital, experts say.

At all levels of government and medicine, that hasn’t happened.

During a visit to the Centers for Disease Control and Prevention this month, President Donald Trump said: “Anybody that wants a test can get a test. That’s what the bottom line is.” In fact, tests were not available. And public health officials told doctors and patients seeking them that they didn’t qualify.

The failure to provide clear answers has continued regarding the availability of ventilators in the event hospitals are overloaded. Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, was asked on Fox News whether hospitals could run out in a crisis. Several times, she didn’t answer the question. “Well, that’s why we have an emergency preparedness system,” Verma responded. “We’re used to dealing with disasters.”

On ABC’s “This Week” on Sunday morning, Fauci was more direct when asked whether the federal ventilator stockpile would be enough: “That may not be enough if we have a situation where we really have a lot of cases.”

The gap between government messages and reality applies to travel as well. Trump restricted travel from Europe and imposed additional health checks on Americans returning from European countries to protect Americans from the virus. “This president is going to continue to take every step necessary to protect the American people and put the health of the American people first,” Vice President Mike Pence said Saturday.

Yet, hours later, airports in Dallas, Chicago and Washington, D.C., were teeming with crowds waiting to get through the immigration checks. Some lamented that they were being exposed to others who may have the virus, the exact opposite of the stated reason for the additional checks.

Mark Morgan, acting commissioner of U.S. Customs and Border Protection, tweeted on Sunday morning that his agency is “aware of the reports of increased wait times at some airports across the nation. CBP along with medical personnel are working diligently to address the longer than usual delays. Nothing is more important than the safety, health and security of our citizens.”

Hours later, Morgan wrote another tweet, calling the waits at some airports “unacceptable.”

Do as I Say, Not as I Do

It goes beyond that. Public health officials have repeatedly called for members of the public to stop shaking hands, but the president has been resisting that advice, at least so far. “Shaking hands is not a great thing to be doing right now, I agree,” Trump said Saturday. “But people put their hand out. Sometimes I’ll put the hand out. You don’t think about it. People are thinking about it more and more. We have to think about it; it’s important.”

Public health officials also have told the public to avoid touching their faces, but sometimes those same officials have touched their faces. A public health official in California held a press conference to tell the public to avoid touching their faces, during which she licked a finger to turn a page in her remarks. (As this reporter has learned, it’s nearly impossible to stop touching your face.)

In a column in The Washington Post, two experts say communication is key, and sports and cultural icons should be brought in to reinforce important messages.

“A communications failure in the face of a pandemic amounts to not just a political problem; it is a public health problem,” wrote Lorien Abroms, a professor and associate dean at the Milken Institute School of Public Health at George Washington University, and Kenneth Baer, a communications consultant and former associate director of communications at the White House Office of Management and Budget.

“Communications can also be the solution: What is needed to help mitigate the severity of the coronavirus epidemic is a few, simple messages delivered by the right messengers. We need a whole-of-culture response — not just political leaders, but also the most influential athletes, actors, social media influencers, singers and personalities using every medium at our disposal to encourage Americans to change their behavior and inspire us to stick with it.”

The Tough Days Ahead

In the days ahead, consistent public health messages will be crucial, Sharfstein said, particularly if the virus continues spreading and places a burden on hospitals. Patients will need to know who to call if they get sick and when and where to seek medical care. Doctors will need to know where to send their patients.

In most cases, the answer is to avoid sending patients to the emergency room if they are showing mild or moderate symptoms of the virus. Those who become sicker or develop trouble breathing should follow up immediately with doctors or seek emergency care.

“A test itself is not treatment,” Sharfstein said. “A test illuminates what’s going on a little bit better. The response may just be to stay at home and monitor yourself. While it’s better to have more testing capability, we’re not powerless because the major response is just going to be to stay at home.”

Pressure Mounts On Insurance Companies To Consider Their Role In Opioid Epidemic

Pressure Mounts On Insurance Companies To Consider Their Role In Opioid Epidemic

Reprinted with permission from ProPublica.

 

A prominent Democratic lawmaker asked major health insurers today whether their policies and preferred prescription drug lists have made the nation’s opioid epidemic worse.

Rep. Elijah Cummings, D-Md., the ranking member of the House Committee on Oversight and Government Reform, wrote to the companies after an article by ProPublica and The New York Times found that insurance companies sometimes favor cheaper, more addictive opioids over less addictive, but more expensive, alternatives.

“This is not a hypothetical problem,” Cummings wrote. “In my home state of Maryland, 550 people died of an overdose in the first three months of 2017 alone. Synthetic opioids like fentanyl are driving up the epidemic’s death toll, but prescription opioids contribute significantly to this crisis by fostering addiction and causing fatal overdoses.”

Cummings wrote that the industry has created financial incentives that may “steer beneficiaries to the very drugs that are fueling the opioid crisis.”

Cummings sent his letter to UnitedHealth Group, its subsidiary Optum, Humana, CVS Health, Aetna, Anthem, and Express Scripts, asking each company to respond to a host of questions. Express Scripts, CVS Health and Optum are pharmacy benefit managers, meaning they are hired by insurance companies and large employers to manage prescription drug benefits, set coverage rules and process medication claims.

For its part, the insurance industry trade group, America’s Health Insurance Plans, said today that it is launching an initiative to track how well doctors are following the government’s guidelines for prescribing opioids for chronic pain. Individual companies have tracked their own data but this is the first industry-wide effort to use standard measures to assess progress. The data will be shared with health plans, but at least initially will not be made public.

For our story last month, ProPublica and the Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them.

Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. And even if they do approve coverage, some insurance companies have set a high out-of-pocket cost for Suboxone, rendering it unaffordable for many addicts, a number of pharmacists and doctors said.

A subsequent research report published in the Annals of Internal Medicine also found that some Medicare prescription drug plans allowed relatively easy access to opioids, even at high doses. Yale University researchers compared Medicare plans from 2006 to 2015. They found that more than two-thirds of opioids — at various dosage strengths — had no restrictions in 2006 and 2011 and about one-third had no restrictions in 2015, even as the epidemic was worsening.

Restrictions usually include limits on the quantity of drugs that can be filled or requirements for prior authorization. Unrestricted access “persisted for many opioids, especially at high doses, including for drugs commonly associated with overdose,” the report said.

Cummings is the latest to ask questions following our story. Attorneys general for 37 states sent a letter to the insurance industry’s trade group, urging its members to reconsider coverage its policies. And days later, Sen. Joe Manchin, D-W.Va., sent letters asking UnitedHealth and Anthem to remove barriers to non-opioid pain treatments.

Of the insurance companies that received Cummings’ letter, Anthem declined to comment. Express Scripts said it intends to cooperate. CVS Health noted that it rolled out a host of initiatives to stem opioid abuse last month, including limits on the number of days it will cover for first-time opioid prescriptions. CVS Health also said it does not require prior approval for medications to treat addiction for members in most employer-provided plans.

Aetna said that it, too, is taking steps to address the issue. For example, it ended its preauthorization requirements on all products containing the drug buprenorphine to treat opioid addiction. “Our goal with many of our initiatives is to prevent addiction, but if it happens, we also want to be an advocate to help with treatment,” the company said.

UnitedHealth Group and Humana did not reply before this article was published.

Have you had trouble paying for prescription drugs? Tell us about it.

 

 

Attorneys General In 37 States Urge Insurance Industry To Do More To Curb Opioid Epidemic

Attorneys General In 37 States Urge Insurance Industry To Do More To Curb Opioid Epidemic

Reprinted with permission from ProPublica.

 

Attorneys general for 37 states sent a letter Monday to the health insurance industry’s main trade group, urging its members to reconsider coverage policies that may be fueling the opioid crisis.

The letter is part of an ongoing investigation by the state officials into the causes of the opioid epidemic and the parties that are most responsible. The group is also focusing on the marketing and sales practices of drug makers and the role of drug distributors.

On Sunday, ProPublica and The New York Times reported that many insurance companies limit access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications. The safer drugs are more expensive.

In their letter to America’s Health Insurance Plans, the trade group based in Washington, D.C., the attorneys general urged insurers to revise their rules “to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain.”

“The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable,” the letter said. “We ask that you quickly initiate additional efforts so that you can play an important role in stopping further deaths.”

The signatories include the attorneys general of California, Florida, New York, Pennsylvania and Michigan.

While opioids, such as hydrocodone and morphine, are often prescribed to relieve pain, they also have been linked to abuse and dependence. Drug overdoses are now the leading cause of death among Americans under 50, and more than 2 million Americans are estimated to misuse opioids. While the crisis has placed the practices of drug makers, pharmaceutical distributors, pharmacies and doctors under scrutiny, the role of insurers in enabling access to cheap, addictive opioids has received less attention.

The Department of Health and Human Services is now studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that insurers are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.

Last week, the New York state attorney general’s office sent letters to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.

In a written statement to ProPublica, Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, said that, “We share the state attorneys general’s commitment to eradicating the opioid epidemic in America.”

“Health plans cover comprehensive, effective approaches to pain management that include evidence-based treatments, more cautious opioid prescribing, and careful patient monitoring,” Donaldson wrote. “Recent research shows that non-opioid medications, even over-the-counter medication like ibuprofen, can provide just as much relief as opioids.”

Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. A number of companies say they have seen marked declines in monthly opioid prescriptions in the past year or so. Moreover, at least two large pharmacy benefit managers, which run insurers’ drug plans, announced this year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply.

“Patients and their care providers should talk openly and honestly about pain and how to manage it — from lifestyle changes and exercise to over-the-counter options and clearly understanding the dangers of opioids,” Donaldson said.

Nonetheless, ProPublica and The New York Times found that companies are sometimes refusing to cover less risky drugs prescribed by doctors while putting no such restrictions on opioids.

We analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them.

Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. And even if they do approve coverage, some insurance companies have set a high out-of-pocket cost for Suboxone, rendering it unaffordable for many addicts, a number of pharmacists and doctors said.

“Everyone — including and especially insurance companies — have an obligation to address the opioid epidemic,” New York Attorney General Eric T. Schneiderman said in a press release today. “Insurers must take a hard look at the systemic problems in our healthcare system that result in the over-prescription of opioids and fuel the cycle of addiction.”

 

Accreditors Can Keep Their Hospital Inspection Reports Secret, Feds Decide

Accreditors Can Keep Their Hospital Inspection Reports Secret, Feds Decide

Reprinted with permission from ProPublica.

Federal health officials have backed down from a controversial proposal that would have required private accreditors to publicly release reports about errors, mishaps and mix-ups in the nation’s hospitals and health care facilities.

The Centers for Medicare and Medicaid Services had proposed in April that accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by these accreditors, not the government.

But in a notice released Wednesday afternoon, the government withdrew the proposal. CMS said that federal law prohibits the agency from disclosing the results of inspections performed by the accrediting organizations and that the proposal — though it required accreditors, not the agency, to release the reports — “may appear as if CMS was attempting to circumvent” the law.

“CMS is committed to ensuring that patients have the ability to review the findings used to determine that a facility meets the health and safety standards required for Medicare participation,” the agency said in a fact sheet. “However, we believe further review, consideration, and refinement of this proposal is necessary to ensure that CMS establishes requirements, consistent with our statutory authority, that will inform patients and continue to support high quality care.”

The government’s proposal, and subsequent about face, comes as federal officials have grown increasingly concerned that private accreditors aren’t picking up on serious problems at health facilities.

Health care facilities that receive federal funding are required to comply with Medicare’s requirements and thus are subject to government oversight. But the law allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight instead.

Every year, CMS and state health agencies inspect a sample of hospitals and other health care facilities accredited by private organizations, in order to validate the work of the groups. In a report to Congress last month, CMS noted that its reviews in fiscal year 2015 found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.

Leah Binder, president and CEO of The Leapfrog Group, a coalition of employers that advocates for quality and transparency in health care, criticized the CMS decision to back down.

“This is disgraceful, unfair to patients as well as employers and other purchasers of health care,” she said in an email. “The public deserves full transparency on how the health care industry performs. Instead, transparency has been sacrificed to accommodate special interests that lobby to avoid disclosing embarrassing information about health care quality.”

The government’s proposal to make accreditors’ reports public was strongly protested by accreditors and the hospitals that pay them for their services. Some questioned its legality; all challenged its wisdom. The Joint Commission, for instance, said the proposal would increase costs and decrease patient safety. “The provision will adversely affect the collaborative efforts of accrediting bodies and healthcare organizations to improve patient safety and engage in continuous quality improvement,” the commission said in a June letter. “Ultimately, there will be increased patient harm and lower quality.”

Another accreditor, the Center for Improvement in Healthcare Quality, raised similar concerns. “Knowing that survey [inspection] reports are public knowledge will only incentivize hospitals and other healthcare entities to go back to the days of ‘hiding’ quality of care issues from accreditors, rather than working with us to improve the quality and safety of care rendered to patients.”

But consumer groups, business alliances and a group representing health care journalists were supportive, saying consumers deserve more information about the quality of hospitals. The Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare policy, had urged CMS to implement the requirement as soon as possible, saying it would “enable Medicare beneficiaries to make more informed decisions” about where to seek health care.

Consumer Reports and its publisher, Consumers Union, likewise supported the proposal. “Such survey [inspection] results provide insight into hospital quality that is not now transparent. … Consumers have a right to know this critical information that is used to determine if facilities are in compliance with health and safety requirements for Medicare patients, and thus, all patients.”

Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,010 hospitals listed on The Joint Commission’s website, more than 99 percent have full accreditation and only eight are on track to lose their “gold seal of approval.”

On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information on inspection findings, even when hospitals are described as receiving a “preliminary denial of accreditation.” For one hospital, the explanation is: “Existence at time of survey of a condition, which in The Joint Commission’s view, poses a threat to patients or other individuals served.” The threat itself is not specified.

Other smaller accrediting organizations provide even less information.

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Report: ‘Extreme’ Use Of Painkillers And Doctor Shopping Plague Medicare

Report: ‘Extreme’ Use Of Painkillers And Doctor Shopping Plague Medicare

Reprinted with permission from ProPublica.

In Washington, D.C., a Medicare beneficiary filled prescriptions for 2,330 pills of oxycodone, hydromorphone and morphine in a single month last year — written by just one of the 42 health providers who prescribed the person such drugs.

In Illinois, a different Medicare enrollee received 73 prescriptions for opioid drugs from 11 prescribers and filled them at 20 different pharmacies. He sometimes filled prescriptions at multiple pharmacies on the same day.

These are among the examples cited in a sobering new report released today by the inspector general of the U.S. Department of Health and Human Services. The IG found that heavy painkiller use and abuse remains a serious problem in Medicare’s prescription drug program, known as Part D, which serves more than 43 million seniors and disabled people. Among the findings:

  • Of the one-third of Medicare beneficiaries in Part D (or roughly 14.4 million people) who filled at least one prescription for an opioid in 2016, some 3.6 million received the painkillers for at least six months.
  • Consistent with data released last week by the Centers for Disease Control and Prevention, there were wide geographic differences in prescribing patterns. Alabama and Mississippi had the highest proportions of patients taking prescription painkillers — more than 45 percent each — while Hawaii and New York had the lowest — 22 percent or less.
  • More than half a million beneficiaries received high doses of opioids for at least three months, meaning they took the equivalent of 12 tablets a day of 10-milligram Vicodin. The figure does not include patients who have cancer or those who are in hospice care, for whom such doses may be appropriate.
  • Almost 70,000 beneficiaries received what the inspector general labeled as extreme amounts of the drugs — an average daily consumption for the year that was more than 2 1/2 times the level the CDC recommends avoiding. Such doses put patients at an increased risk of overdose death. Extreme prescribing could also indicate that a patient’s identity has been stolen, or that the patient is diverting medications for resale.
  • Some 22,000 beneficiaries seem to be doctor shopping — obtaining large amounts of the drugs prescribed by four or more doctors and filled at four or more pharmacies. All states except for Missouri operate Prescription Drug Monitoring Program databases that allow doctors to check whether their patients have received drugs from other doctors before writing their own prescriptions.
  • More than 400 doctors, nurse practitioners and physician assistants had questionable prescribing patterns for the beneficiaries most at risk (meaning those that took extreme doses of the drugs or showed signs of doctor shopping). One Missouri prescriber wrote an average of 31 opioid prescriptions each for 112 patients on Medicare. And four doctors in the same Texas practice ordered opioids for more than 56 beneficiaries who seemed to be doctor shopping. “The patterns of these 401 prescribers are far outside the norm and warrant further scrutiny,” the inspector general said.

To be sure, many seniors suffer from an array of painful conditions, and some opioids are seen as more harmful and addictive than others. Tramadol, often used to treat chronic osteoarthritis pain, was the most frequently prescribed opioid and carries a lower risk of addiction than other opioids, according to the Drug Enforcement Administration.

Moreover, last week’s report from CDC shows that painkiller use is ticking downward after years of explosive growth.

Still, officials in the inspector general’s office said more can and should be done to combat the problems they observed, even if the numbers are beginning to subside.

“I think what we’re saying here is this is still a lot of Medicare beneficiaries,” said Jodi Nudelman, regional inspector general for evaluation and inspections in the New York regional office, who supervised the report. “Regardless of if you are turning a corner, you’re still at these really high levels.”

The inspector general previously has called for Medicare to use its data to focus on doctors who are prescribing drugs in aberrant ways.

The inspector general’s numbers differ somewhat from an April report from the Centers for Medicare and Medicaid Services, which runs Medicare. The CMS report said that 29.6 percent of Part D enrollees used opioids in 2016, down from 31.9 percent in 2011. The inspector general pegged the 2016 figure at 33 percent but did not offer any historical comparisons. It was unclear why the two agencies came up with different figures.

In a statement, CMS said opioid abuse is a priority for the Trump administration. “We are working with patients, physicians, health insurance plans, and states to improve how opioids are prescribed by health care providers and used by patients, how opioid use disorder is diagnosed and managed, and how alternative approaches to pain management could be promoted,” it said.

Officials have known for years that opioid prescribing has been a problem in Medicare. ProPublica first highlighted the problem in 2013 when we published data on the drugs prescribed by every physician in the Part D program. Following that report, CMS put in place what it called an Overutilization Monitoring System, which tracked beneficiaries at the highest risk for overdoses or drug abuse. It asked the private insurance companies that run the drug program on its behalf, under contract, to review the cases and provide a response.

In a memo released in April, CMS said its monitoring system has been a success. From 2011 to 2016, it said, there was a 61 percent decrease in the number of beneficiaries who were labeled as “potential very high risk opioid overutilizers.” People were flagged that way if they were taking high doses of opioids for 90 consecutive days and received prescriptions from three or more doctors at three or more pharmacies. But the agency also said it would be implementing changes in January to better target those at highest risk of abuse.

Separately, in 2014, CMS told health providers they would have to register with the Medicare program in order to prescribe medications for beneficiaries. That way, the government could screen them and take action if their prescribing habits were deemed improper. Up to that point, doctors could prescribe drugs to Medicare patients even if they weren’t registered Medicare providers. Delay after delay has pushed back the requirement until 2019.

Dr. Cheryl Phillips, senior vice president for public policy and health services at LeadingAge, an association of nonprofit service providers for older adults, said managing pain in seniors is complex. Seniors are more likely to have conditions, such as orthopedic problems, cancer or degenerative joint disorders, which result in chronic pain. They sometimes don’t react well to non-prescription pain relievers, such as Tylenol, aspirin or nonsteroidal anti-inflammatory medicines. Health care providers like nursing homes are still evaluated, in part, on how well they manage pain, creating an incentive to turn to drugs.

“We have to challenge the notion that being pain free is a goal,” Phillips said. “It’s not that I want to see people suffering, but being pain free is perhaps a myth that not only society has been seduced with but physicians have as well.”

Phillips said she encourages physicians to explore nondrug alternatives, including meditation, mindfulness, moist heat and exercise.

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The Medicaid Threat That Isn’t Getting Much Attention

The Medicaid Threat That Isn’t Getting Much Attention

Reprinted with permission from ProPublica.
by Charles Ornstein

No corner of the health care system would be harder hit than Medicaid, the federal-state health insurance program for the poor, if Republican leaders in Congress round up the votes to repeal major portions of the Affordable Care Act.

GOP lawmakers have proposed winding down the Medicaid expansion that added 17 million people in 31 states and the District of Columbia under the ACA, and eventually capping the program’s spending per capita.

If the current bill in the Senate becomes law, 15 million fewer people would have coverage through Medicaid by 2026, the Congressional Budget Office has predicted.

But other efforts that are garnering much less attention would further reshape Medicaid, potentially knocking millions more off the rolls. They include asking beneficiaries to verify their eligibility twice a year, instead of once under the current law.

In many ways, the current battles pit those who view Medicaid as a health insurance program, in which higher enrollment is not seen as a problem, against those who see it as a welfare program, in which lower enrollment is prized. Some states that have experimented with more frequent verification and other techniques to manage enrollment say they’ve worked well while others say they’re not cost-effective and are overly burdensome.

In addition, the Trump administration has said it wants to let states experiment more with their Medicaid programs, inviting them to ask for waivers that do not need congressional approval. In recent months, states have proposed requiring able-bodied adults on Medicaid to work, drug testing enrollees, capping the length of time some can stay on the program and limiting the number of people who can be on the program at once. The Obama administration had rebuffed some of those efforts.

“All of the bells and whistles and hoops that people have to jump through create an enormous amount of red tape and that depresses enrollment,” says Joan Alker, executive director of the Center for Children and Families, a research center at Georgetown University. “That’s a proven strategy.”

Some 74.5 million people are now enrolled in Medicaid — more than the 58 million covered by Medicare, the program for seniors and the disabled. Since the implementation of the Medicaid expansion under the Affordable Care Act in 2014, Medicaid enrollment has grown by 16.7 million. That increase alone is larger than the number of people who purchase health insurance through the marketplaces set up by the ACA.

Health policy researchers say there’s ample evidence that adding paperwork and administrative burdens on beneficiaries in Medicaid increases turnover, called churn. For the most part, it’s not because people are no longer eligible for the program, they say; it’s that poor people move frequently and often face a host of challenges that make them less likely to turn in required paperwork.

Even before the ACA passed, many states were moving to make it easier for people, particularly children, to get enrolled and stay enrolled in Medicaid and the Children’s Health Insurance Program. The Affordable Care Act only allows states to formally reassess people’s enrollment eligibility once a year. But Medicaid enrollees are required to notify authorities in the interim if they have a change in life circumstances, such as finding a job. And that can prompt another review.

The House bill to replace the Affordable Care Act, passed May 4, would require reassessments every six months for enrollees who became eligible through the Medicaid expansion. The bill pending in the Senate would allow them every six months or more frequently, but would not require them.

Proponents of the changes say too many people stay on Medicaid when they are no longer eligible. They point to Illinois, which hired a consultant a few years ago to help it improve its renewal process. During the first three quarters of fiscal year 2017, which just ended, 623,530 individuals had their Medicaid canceled during the renewal process — the vast majority for not responding to requests for information. Of those, nearly 148,000 eventually re-enrolled after submitting the requested information.

“Certainly, at least some percentage of clients who did not respond did so because their circumstances were such that they were indeed not eligible,” the state said in its most recent report. “The people who are more likely to respond are those who are eligible.”

Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability who has tracked the Illinois project, says the state’s Medicaid rolls had included people who died years earlier, as well as those who no longer lived in the state.

Critics of more frequent renewals “are correct to say that it would decrease enrollment,” Archambault says. “But these are all people who would not qualify.”

He said not all checks have to be intrusive. States, for instance, can more frequently check federal and state databases to look for whether a person has a life change, has moved or has a new job. “If somebody gets a job, that’s great. They may no longer be able to qualify for the program,” he says. “If they still qualify, they can sign right back up.”

That’s what’s happened in Texas. The state regularly checks the finances of families whose children are enrolled. State data appears to show that the number of children experiencing a temporary gap in their Medicaid coverage has increased since the state instituted the new process in 2014, according to Kaiser Health News.

Avik Roy, a conservative who has advised Republican leaders on health policy, said by letting states check people’s eligibility for Medicaid more often, “you’re giving states a tool to make sure that the people who are enrolled in the Medicaid program are the people who the program is meant to help.”

That’s not how officials in California see it. They say the current system works well compared to many years ago when people had to prove their eligibility more often, up to four times a year. It was burdensome for enrollees and costly for the state and its counties, which handle the process.

In California’s experience, when people have a change in life circumstances, they generally report it right away, as required. Moreover, California has moved from a system that was dependent on paper to one that is largely electronic, easing the burden further.

“Medicaid programs have a responsibility to help ensure that those people who are eligible for the program, that they’re enrolled and they receive the services that they’re in fact eligible for,” says René Mollow, deputy director for health care benefits and eligibility at the California Department of Health Care Services.

Mollow said when people are on Medicaid, their income doesn’t change much from year to year, especially children, the elderly and the disabled.

While California has sought ways to expand access to its Medicaid program, other states have looked for ways to tighten eligibility, ensuring it is only available for those who they believe truly need it.

When Indiana expanded its Medicaid program, for example, it also deployed a complex system of rewards and penalties that requires enrollees to make token regular payments or get barred from the program. It did so with the help of a consultant named Seema Verma, who is now the administrator of the federal Centers for Medicare and Medicaid Services, the agency that decides whether to grant states permission to make changes to their Medicaid programs.

And more states are seeking changes to their programs. Indiana and Maine, for example, are among states that have proposed work requirements for able-bodied adults in the program. (Indiana estimates that a quarter of those required to work won’t and “will have HIP [Medicaid] eligibility suspended until compliance has been demonstrated.”) States say that by making Medicaid contingent on work, potential beneficiaries will be incentivized to find jobs that offer health insurance.

Wisconsin is asking the federal government to approve a drug testing requirement for those same adults, saying it will help get addicts into treatment and prepare them for jobs. Arizona wants to cap the amount of time certain non-disabled adults can remain on Medicaid to five years, taking a page from the welfare reform playbook of the 1990s. And Utah is proposing a limit on the number of adults without dependent children who can enroll in its Medicaid program.

Such requests are popping up all across the country, according to a recent analysis by the Kaiser Family Foundation, a nonprofit think tank.

So far, the Trump administration hasn’t approved any of these requests, but it signaled in a letter to governors in March that it would be more flexible than the Obama administration, which did not approve requests from Indiana and Arizona in the past.

“We commit to ushering in a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population,” wrote Health and Human Services Secretary Tom Price and Verma.

Diane Rowland, executive vice president of the Kaiser Family Foundation, says many of the state proposals treat Medicaid as they do welfare programs. “You see work requirements. You see drug testing. You see things that would discourage people from enrolling,” she says. “The other side is that a lot of people on Medicaid are already working. They just don’t work in jobs that have health insurance.”

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Medicare Halts Release Of Much-Anticipated Data

Medicare Halts Release Of Much-Anticipated Data

Reprinted with permission from ProPublica.
by Charles Ornstein

In the past few years, many seniors and disabled people have eschewed traditional Medicare coverage to enroll in privately run health plans paid for by Medicare, which often come with lower out-of-pocket costs and some enhanced benefits.

These so-called Medicare Advantage plans now enroll more than a third of the 58 million beneficiaries in the Medicare program, a share that grows by the month.

But little is known about the care delivered to these people, from how many services they get to which doctors treat them to whether taxpayer money is being well-spent or misused.

The government has collected data on patients’ diagnoses and the services they receive since 2012 and began using it last year to help calculate payments to private insurers, which run the Medicare Advantage plans. But it has never made that data public.

Officials at the Centers for Medicare and Medicaid Services have been validating the accuracy of the data and, in recent months, were preparing to release it to researchers. Medicare already shares data on the 38 million patients in the traditional Medicare program, which the government runs. (ProPublica has created a tool called Treatment Tracker that enables people to compare how doctors and others use services in the traditional Medicare program.)

The grand unveiling of the new data was scheduled to take place at the annual research meeting of AcademyHealth, a festival of health wonkery, which just concluded in New Orleans.

But at the last minute, the session was canceled.

The change caught researchers — and even some former Medicare officials — off guard as the data’s release was a highly anticipated expansion of the government’s effort to share information.

In a statement, CMS said there were enough questions about the data’s accuracy that it should not be released for research use. CMS said it will examine the data for 2015 “to determine if it is robust enough to support research use.”

Niall Brennan, until January the chief data officer of the Centers for Medicare and Medicaid Services, worked on the data — known as encounter data — during his time in office. “Hugely disappointing,” he tweeted, with a photo of the sign announcing the session’s cancellation. “Hope CMS not backsliding on #opendata.”

In response to a question about whether the data had problems, he tweeted, “Like any new data source [Medicare Advantage] data had some quirks to be sure but if it was used for payment why can’t it be used for research?” he said in a tweet this week.

Health economist Austin Frakt, who is affiliated with a number of academic institutions, said he was disappointed by the decision to halt the data’s release. He said he wants access to the data as a researcher — and as a taxpayer. “We are paying an enormous amount of money to private insurance companies … but we know very little about what we’re getting for that money,” he said.

Frakt notes that researchers know “vastly more” about traditional Medicare because the data has been available for decades. “The claim is that private insurers are innovating in ways that traditional program is not. We need to validate that. We need to know what they’re doing for the benefit of everyone. We can’t do that without the data.”

Frakt acknowledged that the data has limitations, “but I don’t think it justifies withholding the data. … Researchers are highly skilled at dealing with messy data. We’ve done it before.”

In recent years, private insurers that run Medicare Advantage plans have been under fire for allegedly overcharging Medicare. The Center for Public Integrity reported last year that more than three dozen audits had found that plans overstated the severity of enrollees’ medical conditions to garner more money. (The Center had to file a Freedom of Information lawsuit to access the audits.) In 2014, the Center’s reporting suggested that insurers had collected $70 billion in improper payments from 2008 to 2013.

The Department of Justice recently intervened in two federal lawsuits in Los Angeles (here and here) accusing UnitedHealth Group of providing “untruthful and inaccurate information about the health status of beneficiaries” to boost its revenues. The company has denied wrongdoing.

If the data on Medicare Advantage plans was made available to researchers, it could shed light on these kinds of issues.

For its part, the insurance industry has been raising questions about the accuracy of the encounter data but said it did not ask CMS administrator Seema Verma to delay its release to researchers.

“The system used to capture encounter data has numerous unresolved operational and technical issues and fails to capture a reliable, comprehensive picture of beneficiaries’ diagnoses,” a spokeswoman for America’s Health Insurance Plans said in an email. “This could put payments at risk, which could also increase premiums and decrease benefits. We look forward to working with Administrator Verma and CMS to improve the encounter data and address these issues.”

Earlier this year, the Government Accountability Office issued a report calling on CMS to do more to validate the completeness and accuracy of the encounter data before using it as a basis for paying the health plans.

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Veterans Affairs Official Downplays Agent Orange Risks, Questions Critics

Veterans Affairs Official Downplays Agent Orange Risks, Questions Critics

Reprinted with permission from ProPublica.
by Charles Ornstein

A key federal official who helps adjudicate claims by veterans who say they were exposed to Agent Orange has downplayed the risks of the chemical herbicide and questioned the findings of scientists, journalists and even a federal administrative tribunal that conflict with his views.

Jim Sampsel, a lead analyst within the Department of Veterans Affairs’ compensation service, told a VA advisory committee in March that he believes much of the renewed attention to Agent Orange — used during the Vietnam War to kill brush and deny cover to enemy troops — is the result of media “hype” and “hysteria,” according to a transcript of the meeting released to ProPublica.

“When it comes to Agent Orange, the facts don’t always matter,” said Sampsel, himself a Vietnam veteran who also handles Gulf War-related illness questions. “So we have to deal with the law as written.”

Part of Sampsel’s job entails reviewing evidence to determine whether a veteran or group of veterans came in contact with Agent Orange outside of Vietnam. By law, veterans are presumed to have been exposed to Agent Orange if they served or stepped foot in Vietnam; they have to prove exposure if they served at sea or in another country during the war. They also must have a disease that the VA ties to exposure to the herbicide.

“From my point of view, I will do anything to help veterans, any legitimate veteran, and I’ve done it plenty of times,” he told the Advisory Committee on Disability Compensation, a group that advises the VA. “Unfortunately when it comes to this Agent Orange, we have to have a lot of denials.”

Sampsel also offered a window, for the first time, into ongoing internal deliberations at the VA about adding new diseases to the list of those connected to Agent Orange exposure. He suggested that despite increasing evidence tying the herbicide to hypertension, or high blood pressure, the VA is not going to extend benefits to veterans with that condition.

Reached by phone, Sampsel said, “You’re going to try to frame me, too,” before referring a reporter to the VA’s media relations office. ProPublica and The Virginian-Pilot examined the effects of Agent Orange on veterans and their offspring in a series of articles in 2015 and 2016, raising questions about the VA’s handling of the matter.

The VA provided two written statements in response to questions for this article. Initially, a spokesman said that Sampsel was speaking as an individual at the meeting, and not for the VA.

“The objective of a federal advisory committee is to have open and public discussion of the issues for which it is chartered from the experts who understand and bring their own unique perspectives,” the statement said. “The March 2017 meetings were no exception and Mr. Sampsel’s comments did not fully or accurately reflect VA’s position concerning these issues.”

The VA said no decisions have been made about which new diseases to add to its list of those linked to Agent Orange exposure.

Asked whether it continued to support Sampsel, the VA said in a subsequent statement that he “is highly dedicated and respected within and outside of VA for the work he has done to establish many of the present policies that provide veterans, their families and survivors the benefits they are entitled to under the law.” The department also questioned the quotes a reporter asked about from the advisory committee meeting. “Taking quotes out of context without fully understanding the law, science, reasons or intent behind those words is a disservice to the advisory committee and the veteran community at large as well as Mr. Sampsel.” (Read the full transcript.)

Veteran advocates said they were furious to learn a VA official charged with objectively weighing evidence related to Agent Orange had shared controversial personal views.

Rick Weidman, legislative director for Vietnam Veterans of America, said he met with VA Secretary David Shulkin last week and told him, among other things, that Sampsel and others in the Veterans Benefits Administration need to be replaced. “Where they are now is doing active evil,” Weidman said. He added that he doesn’t expect Sampsel and other VA employees to necessarily be advocates “but we do expect them to be neutral and honest arbiters of science — and they are not.”

Although Agent Orange hasn’t been used in more than 40 years, it remains controversial because it contained dioxin, one of the world’s most toxic chemicals. Its effects can take decades to show up. Scientists continue to associate exposure to Agent Orange with diseases, and the VA continues to weigh whether to extend benefits to groups who say they were exposed to it outside of Vietnam.

Members of Congress who are leaders on veterans’ issues said the VA has an obligation to care for vets injured by Agent Orange. “I strongly believe we must do everything in our power to ensure veterans struggling with negative health effects as a result of exposure to Agent Orange receive the care and compensation they deserve; we owe nothing less to these brave men and women who have sacrificed more than enough for our country,” Rep. Tim Walz, D-Minn., the ranking Democrat on the House Committee on Veterans’ Affairs, said in a statement.

Among Sampsel’s statements:

  • He said he believes Agent Orange contained “very, very small amounts” of dioxin, which was quickly destroyed by sunlight and the open air. “That’s not commonly acknowledged by advocates,” he said. Moreover, Sampsel said, U.S. planes did not spray it when American troops were in the area.

    In fact, a report by the Aspen Institute notes that on leaf and soil surfaces, dioxin will last one to three years and that dioxin under the surface could have a half-life of more than 100 years. Moreover, scientists have said that there are numerous ways in which American troops may have been exposed to the herbicide and some disagree that few troops were exposed.

  • Sampsel pushed back against claims that veterans who served outside of Vietnam were exposed to Agent Orange. “When we get to outside of Vietnam, there’s a lot of controversy about Agent Orange use. And primarily it’s media hype, in my opinion.”

    In fact, veterans who served in Thailand, near the Korean demilitarized zone, in Okinawa, Japan, and aboard ships off the coast of Vietnam contend they were exposed in a variety of ways. Some have produced memos, photos and testimonials that have been enough to convince the Board of Veterans Appeals, the VA’s tribunal, that there was sufficient evidence to prove exposure and that they were entitled to benefits.

  • Sampsel criticized the Board of Veterans Appeals for its decisions. “BVA is, can do anything they want. I don’t know if everybody understands BVA. BVA has caused a lot of, what I would call misinformation about Agent Orange issues.”

    A member of the advisory panel, Thomas J. Pamperin, responded to Sampsel at the March meeting: “A decision by the Board of Veterans Appeals is the secretary’s final decision. I mean, we can’t distance ourselves from the Board of Veterans Appeals. It is part of the VA.”

    And in its statement, the VA said it, too, respects the BVA. “BVA is the highest appellate authority in VA,” it said. “They are attorneys who review the evidence of record and make decisions.” While the VA may not always agree with a decision, “their decisions are final and are implemented when issued.”

  • Sampsel criticized the prestigious Institute of Medicine, a congressionally chartered research organization hired by the VA, which in 2015 determined that the evidence suggested that a group of Air Force reservists could have been exposed to Agent Orange years after the Vietnam War when they flew aboard the C-123 planes that had been used to spray the herbicide.

    “One scientist from Harvard or somewhere said that dried, solidified TCDD dioxin never stops emanating molecules into the air,” Sampsel said. “Hardly anybody bought that at the time, but the IOM went with it.”

    He added a bit later: “I don’t think the science supports it. Most scientists don’t think the science supports it, but the law is what it is.”

    The Institute of Medicine, now called the National Academy of Medicine, found that the dioxin present on the aircraft could have exposed reservists who flew the planes years later. In its report, it said one contention of the VA and its expert, Alvin Young, was “inaccurate,” another “appears to be conjecture and not evidence-based” and a third was based on a study funded by Dow Chemical Co., one of the herbicide’s makers.

    In its statement, the VA said the Institute of Medicine “provides a valuable service to VA.”

  • Sampsel favorably cited Young, an Air Force officer, federal official and later the government’s go-to consultant, who has guided the stance of the military and the VA on Agent Orange and whether it has harmed service members. “I’m not the scientist,” Sampsel said at one point. “But I know that Dr. Alvin Young and the majority, the vast majority, of scientists don’t think that anybody gets any harmful effects from something that’s in the soil, buried in the soil.”

    But ProPublica and The Virginian-Pilot reported last fall that critics say Young’s work is compromised by inaccuracies, inconsistencies or omissions of key facts, and relies heavily on his previous work, some of which was funded by Monsanto Co. and Dow Chemical Co., the makers of Agent Orange. Young also served as an expert for the chemical companies in 2004 when Vietnam vets sued them. In an interview at the time, Young defended his work.

  • Sampsel said Young’s research showed that Agent Orange “never went to the Philippines, never went to Okinawa, never went to Guam,” as some veterans contend.

    A member of the panel interjected because he felt that Sampsel was being overly broad.

    “I’m sorry. I’m sorry. Yes, yes. You’re, you’re absolutely correct,” Sampsel said, noting he should have said there was currently no evidence. “And if evidence does show up, we’ll certainly change our policy. … You’re right.”

During his presentation, Sampsel also summarized internal deliberations within the VA about which diseases should be formally linked to Agent Orange. Last year, the Institute of Medicine said there is now evidence to suggest that Agent Orange exposure may be linked to bladder cancer and hypothyroidism. It also confirmed, as previous experts have said, that there is some evidence of an association with hypertension, stroke and various neurological ailments similar to Parkinson’s Disease.

Since then, a VA-led study has found stronger evidence to link hypertension to Agent Orange exposure. The VA has been reviewing the matter since last year to decide whether to cover the diseases.

Sampsel said the Veterans Health Administration had recommended that the VA acknowledge the connection between Agent Orange and hypertension, but that benefits officials at the VA worked to kill that effort and believe they succeeded.

“I believe the secretary, the information I got recently, is not going to go with hypertension. As to the other ones, there’s the likelihood that they’ll become added to the list,” Sampsel said.

The VA, in its statement, said it could not comment on internal discussions “other than to say those deliberations are underway.” But it did note that no recommendations had gone to the secretary for his consideration.

If the VA ultimately decides to add hypertension to its list of covered diseases, it could be costly. Hypertension is the most common ailment among veterans seeking health care at the VA — indeed it is one of the most common ailments among older adults generally.

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Trump’s Not The Only One Blocking Constituents On Twitter

Trump’s Not The Only One Blocking Constituents On Twitter

Reprinted with permission from ProPublica.

As President Donald Trump faces criticism for blocking users on his Twitter account, people across the country say they, too, have been cut off by elected officials at all levels of government after voicing dissent on social media.

In Arizona, a disabled Army veteran grew so angry when her congressman blocked her and others from posting dissenting views on his Facebook page that she began delivering actual blocks to his office.

A central Texas congressman has barred so many constituents on Twitter that a local activist group has begun selling T-shirts complaining about it.

And in Kentucky, the Democratic Party is using a hashtag, #BevinBlocked, to track those who’ve been blocked on social media by Republican Gov. Matt Bevin. (Most of the officials blocking constituents appear to be Republican.)

The growing combat over social media is igniting a new-age legal debate over whether losing this form of access to public officials violates constituents’ First Amendment rights to free speech and to petition the government for a redress of grievances. Those who’ve been blocked say it’s akin to being thrown out of a town hall meeting for holding up a protest sign.

On Tuesday, the Knight First Amendment Institute at Columbia University called upon Trump to unblock people who’ve disagreed with him or directed criticism at him or his family via the @realdonaldtrump account, which he used prior to becoming president and continues to use as his principal Twitter outlet.

“Though the architects of the Constitution surely didn’t contemplate presidential Twitter accounts, they understood that the president must not be allowed to banish views from public discourse simply because he finds them objectionable,” Jameel Jaffer, the Knight Institute’s executive director, said in a statement.

The White House did not respond to a request for comment, but press secretary Sean Spicer said earlier Tuesday that statements the president makes on Twitter should be regarded as official statements.

Similar flare-ups have been playing out in state after state.

Earlier this year, the American Civil Liberties Union of Maryland called on Gov. Larry Hogan, a Republican, to stop deleting critical comments and barring people from commenting on his Facebook page. (The Washington Post reported that the governor had blocked 450 people as of February.)

Deborah Jeon, the ACLU’s legal director, said Hogan and other elected officials are increasingly foregoing town hall meetings and instead relying on social media as their primary means of communication with constituents. “That’s why it’s so problematic,” she said. “If people are silenced in that medium,” they can’t effectively interact with their elected representative.

The governor’s office did not respond to a request for comment this week. After the letter, however, it reinstated six of the seven people specifically identified by the ACLU (it said it couldn’t find the seventh). “While the ACLU should be focusing on much more important activities than monitoring the governor’s Facebook page, we appreciated them identifying a handful of individuals — out of the over 1 million weekly viewers of the page — that may have been inadvertently denied access,” a spokeswoman for the governor told the Post.

Practically speaking, being blocked cuts off constituents from many forms of interacting with public officials. On Facebook, it means no posts, no likes and no questions or comments during live events on the page of the blocker. Even older posts that may not be offensive are taken down. On Twitter, being blocked prevents a user from seeing the other person’s tweets on his or her timeline.

Moreover, while Twitter and Facebook themselves usually suspend account holders only temporarily for breaking rules, many elected officials don’t have established policies for constituents who want to be reinstated. Sometimes a call is enough to reverse it, other times it’s not.

Eugene Volokh, a constitutional law professor at the UCLA School of Law, said that for municipalities and public agencies, such as police departments, social media accounts would generally be considered “limited public forums” and therefore, should be open to all.

“Once they open it up to public comments, they can’t then impose viewpoint-based restrictions on it,” he said, for instance allowing only supportive comments while deleting critical ones.

But legislators are different because they are people. Elected officials can have personal accounts, campaign accounts and officeholder accounts that may appear quite similar. On their personal and campaign accounts, there’s little disagreement that officials can engage with — or block — whoever they want. Last month, for instance, ProPublica reported how Rep. Peter King, R-N.Y., blocked users on his campaign account after they criticized his positions on health reform and other issues.

But what about their officeholder social media accounts?

The ACLU’s Jeon says that they should be public if they use government resources, including staff time and office equipment to maintain the page. “Where that’s the situation and taxpayer resources are going to it, then the full power of the First Amendment applies,” she said. “It doesn’t matter if they’re members of Congress or the governor or a local councilperson.”

Volokh of UCLA disagreed. He said that members of Congress are entitled to their own private speech, even on official pages. That’s because each is one voice among many, as opposed to a governor or mayor. “It’s clear that whatever my senator is, she’s not the government. She is one person who is part of a legislative body,” he said. “She was elected because she has her own views and it makes sense that if she has a Twitter feed or a Facebook page, that may well be seen as not government speech but the voice of somebody who may be a government official.”

Volokh said he’s inclined to see Trump’s @realdonaldtrump account as a personal one, though other legal experts disagree.

“You could imagine actually some other president running this kind of account in a way that’s very public minded — ‘I’m just going to express the views of the executive branch,'” he said. “The @realdonaldtrump account is very much, ‘I’m Donald Trump. I’m going to be expressing my views, and if you don’t like it, too bad for you.’ That sounds like private speech, even done by a government official on government property.”

It’s possible the fight over the president’s Twitter account will end up in court, as such disputes have across the country. Generally, in these situations, the people contesting the government’s social media policies have reached settlements ending the questionable practices.

After being sued by the ACLU, three cities in Indiana agreed last year to change their policies by no longer blocking users or deleting comments.

In 2014, a federal judge ordered the City and County of Honolulu to pay $31,000 in attorney’s fees to people who sued, contending that the Honolulu Police Department violated their constitutional rights by deleting their critical Facebook posts.

And San Diego County agreed to pay the attorney’s fees of a gun parts dealer who sued after its Sheriff’s Department deleted two Facebook posts that were critical of the sheriff and banned the dealer from commenting. The department took down its Facebook page after being sued and paid the dealer $20 as part of the settlement.

Angela Greben, a California paralegal, has spent the past two years gathering information about agencies and politicians that have blocked people on social media — Democrats and Republican alike — filing ethics complaints and even a lawsuit against the city of San Mateo, California, its mayor and police department. (They settled with her, giving her some of what she wanted.)

Greben has filed numerous public-records requests to agencies as varied as the Transportation Security Administration, the Seattle Police Department and the Connecticut Lottery seeking lists of people they block. She’s posted the results online.

“It shouldn’t be up to the elected official to decide who can tweet them and who can’t,” she said. “Everybody deserves to be treated equally and fairly under the law.”

Even though she lives in California, Greben recently filed an ethics complaint against Atlanta Mayor Kasim Reed, a Democrat, who has been criticized for blocking not only constituents but also journalists who cover him. Reed has blocked Greben since 2015 when she tweeted about him … well, blocking people on Twitter. “He’s notorious for blocking and muting people,” she said, meaning he can’t see their tweets but they can still see his.

In a statement, a city spokeswoman defended the mayor, saying he’s now among the top five most-followed mayors in the country. “Mayor Reed uses social media as a personal platform to engage directly with constituents and some journalists. … Like all Twitter users, Mayor Reed has the right to stop engaging in conversations when he determines they are unproductive, intentionally inflammatory, dishonest and/or misleading.”

Asked how many people he has blocked, she replied that the office doesn’t keep such a list.

J’aime Morgaine, the Arizona veteran who delivered blocks to the office of Rep. Paul Gosar, a Republican, said being blocked on Facebook matters because her representative no longer hosts in-person town hall meetings and has started to answer questions on Facebook Live. Now she can’t ask questions or leave comments.

“I have lost and other people who have been blocked have lost our right to participate in the democratic process,” said Morgaine, leader of Indivisible Kingman, a group that opposes the president’s agenda. “I am outraged that my congressman is blocking my voice and trampling upon my constitutional rights.”

Morgaine said the rules are not being applied equally. “They’re not blocking everybody who’s angry,” she said. “They’re blocking the voices of dissent, and there’s no process for getting unblocked. There’s no appeals process. There’s no accountability.”

A spokeswoman for Gosar defended his decision to block constituents but did not answer a question about how many have been blocked.

“Congressman Gosar’s policy has been consistent since taking office in January 2010,” spokeswoman Kelly Roberson said in an email. “In short: ‘Users whose comments or posts consist of profanity, hate speech, personal attacks, homophobia or Islamophobia may be banned.'”

On his Facebook page, Gosar posts the policy that guides his actions. It says in part, “Users are banned to promote healthy, civil dialogue on this page but are welcome to contact Congressman Gosar using other methods,” including phone calls, emails and letters.

Sometimes, users are blocked repeatedly.

Community volunteer Gayle Lacy was named 2015 Wacoan of the Year for her effort to have the site of mammoth fossils in Waco, Texas, designated a national monument. Lacy’s latest fight has been with her congressman, Bill Flores, who was with her in the Oval Office when Obama designated the site a national monument in 2015. She has been blocked three times by Flores’ congressional Twitter account and once by his campaign account. One of those blocks happened after she tweeted at him: “My father died in service for this country, but you are not representative of that country and neither is your dear leader.”

Lacy said she was able to get unblocked each time from Flores’ congressional account by calling his office but remains blocked on the campaign one. “I don’t know where to call,” she said. “I asked in his D.C. office who I needed to call and I was told that they don’t have that information.”

Lacy and others said Flores blocks those who question him. Austin lawyer Matt Miller said he was blocked for asking when Flores would hold a town hall meeting. “It’s totally inappropriate to block somebody, especially for asking a legitimate question of my elected representative,” Miller said.

In a statement, Flores spokesman Andre Castro said Flores makes his policies clear on Twitter and on Facebook. “We reserve the right to block users whose comments include profanity, name-calling, threats, personal attacks, constant harping, inappropriate or false accusations, or other inappropriate comments or material. As the Congressman likes to say — ‘If you would not say it to your grandmother, we will not allow it here.'”

Ricardo Guerrero, an Austin marketer who is one of the leaders of a local group opposed to Trump’s agenda, said he has gotten unblocked by Flores twice but then was blocked again and “just kind of gave up.”

“He’s creating an echo chamber of only the people that agree with him,” Guerrero said of Flores. “He’s purposefully removing any semblance of debate or alternative ideas or ideas that challenge his own — and that seems completely undemocratic. That’s the bigger issue in my mind.”

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Three Strategies To Defend GOP Health Bill: Euphemisms, False Statements And Deleted Comments

Three Strategies To Defend GOP Health Bill: Euphemisms, False Statements And Deleted Comments

Reprinted with permission from ProPublica.
by Charles Ornstein

Earlier this month, a day after the House of Representatives passed a bill to repeal and replace major parts of the Affordable Care Act, Ashleigh Morley visited her congressman’s Facebook page to voice her dismay.

“Your vote yesterday was unthinkably irresponsible and does not begin to account for the thousands of constituents in your district who rely upon many of the services and provisions provided for them by the ACA,” Morley wrote on the page affiliated with the campaign of Rep. Peter King, R-N.Y. “You never had my vote and this confirms why.”

The next day, Morley said, her comment was deleted and she was blocked from commenting on or reacting to King’s posts. The same thing has happened to others critical of King’s positions on health care and other matters. King has deleted negative feedback and blocked critics from his Facebook page, several of his constituents say, sharing screenshots of comments that are no longer there.

“Having my voice and opinions shut down by the person who represents me — especially when my voice and opinion wasn’t vulgar and obscene — is frustrating, it’s disheartening, and I think it points to perhaps a larger problem with our representatives and maybe their priorities,” Morley said in an interview.

King’s office did not respond to requests for comment.

As Republican members of Congress seek to roll back the Affordable Care Act, commonly called Obamacare, and replace it with the American Health Care Act, they have adopted various strategies to influence and cope with public opinion, which polls show mostly opposes their plan. ProPublica, with our partners at Kaiser Health News, Stat and Vox, has been fact-checking members of Congress in this debate and we’ve found misstatements on both sides, though more by Republicans than Democrats. The Washington Post’s Fact Checker has similarly found misstatements by both sides.

Today, we’re back with more examples of how legislators are interacting with constituents about repealing Obamacare, whether online or in traditional correspondence. Their more controversial tactics seem to fall into three main categories: providing incorrect information, using euphemisms for the impact of their actions, and deleting comments critical of them. (Share your correspondence with members of Congress with us.)

Incorrect Information

Rep. Vicky Hartzler, R-Mo., sent a note to constituents this month explaining her vote in favor of the Republican bill. First, she outlined why she believes the ACA is not sustainable — namely, higher premiums and few choices. Then she said it was important to have a smooth transition from one system to another.

“This is why I supported the AHCA to follow through on our promise to have an immediate replacement ready to go should the ACA be repealed,” she wrote. “The AHCA keeps the ACA for the next three years then phases in a new approach to give people, states, and insurance markets plenty of time to make adjustments.”

Except that’s not true.

“There are quite a number of changes in the AHCA that take effect within the next three years,” wrote ACA expert Timothy Jost, an emeritus professor at Washington and Lee University School of Law, in an email to ProPublica.

The current law’s penalties on individuals who do not purchase insurance and on employers who do not offer it would be repealed retroactively to 2016, which could remove the incentive for some employers to offer coverage to their workers. Moreover, beginning in 2018, older people could be charged premiums up to five times more than younger people — up from three times under current law. The way in which premium tax credits would be calculated would change as well, benefiting younger people at the expense of older ones, Jost said.

“It is certainly not correct to say that everything stays the same for the next three years,” he wrote.

In an email, Hartzler spokesman Casey Harper replied, “I can see how this sentence in the letter could be misconstrued. It’s very important to the Congresswoman that we give clear, accurate information to her constituents. Thanks for pointing that out.”

Other lawmakers have similarly shared incorrect information after voting to repeal the ACA. Rep. Diane Black, R-Tenn., wrote in a May 19 email to a constituent that “in 16 of our counties, there are no plans available at all. This system is crumbling before our eyes and we cannot wait another year to act.”

Black was referring to the possibility that, in 16 Tennessee counties around Knoxville, there might not have been any insurance options in the ACA marketplace next year. However, 10 days earlier, before she sent her email, BlueCross BlueShield of Tennessee announced that it was willing to provide coverage in those counties and would work with the state Department of Commerce and Insurance “to set the right conditions that would allow our return.”

“We stand by our statement of the facts, and Congressman Black is working hard to repeal and replace Obamacare with a system that actually works for Tennessee families and individuals,” her deputy chief of staff Dean Thompson said in an email.

On the Democratic side, the Washington Post Fact Checker has called out representatives for saying the AHCA would consider rape or sexual assault as pre-existing conditions. The bill would not do that, although critics counter that any resulting mental health issues or sexually transmitted diseases could be considered existing illnesses.

Euphemisms

A number of lawmakers have posted information taken from talking points put out by the House Republican Conference that try to frame the changes in the Republican bill as kinder and gentler than most experts expect them to be.

An answer to one frequently asked question pushes back against criticism that the Republican bill would gut Medicaid, the federal-state health insurance program for the poor, and appears on the websites of Rep. Garret Graves, R-La., and others.

“Our plan responsibly unwinds Obamacare’s Medicaid expansion,” the answer says. “We freeze enrollment and allow natural turnover in the Medicaid program as beneficiaries see their life circumstances change. This strategy is both fiscally responsible and fair, ensuring we don’t pull the rug out on anyone while also ending the Obamacare expansion that unfairly prioritizes able-bodied working adults over the most vulnerable.”

That is highly misleading, experts say.

The Affordable Care Act allowed states to expand Medicaid eligibility to anyone who earned less than 138 percent of the federal poverty level, with the federal government picking up almost the entire tab. Thirty-one states and the District of Columbia opted to do so. As a result, the program now covers more than 74 million beneficiaries, nearly 17 million more than it did at the end of 2013.

The GOP health care bill would pare that back. Beginning in 2020, it would reduce the share the federal government pays for new enrollees in the Medicaid expansion to the rate it pays for other enrollees in the state, which is considerably less. Also in 2020, the legislation would cap the spending growth rate per Medicaid beneficiary. As a result, a Congressional Budget Office review released Wednesday estimates that millions of Americans would become uninsured.

Sara Rosenbaum, a professor of health law and policy at the Milken Institute School of Public Health at George Washington University, said the GOP’s characterization of its Medicaid plan is wrong on many levels. People naturally cycle on and off Medicaid, she said, often because of temporary events, not changing life circumstances — seasonal workers, for instance, may see their wages rise in summer months before falling back.

“A terrible blow to millions of poor people is recast as an easing off of benefits that really aren’t all that important, in a humane way,” she said.

Moreover, the GOP bill actually would speed up the “natural turnover” in the Medicaid program, said Diane Rowland, executive vice president of the Kaiser Family Foundation, a health care think tank. Under the ACA, states were only permitted to recheck enrollees’ eligibility for Medicaid once a year because cumbersome paperwork requirements have been shown to cause people to lose their coverage. The American Health Care Act would require these checks every six months — and even give states more money to conduct them.

Rowland also took issue with the GOP talking point that the expansion “unfairly prioritizes able-bodied working adults over the most vulnerable.” At a House Energy and Commerce Committee hearing earlier this year, GOP representatives maintained that the Medicaid expansion may be creating longer waits for home- and community-based programs for sick and disabled Medicaid patients needing long-term care, “putting care for some of the most vulnerable Americans at risk.”

Research from the Kaiser Family Foundation, however, showed that there was no relationship between waiting lists and states that expanded Medicaid. Such waiting lists pre-dated the expansion and they were worse in states that did not expand Medicaid than in states that did.

“This is a complete misrepresentation of the facts,” Rosenbaum said.

Graves’ office said the information on his site came from the House Republican Conference. Emails to the conference’s press office were not returned.

The GOP talking points also play up a new Patient and State Stability Fund included in the AHCA, which is intended to defray the costs of covering people with expensive health conditions. “All told, $130 billion dollars would be made available to states to finance innovative programs to address their unique patient populations,” the information says. “This new stability fund ensures these programs have the necessary funding to protect patients while also giving states the ability to design insurance markets that will lower costs and increase choice.”

The fund was modeled after a program in Maine, called an invisible high-risk pool, which advocates say has kept premiums in check in the state. But Sen. Susan Collins, R-Maine, says the House bill’s stability fund wasn’t allocated enough money to keep premiums stable.

“In order to do the Maine model — which I’ve heard many House people say that is what they’re aiming for — it would take $15 billion in the first year and that is not in the House bill,” Collins told Politico. “There is actually $3 billion specifically designated for high-risk pools in the first year.”

Deleting Comments

Morley, 28, a branded content editor who lives in Seaford, New York, said she moved into Rep. King’s Long Island district shortly before the 2016 election. She said she did not vote for him and, like many others across the country, said the election results galvanized her into becoming more politically active.

Earlier this year, Morley found an online conversation among King’s constituents who said their critical comments were being deleted from his Facebook page. Because she doesn’t agree with King’s stances, she said she wanted to reserve her comment for an issue she felt strongly about.

A day after the House voted to repeal the ACA, Morley posted her thoughts. “I kind of felt that that was when I wanted to use my one comment, my one strike as it would be,” she said.

By noon the next day, it had been deleted and she had been blocked.

“I even wrote in my comment that you can block me but I’m still going to call your office,” Morley said in an interview.

Some negative comments about King remain on his Facebook page. But King’s critics say his deletions fit a broader pattern. He has declined to hold an in-person town hall meeting this year, saying, “to me all they do is just turn into a screaming session,” according to CNN. He held a telephonic town hall meeting but only answered a small fraction of the questions submitted. And he met with Liuba Grechen Shirley, the founder of a local Democratic group in his district, but only after her group held a protest in front of his office that drew around 400 people.

“He’s not losing his health care,” Grechen Shirley said. “It doesn’t affect him. It’s a death sentence for many and he doesn’t even care enough to meet with his constituents.”

King’s deleted comments even caught the eye of Andy Slavitt, who until January was the acting administrator of the Centers for Medicare and Medicaid Services. Slavitt has been traveling the country pushing back against attempts to gut the ACA.

Since the election, other activists across the country who oppose the president’s agenda have posted online that they have been blocked from following their elected officials on Twitter or commenting on their Facebook pages because of critical statements they’ve made about the AHCA and other issues.

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With Drug Reps Kept At Bay, Doctors Prescribe More Judiciously

With Drug Reps Kept At Bay, Doctors Prescribe More Judiciously

Reprinted with permission from ProPublica.
by Charles Ornstein 

When teaching hospitals put pharmaceutical sales representatives on a shorter leash, their doctors tended to order fewer promoted brand-name drugs and used more generic versions instead, a study published today in the Journal of the American Medical Association shows.

The results were significant compared to doctors who did not work at hospitals that limited sales reps from freely walking their halls or providing meals or gifts, according to research by Ian Larkin, an assistant professor of strategy at the University of California, Los Angeles Anderson School of Management, and colleagues.

Conflicts of interest in medicine have been ubiquitous for many years, but a string of lawsuits, coupled with a crackdown by academic medical centers and public disclosure of industry payments, have brought renewed focus on how these relationships affect prescribing.

For the past 6 1/2 years, ProPublica has tracked payments to doctors, building a tool called Dollars for Docs to let users look up their physicians and sort information in various ways. We’ve found that some practitioners earn hundreds of thousands of dollars or more each year working with drug and device companies. We’ve reported how the drugs most aggressively promoted to doctors typically aren’t cures or even big medical breakthroughs.

And last year we found an association between payments and higher rates of brand-name prescribing, on average.

Today’s issue of JAMA is devoted to conflicts of interest in medicine and includes a viewpoint on what ProPublica has learned by publishing Dollars for Docs and a related tool called Prescriber Checkup, which compares doctors to their peers based on how they prescribe drugs in Medicare.

The teaching hospital study focused on 19 centers in five states that restricted visits by drug reps in one or more ways: limiting access, limiting gifts or punishing those who broke the rules. Larkin’s team compared prescriptions by 2,126 doctors at those hospitals with 24,593 peers with similar characteristics who were not subject to the marketing limits. It examined more than 16 million prescriptions in total, using data from CVS Caremark, a large pharmacy benefit manager.

The researchers found significant changes in six of the eight drug classes studied and at nine of the 19 hospitals reviewed. The policies were put in place at different times from 2006 to 2011, but changes in prescribing started immediately and lasted for 12 to 36 months afterward.

Having a policy governing pharmaceutical marketing, known as “detailing,” was associated with a 1.67 percentage point decrease in market share for the average promoted drug. Before the policies, the average promoted drug had a market share of 19.3 percent. Those with tougher policies, including an enforcement component, appeared to have more significant results.

“These weren’t terribly onerous restrictions, yet at the same time, they changed prescribing in a way that has really significant cost implications,” Larkin said.

Among the centers that did not have statistically significant changes was Stanford University, one of the earliest adopters of restrictive policies. In 2010, ProPublica reported how Stanford was not enforcing its rules limiting the relationships between doctors and drug companies. It has tightened its oversight since. Stanford doctors prescribed fewer promoted drugs but not enough for the result to be significant.

“We were surprised that some of them [teaching hospitals] were not as significant as we expected them to be,” said Larkin, without singling out particular hospitals. “You can’t just put in a policy. You have to think about it carefully, think about the efforts that really matter and involve the [medical] community.”

The study had several limitations. First, it did not find that the policies caused the change in prescribing, only that there was an association between the two. Also, the study was observational, meaning that doctors were not randomly assigned to hospitals with and without policies. And the study took policies at their word, not looking at their implementation or follow through.

Dr. Howard Bauchner, JAMA’s editor in chief, said the study helps to crystallize the need to limit pharmaceutical company marketing in teaching hospitals “as a way of ensuring that there’s no influence, no inappropriate influence over prescribing.”

Bauchner said he isn’t bothered that the researchers only found significant results in fewer than half of the teaching hospitals studied. “Nothing is ever 100 percent effective,” he said. “To me that’s no different than a clinical trial. Not everyone benefits.”

An editorial that accompanied the research suggests that alternative approaches to educating doctors about drugs — besides relying on drug company promotion — need to be tested. “It has never been more important for physicians to come together to consider these alternatives, generate evidence about their effectiveness, and move the health care system toward solutions that lower costs for patients and minimize” conflicts of interest, wrote Colette DeJong and Dr. R. Adams Dudley of the University of California, San Francisco.

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Secret Hospital Inspections May Become Public At Last

Secret Hospital Inspections May Become Public At Last

Reprinted with permission from ProPublica.
by Charles Ornstein 

The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation’s hospitals that put patients’ health and safety at risk, under a groundbreaking proposal from federal health officials.

The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by those accreditors, not the government.

There’s increasing concern among regulators that private accreditors aren’t picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.

In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity “raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies” during inspections, CMS officials wrote when they released draft regulations including the proposed change on Friday.

The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool, Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.

Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.

But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS’ proposed rules are designed to fix this.

“We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements” publicly available, CMS officials wrote.

“It’s huge, absolutely,” says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. “Right now the public has very little information about the places where they’re putting their life on the line, and that’s just not acceptable. If you’re a good place, what are they afraid of?”

Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.

To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn’t fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.

State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commission conducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise. Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,018 hospitals listed on the The Joint Commission’s website, more than 99 percent have full accreditation and only seven are on track to lose their “gold seal of approval.”

The Joint Commission said it is reviewing the CMS proposal and couldn’t comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. “We haven’t talked to our hospital partners,” says Gary Ley, its executive director. “It would be a major change for them also. It’s hard not to support the goals but we have to look at the execution.”

For its part, the American Hospital Association said it supports providing the public “useful information” about hospital quality, but has doubts that detailed inspection reports fit that description.

“It’s important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,” says Nancy Foster, AHA’s vice president of quality and patient safety, in a statement. “We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.”

Foster says it might be more useful to provide a one- or two-page “accurate summary” of inspection findings, with “key takeaways” and why they are important. “This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,” Foster says.

For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, the Chicago Tribune reported how The Joint Commission gave its seal of approval to “medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.”

Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a “Top Performer in Key Quality Measures” by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it “is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.”

In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it “is proud of the care it provides patients at Shadow Mountain Behavioral Health.”

On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, even when hospitals are described as receiving a “preliminary denial of accreditation.” For one hospital, the explanation is: “Existence at time of survey of a condition, which in The Joint Commission’s view, poses a threat to patients or other individuals served.” The threat itself is not disclosed.

Consumers Union’s Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. “The information that’s available now is so minimal and would not really inform anyone about real quality of a hospital,” she says.

Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.

Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so.

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