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Addiction Medicine Mostly Prescribed To Whites, Even As Opioid Deaths Rose Among Blacks

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Buprenorphine, better known as Suboxone, is used to treat substance use disorders. Extensive research has shown opioid-addicted people who are properly prescribed buprenorphine or methadone are much less likely to relapse and overdose than people who try to recover without medication. Photo: Craig F. Walker/The Boston Globe via Getty Images

White drug users addicted to heroin, fentanyl and other opioids have had near-exclusive access to buprenorphine, a drug that curbs the craving for opioids and reduces the chance of a fatal overdose. That’s according to a study out Wednesday from the University of Michigan. It appears in JAMA Psychiatry.

Researchers reviewed two national surveys of physician-reported prescriptions. From 2012 to 2015, as overdose deaths surged in many states so did the number of visits during which a doctor or nurse practitioner prescribed buprenorphine, often referred to by the brand name Suboxone. The researchers assessed 13.4 million medical encounters involving the drug but found no increase in prescriptions written for African Americans.

“White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,” said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and the study’s lead author.

The dominant use of buprenorphine to treat whites occurred while opioid overdose deaths were rising faster for blacks than for whites.

“This epidemic over the last few years has been framed by many as largely a white epidemic, but we know now that’s not true,” Lagisetty said.

What is true, Lagisetty added, is that most of the white patients either paid cash (40 percent) or relied on private insurance (35 percent) to fund their buprenorphine treatment. The fact that just 25 percent of the visits were paid for through Medicaid and Medicare “does highlight that many of these visits could be very costly for persons of low income,” Lagisetty said.

Doctors and nurse practitioners can demand cash payments because there’s a shortage of clinicians who can prescribe buprenorphine, according to Dr. Andrew Kolodny, co-director of Opioid Policy Research at Brandeis University’s Heller School for Social Policy and Management. Only about 5 percent of physicians have taken the special training required to prescribe buprenorphine.

“The few that are doing it are really able to name their price, and that’s what we’re seeing here and that’s the reason why individuals with more resources — who are more likely to be white — are more likely to access treatment with buprenorphine,” said Kolodny, who was not involved in the study.

Kolodny wants the federal government to eliminate the required special training for buprenorphine and a related cap on the number of patients a doctor can manage on the drug.

Some physicians who’ve studied racial disparities in addiction treatment say the root causes date to 2000, when buprenorphine was approved. At that time, proponents argued that buprenorphine was needed to help treat suburban youth, according to Dr. Helena Hansen at New York University. Those young patients didn’t see themselves as addicted to heroin in the same way as hard-core urban heroin users who went to methadone clinics for treatment.

“Buprenorphine was introduced as private-office treatment, for a private market with the means to pay,” said Hansen, an associate professor of psychiatry and anthropology. “So the unequal dissemination of buprenorphine for opioid dependence is not accidental.”

Hansen added that the fix must include universal access to treatment in a primary care setting, an end to the criminalization of opioid dependence (which puts more blacks in prison for drug use than whites) and more federal funding to expand access to buprenorphine for all patients.

Several leaders in the fight to reduce opioid overdose deaths say the study results are disturbing.

“It really demands for us to be looking at equitable treatment for addiction for African Americans as we do for white Americans,” said Michael Botticelli, director of the Grayken Center for Addiction at Boston Medical Center and the former director of the Office of National Drug Control Policy.

Botticelli identified key issues that may contribute to the racial treatment gap and deserve further investigation. For example, he wants to know if Medicaid reimbursement rates are simply too low to entice more doctors to work with low-income patients, or if there are too few inner-city doctors prescribing buprenorphine or if African Americans themselves are somehow reluctant to seek this form of treatment.

Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, called the findings surprising and disturbing. Surprising because the disparity is so large, and disturbing because her agency has prioritized educating doctors about the value of prescribing buprenorphine.

Volkow also expressed disappointment that federal parity laws, which are supposed to guarantee equal access to all types of medications, don’t seem to be working for buprenorphine.

“We need to ensure that we have capacity to provide these treatments,” Volkow said, “because if you say you have to pay for them, but there are no services that can provide the treatments, then the issue of paying for them is secondary.”

Volkow has noted that fewer than half of Americans with an opioid use disorder have access to buprenorphine or two other medications used to treat opioid addiction: methadone and naltrexone. Volkow said she’s glad that the use of buprenorphine is on the rise, but the U.S. needs to understand why this lifesaving treatment isn’t benefiting all patients who need it.

This story is part of a partnership that includes WBURNPR and Kaiser Health News.

This article was originally published by Kaiser Health News.

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W.Va. Bucks Rising U.S. Maternal Mortality Trend

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Lauren Headley and her daughter Reese. Photo courtesy of Lauren Headley

The United States has some of the highest maternal mortality rates in the developed world — and unlike most other first-world countries, our rates are going in the wrong direction.

American women are three times more likely to die during or after birth than women in Great Britain and eight times more likely than women in Scandinavian countries.

But despite the prevalence of major risk factors such as low access to prenatal care, a high poverty rate and a largely rural population, West Virginia, is bucking the maternal mortality trend. Maternal deaths are not only low, they’re also stable.

Part of that may be due to statewide initiatives to improve outcomes.

Lauren Headley

When Lauren Headley was 35, she got pregnant. Her age categorizes her as high-risk, but she is a nonsmoker and was a Zumba teacher at a healthy weight at the time she conceived.

Headley in the hospital shortly before the birth of her daughter. Photo courtesy of Lauren Headley

About six months into her pregnancy, though, Headley was diagnosed with gestational diabetes. Her obstetrician was concerned that, as a result, her baby would be born large and wouldn’t fit through her birth canal. So at around 39 weeks, doctors induced labor. The baby girl was born healthy and neither mother or infant had any complications.

Then on the 10th day after she gave birth, Headley woke up bleeding.

“But this was like gushing and red clots of Jell-O,” she said.

She called her doctor’s office and her doctor told her that some bleeding was normal but, if it continued, to go to the emergency department or to call back. So she got into the shower to see if that would calm things down.

“As I’m in the shower, the blood just pours out,” she said. “I mean cups of red Jell-O is what it looks like and it’s just pouring out. And I get really weak and I sit down in the shower and yell for my husband, and he comes in and he looks in there and he’s like ‘Oh dear God, you need to call your doctor back. There’s no way this is normal.’”

Headley was taken by ambulance to the emergency department at Thomas Health, where she was diagnosed with a severe postpartum hemorrhage — which is one of the leading complications that causes maternal mortality in the United States.

Postpartum hemorrhage 10 days after birth is admittedly pretty rare, but how well a hospital is prepared to deal with obstetric emergencies can mean the difference between life and death for someone like Headley.

Which may be part of why West Virginia’s rates are so low.

West Virginia’s rates are low — but why?

West Virginia actually ranks 5th in the country — tied with Hawaii — for least number of maternal mortality deaths in the nation — behind California, Massachusetts, Colorado and Nevada, according to data from the Centers for Disease Control and Prevention.

Headley with her daughter shortly after giving birth. Headley badly hemorrhaged 10 days later, but the bleeding was stopped at the hospital. Postpartum hemorrhage is one of the leading causes of maternal death in the U.S. Photo courtesy of Lauren Headley

Maternal deaths in West Virginia related to pregnancy and childbirth have bounced between one to four deaths a year during the past 11 years. Even though West Virginia is a small state and has few births annually, this is a pretty low rate and surprising because West Virginia is poor, rural and has higher rates of comorbidities, which are all risk factors.

But when you try to dig into the numbers, “it’s hard to know exactly why our rates are lower,” said Amy Tolliver, director of the West Virginia Perinatal Partnership. She said over the last 10 years, they’ve been working closely with all of the hospitals in the state that deliver babies to improve the care they offer to moms.

“We have been implementing different training programs specifically around maternal hemorrhage — that is one of the bigger drivers that we see in regard to maternal morbidity and nationally in terms of maternal mortality,” Tolliver said.

Tolliver said every hospital in the state that delivers babies has a specific set of protocols they are supposed to adhere to in the event of complications like uncontrolled postpartum bleeding.  

“To have the crash carts available with all of the equipment necessary, to have trainings in place, and to continue doing those staff trainings — we think that’s one of the biggest factors in improving care is practicing for the high-risk patient.”

“I think we also do a good job in this state of accepting the fact that we have a lot of the risk factors that increase the risk for maternal mortality,” said Dr. Ally Roy, an obstetrician at Marshall Health.

Roy delivers babies at Cabell Huntington Hospital. When a patient is admitted there, she says there is a checklist the staff goes through with the patient. If they meet the criteria for moderate or high risk for postpartum hemorrhage, they receive intervention at delivery time aimed at reducing their risk. Anecdotally, she said, the protocols have greatly improved outcomes for patients with postpartum hemorrhage.

“When you have an emergency, you want people to be able to react smoothly and seamlessly,” said Tolliver. “There should be no downtime in trying to figure out what they need to do next. It needs to be very quick, very regimented, getting the process in place.”

In an email exchange with Thomas Health, the hospital Headley was taken to, a representative said that Thomas has protocols in place for how to deal with hemorrhages that were developed in conjunction with the statewide initiatives.

But experts working in this field in West Virginia say there’s still work to be done.

In 2008, West Virginia established a maternal mortality review committee made up of experts from across the state that basically looks at all of the data around deaths linked to pregnancy and childbirth and sees what happened. They then make recommendations based on the findings. About half of U.S. states currently have such committees.

“One of the first things that we did find was that some of our women who were postpartum may have presented in an emergency room with a severe headache and other symptoms, but they weren’t caught quickly enough in regard to understanding that that was preeclampsia, for example, that they may have been experiencing,” said Tolliver. “So there were some efforts put together to do some education with our emergency room staffing.”

Preeclampsia is a pregnancy complication that is usually characterized by high blood pressure and, if untreated, can cause organ damage and even death.

Last year, the committee recommended a renewal of those education efforts, so the Perinatal Partnership is getting ready to go out around the state to do more trainings.

Tolliver said the objective is to have caregivers “be prepared to be looking at the patient just a little bit differently [and] to ask the question, ‘Has she given birth recently?’ Those answers to those questions may drive the care in a different direction and get to the bottom of what is going on with her much more quickly,” she said.

So is there anything women could do to protect themselves against dying in childbirth? First, say experts, understand that women can experience life-threatening complications during childbirth, thus they recommend that women listen to their bodies, advocate for themselves, and talk about risk with their care team.

This article was originally published by West Virginia Public Broadcasting.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from Marshall Health and Charleston Area Medical Center.

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Rural Hospital CEOs Call for Medicaid Expansion in N.C.

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In this Wednesday, Dec. 19, 2018 file photo, North Carolina Gov. Roy Cooper speaks to the Associated Press during an interview at the Governor's mansion in Raleigh, N.C. In a roundtable discussion with rural hospital executives, Cooper increased pressure on Republican state senators to support legislation that would expand Medicaid coverage to uninsured adults who don't meet current requirements. A similar bill was proposed in 2017, but failed after GOP opposition. Photo: AP Photo/Gerry Broome, File

A group detailed to Gov. Roy Cooper the problems they have keeping their doors open and bills paid.

At a roundtable meeting April 24, CEOs of rural North Carolina hospitals explained to Gov. Roy Cooper and state Health and Human Services Sec. Mandy Cohen that expanding Medicaid would help their institutions keep the doors open.

There were some common elements to all their stories. For starters, all of their hospitals are operating on thin margins.

The group nodded in agreement as each talked about excessive use of their emergency departments and the uncompensated care resulting from ED patients who were uninsured or unable to pay.

Adding to their problems, many said they have a difficult time recruiting medical professionals, and that their counties are turning into “doctor deserts.”

The consensus was that Medicaid expansion wouldn’t solve all their problems overnight, but they agreed it would go a long way to relieving pressure on their emergency departments and create a healthier patient population.

“We can talk about the present, but we really need to talk about where we are going to be in three to five years,” Chris Lumsden, CEO of Northern Hospital of Surry County, told the group. “This issue is monumental to us. [Medicaid expansion] is something we can do today that will impact patient care and economic development down the road.”

In North Carolina, there have been six rural hospital closures since 2010. Across the U.S., there have been 104 closures during that same time, according to data compiled by the UNC Sheps Center for Health Services Research.

Cohen said that 80 percent of the hospital closures nationwide occurred in states that didn’t expand Medicaid.

Big employers

The CEOs’ pleas have some backing from the research. Greg Tung, a health economist from the University of Colorado, found in his research that Medicaid expansion has had a positive impact on hospitals’ financial situations and that they were less likely to close their doors.

Rural hospitals are most at risk for closure in states that did not expand, he said.

“Rural hospitals tend to be in a more financially precarious situation compared to urban hospitals,” Tung told NC Health News.

He said this has a trickle-down effect to the rural economy surrounding each institution.

“Rural hospitals are anchor institutions in their communities. They are kind of a pillar of the local community and the local economy, they provide a lot of skilled, well-paying jobs for that area,” he said. “So when a rural hospital closes, it has a disproportionately large impact on that community, especially in comparison to an urban hospital closure.”

Lumsden said the financial stability of his hospital is vital to the health of the surrounding economy.

Northern Hospital employs 900 people, not including physicians, and it’s one of the largest employers in the area.

“The issue of Medicaid expansion needs to be dealt with quickly,” Lumsden said.

Uncompensated care

Lumsden also brought up the large amount of uncompensated mental health care his emergency department provides. Currently, Northern Hospital averages 50 to 60 involuntary commitments a month.

“They are sequestered in the ER department for sometimes days,” he said. “They are complex, difficult patients. Very tough on staff. And we don’t get paid. We provide at least a million dollars of free care to [involuntary commitment] patients and that just adds to the dynamics.”

Michael Nagowski, CEO of Cape Fear Valley Health System, said he has one of the busiest emergency departments in the state with 140,000 visits a year to one ED. More than 20 percent of Cape Fear’s ED visits are uncompensated.

“We see the things that should be handled in the urgent care or primary care, but they won’t accept those patients,” he said. “If you don’t have a payer source, some people just don’t go until it’s a real emergency. Now we have a cost of care issue at another level.”

“And think about the human impact,” he said. “Let’s catch you before you’re diabetic. Let’s catch you before you have heart disease.”

Cohen echoed Nagowski’s remarks, pointing out that conditions such as high blood pressure are manageable with the right medications.

“What happens when you don’t take your blood pressure medicine is you end up in the emergency room with a stroke,” Cohen said. “And caring for a stroke is not only enormously expensive, but that person is not going back to work, certainly not right away.”

“Now we’ve not only lost a worker for one of our businesses, but someone who is the breadwinner for their family, and now they are in medical bankruptcy,” she said. “And you have uncompensated care.”

Cohen said she often finds herself explaining to people with health insurance how Medicaid expansion will benefit them.

“It’s actually keeping the hospital doors open for them,” Cohen said. “But also keeping prices down for everyone who is lucky enough to get insurance through their employers.”

‘All of it is negotiable’

Nash UNC Health Care CEO Lee Isley said he’s in favor of Medicaid expansion because “it’s the right thing for the community,” but he had a concern.

According to his calculations, closing the coverage gap would bring Nash UNC about $10 million, but under some Medicaid expansion proposals, the state’s hospitals would take on 10 percent the cost in the form of an assessment. For Nash, that would come to about $7.5 million. He added that moving to Medicaid managed care will likely cost his institution about $1.7 million, bringing his hospital right back to breaking even.

Isley told the governor that hospitals should take on part of that assessment, but he asked if it would be possible to share the cost with other health care entities.

Cooper said he was looking into putting some of that cost on insurance companies.

But does Medicaid expansion have a chance in North Carolina?

Cooper said there are enough votes to pass a GOP-backed version of expansion in the state House right now if the Republican leadership would bring it to the floor for a vote.

He expressed less confidence about prospects in the state Senate.

“Obviously the leadership of the Senate has some concerns about this, but we hope that all of it is negotiable,” he said. “It’s so important for us to take this step here in North Carolina.”

Some have expressed fear that the federal money to expand Medicaid might disappear, but Cooper said he doesn’t think it will. People in Washington D.C. have been trying to do away with these policies for the past two years and have not succeeded, he said.

“They couldn’t kill it,” he said. “One, because people need health care. Two, because Republican and Democrat governors in states that have expanded came to Washington and said, ‘This is working. Don’t take this away.’

“Plus you can write safeguards into the legislation that can stop coverage if the federal money dries up,” Cooper said. “But I don’t see this happening. If it didn’t happen in the last two years, it’s certainly not going to happen any time soon in a divided Congress.”

This article was originally published at North Carolina Health News.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.

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Millions of Dollars in W.Va. Drug Treatment at Stake in ACA Repeal Fight

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This Tuesday, Aug. 15, 2017 photo shows an arrangement of pills of the opioid oxycodone-acetaminophen in New York. AP Photo.

This article was originally published by the Charleston Gazette-Mail.

Low-income West Virginians received $90 million worth of mental health and substance abuse treatment last year, and nearly $300 million over the last four years, under a law the Trump administration is trying to repeal, according to West Virginia health officials.

Under the Affordable Care Act, commonly known as Obamacare, West Virginia expanded its Medicaid program to those who make up to 138 percent of the federal poverty line.

According to the West Virginia Department of Health and Human Resources, the state’s expanded Medicaid program spentabout $58 million on mental health and substance abuse in fiscal year 2015, $61 million in 2016, $79 million in 2017 and $90 million in 2018.

President Donald Trump’s administration said Tuesday it supports striking down the entire Affordable Care Act. Trump’s Department of Justice wrote that it agrees with a Texas judge’s December ruling that the law is unconstitutional.

The Trump administration had previously argued that only parts of the law — protections for those with pre-existing conditions and limits on premiums for older, sicker people — should be struck down. Trump urged congressional Republicans last week to come up with a law to replace the ACA if it is repealed, although Congress could not do that in 2017-18, when both the Senate and House were controlled by Republicans.

West Virginia is among the states that would be hardest hit by the loss of the health care law, said Simon Haeder, an assistant professor of political science in the John D. Rockefeller IV School of Policy & Politics at West Virginia University.

Loss of access to drug treatment is one of a “slew” of reasons why, Haeder said.

The law requires that health insurance companies pay for substance abuse treatment. Between expanded Medicaid and those who bought plans this year on the state’s health insurance marketplace — which also was created under the ACA — the law provides health care coverage for about 180,000 West Virginians.

“When you gain coverage, you gain access to treatment services,” Haeder said.

West Virginians die from drug overdoses more frequently than residents of any other state.

Haeder said the number of West Virginians who have gotten drug treatment after gaining health care coverage through the ACA “has to be in the tens of thousands of individuals.”

At PROACT, an outpatient drug treatment facility that opened in October in Huntington, between 71 and 75 percent of patients are Medicaid recipients, said Mike Haney, the facility’s director. He doesn’t know how many of PROACT’s Medicaid patients have coverage because of the Medicaid expansion.

But Haney said it would be difficult for PROACT to keep its doors open if expanded Medicaid patients were to lose coverage and stop treatment.

“We would probably have to step back and look at the kind of services we offer,” Haney said. “Because there’s some services, such as the spiritual care, that’s not billable but it’s needed and we can offset it with the money from the traditional-type services.

“But if it came down to our funding, we would have to look at realistically some of the programs that we offer and how can we make them sustainable on their own,” Haney said.

Haney said the ACA has also made it easier for people to get drug treatment by requiring that health insurance companies cover it.

If the ACA goes away, so does that requirement, Haney said. But he wonders if insurance companies might choose to continue coverage anyway, because it’s cheaper for an insurance company to pay for drug treatment than the health complications that come with addiction.

For instance, it would be cheaper to pay for three years of drug treatment than for a heart valve replacement for a drug user who got a heart infection related to intravenous drug use, he said.

Debrin Jenkins, executive director of the West Virginia Rural Health Association, said striking down the law would cause some of West Virginia’s small rural hospitals to shut their doors.

“The rural hospitals who are working on very small margins, some of them negative budgetary constraints will probably go under,” Jenkins said.

Rural hospitals have been closing in states like Kansas, Oklahoma and Alabama, Haeder said.

“One thing that’s keeping [rural hospitals] open in West Virginia is Medicaid expansion,” he said. “Those 200,000 individuals who gained coverage, they have a payer for the hospital services.

“Once a rural hospital closes that’s just not just poor people [who are affected], that’s the entire community that’s losing access to important services. So that’s a problem.”

Jenkins said striking down the ACA would make West Virginia’s rural health care shortage even worse.

“We have a shortage of physicians and nurse practitioners and [physician assistants] now in rural areas,” Jenkins said. “I believe that that will negatively affect their practice and they may move, because again they’re working on very small margins. They can only do so much uncompensated care.”

As of March 25, about 159,000 West Virginians were enrolled in expanded Medicaid, according to the state Department of Health and Human Resources.

The ACA allowed states to expand their Medicaid programs to offer health coverage to people who make up to 138 percent of the federal poverty line.

About 22,600 West Virginians signed up for a plan this year under the state’s health insurance marketplace, another provision of the ACA.

Jenkins said because hospitals are often the largest employers in their counties, their closures would have a negative effect on local economies as a whole.

“If that hospital closes, that county dies, that tax base just plummets,” Jenkins said. “All those subsequent businesses that make their money off of hospital employees — which could be anything from restaurants to dry cleaners to grocery stores to whole medical delivery — all of that just goes down the tube.”

Jenkins said the loss of expanded Medicaid could hurt also the state’s economy.

“For West Virginia to grow economically, sustainably you have to have good medical infrastructure and you have to have a healthy workforce or companies don’t come and set up businesses,” Jenkins said. “If you close the hospitals, you’re not going to have that infrastructure and you’re not going to have that healthy workforce, so we’re shooting ourselves in the foot that way.”

Repealing the law would also put those with pre-existing conditions, like diabetes and cancer, at risk of losing their health care coverage. The ACA requires that insurance companies cover those with pre-existing conditions.

“The state has some of the highest rates of disabilities and illnesses and cancers and childhood obesity,” Haeder said. “And you take the pre-existing conditions protections out of the ACA, those people will not be able to access services because they will be priced out of the market.”

The law also makes it easier for black lung patients and their families to get benefits and requires health insurance plans to cover preventive care like vaccines and well child visits, Haeder pointed out.

“A lot of people think the ACA is something for poor people to gain coverage, but it’s really everyone,” Haeder said.

The Associated Press contributed to this report.

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