Kaiser Health News
Tribal Nations Invest Opioid Settlement Funds in Traditional Healing to Treat Addiction
Aneri Pattani and Jazmin Orozco Rodriguez
Wed, 15 May 2024 09:00:00 +0000
PRESQUE ISLE, Maine — Outside the Mi’kmaq Nation’s health department sits a dome-shaped tent, built by hand from saplings and covered in black canvas. It’s one of several sweat lodges on the tribe’s land, but this one is dedicated to helping people recover from addiction.
Up to 10 people enter the lodge at once. Fire-heated stones — called grandmothers and grandfathers, for the spirits they represent — are brought inside. Water is splashed on the stones, and the lodge fills with steam. It feels like a sauna, but hotter. The air is thicker, and it’s dark. People pray and sing songs. When they leave the lodge, it is said, they reemerge from the mother’s womb. Cleansed. Reborn.
The experience can be “a vital tool” in healing, said Katie Espling, health director for the roughly 2,000-member tribe.
She said patients in recovery have requested sweat lodges for years as a cultural element to complement the counseling and medications the tribe’s health department already provides. But insurance doesn’t cover sweat ceremonies, so, until now, the department couldn’t afford to provide them.
In the past year, the Mi’kmaq Nation received more than $150,000 from settlements with companies that made or sold prescription painkillers and were accused of exacerbating the overdose crisis. A third of that money was spent on the sweat lodge.
Health care companies are paying out more than $1.5 billion to hundreds of tribes over 15 years. This windfall is similar to settlements that many of the same companies are paying to state governments, which total about $50 billion.
To some people, the lower payout for tribes corresponds to their smaller population. But some tribal citizens point out that the overdose crisis has had a disproportionate effect on their communities. Native Americans had the highest overdose death rates of any racial group each year from 2020 to 2022. And federal officials say those statistics were likely undercounted by about 34% because Native Americans’ race is often misclassified on death certificates.
Still, many tribal leaders are grateful for the settlements and the unique way the money can be spent: Unlike the state payments, money sent to tribes can be used for traditional and cultural healing practices — anything from sweat lodges and smudging ceremonies to basketmaking and programs that teach tribal languages.
“To have these dollars to do that, it’s really been a gift,” said Espling of the Mi’kmaq tribe. “This is going to absolutely be fundamental to our patients’ well-being” because connecting with their culture is “where they’ll really find the deepest healing.”
Public health experts say the underlying cause of addiction in many tribal communities is intergenerational trauma, resulting from centuries of brutal treatment, including broken treaties, land theft, and a government-funded boarding school system that sought to erase the tribes’ languages and cultures. Along with a long-running lack of investment in the Indian Health Service, these factors have led to lower life expectancy and higher rates of addiction, suicide, and chronic diseases.
Using settlement money to connect tribal citizens with their traditions and reinvigorate pride in their culture can be a powerful healing tool, said Andrea Medley, a researcher with the Johns Hopkins Center for Indigenous Health and a member of the Haida Nation. She helped create principles for how tribes can consider spending settlement money.
Medley said that having respect for those traditional elements outlined explicitly in the settlements is “really groundbreaking.”
‘A Drop in the Bucket’
Of the 574 federally recognized tribes, more than 300 have received payments so far, totaling more than $371 million, according to Kevin Washburn, one of three court-appointed directors overseeing the tribal settlements.
Although that sounds like a large sum, it pales in comparison with what the addiction crisis has cost tribes. There are also hundreds of tribes that are excluded from the payments because they aren’t federally recognized.
“These abatement funds are like a drop in the bucket compared to what they’ve spent, compared to what they anticipate spending,” said Corey Hinton, a lawyer who represented several tribes in the opioid litigation and a citizen of the Passamaquoddy Tribe. “Abatement is a cheap term when we’re talking about a crisis that is still engulfing and devastating communities.”
Even leaders of the Navajo Nation — the largest federally recognized tribe in the United States, which has received $63 million so far — said the settlements can’t match the magnitude of the crisis.
“It’ll do a little dent, but it will only go so far,” said Kim Russell, executive director of the Navajo Department of Health.
The Navajo Nation is trying to stretch the money by using it to improve its overall health system. Officials plan to use the payouts to hire more coding and billing employees for tribe-operated hospitals and clinics. Those workers would help ensure reimbursements keep flowing to the health systems and would help sustain and expand services, including addiction treatment and prevention, Russell said.
Navajo leaders also want to hire more clinicians specializing in substance use treatment, as well as primary care doctors, nurses, and epidemiologists.
“Building buildings is not what we want” from the opioid settlement funds, Russell said. “We’re nation-building.”
High Stakes for Small Tribes
Smaller nations like the Poarch Band of Creek Indians in southern Alabama are also strategizing to make settlement money go further.
For the tribe of roughly 2,900 members, that has meant investing $500,000 — most of what it has received so far — into a statistical modeling platform that its creators say will simulate the opioid crisis, predict which programs will save the most lives, and help local officials decide the most effective use of future settlement cash.
Some recovery advocates have questioned the model’s value, but the tribe’s vice chairman, Robert McGhee, said it would provide the data and evidence needed to choose among efforts competing for resources, such as recovery housing or peer support specialists. The tribe wants to do both, but realistically, it will have to prioritize.
“If we can have this model and we put the necessary funds to it and have the support, it’ll work for us,” McGhee said. “I just feel it in my gut.”
The stakes are high. In smaller communities, each death affects the whole tribe, McGhee said. The loss of one leader marks decades of lost knowledge. The passing of a speaker means further erosion of the Native language.
For Keesha Frye, who oversees the Poarch Band of Creek Indians’ tribal court and the sober living facility, using settlement money effectively is personal. “It means a lot to me to get this community well because this is where I live and this is where my family lives,” she said.
Erik Lamoreau in Maine also brings personal ties to this work. More than a decade ago, he sold drugs on Mi’kmaq lands to support his own addiction.
“I did harm in this community and it was really important for me to come back and try to right some of those wrongs,” Lamoreau said.
Today, he works for the tribe as a peer recovery coordinator, a new role created with the opioid settlement funds. He uses his experience to connect with others and help them with recovery — whether that means giving someone a ride to court, working on their résumé, exercising together at the gym, or hosting a cribbage club, where people play the card game and socialize without alcohol or drugs.
Beginning this month, Lamoreau’s work will also involve connecting clients who seek cultural elements of recovery to the new sweat lodge service — an effort he finds promising.
“The more in tune you are with your culture — no matter what culture that is — it connects you to something bigger,” Lamoreau said. “And that’s really what we look at when we’re in recovery, when we talk about spiritual connection. It’s something bigger than you.”
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By: Aneri Pattani and Jazmin Orozco Rodriguez
Title: Tribal Nations Invest Opioid Settlement Funds in Traditional Healing to Treat Addiction
Sourced From: kffhealthnews.org/news/article/tribal-nations-opioid-settlement-funds-cultural-traditional-healing/
Published Date: Wed, 15 May 2024 09:00:00 +0000
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https://www.biloxinewsevents.com/after-a-childs-death-california-weighs-rules-for-phys-ed-during-extreme-weather/
Kaiser Health News
Harris’ California Health Care Battles Signal Fights Ahead for Hospitals if She Wins
Bernard J. Wolfson and Phil Galewitz, KFF Health News
Mon, 05 Aug 2024 09:00:00 +0000
When Kamala Harris was California’s top prosecutor, she was concerned that mergers among hospitals, physician groups, and health insurers could thwart competition and lead to higher prices for patients. If she wins the presidency in November, she’ll have a wide range of options to blunt monopolistic behavior nationwide.
The Democratic vice president could influence the Federal Trade Commission and instruct the departments of Justice and Health and Human Services to prioritize enforcement of antitrust laws and channel resources accordingly. Already, the Biden administration has taken an aggressive stance against mergers and acquisitions. In his first year in office, President Joe Biden issued an executive order intended to intensify antitrust enforcement across multiple industries, including health care.
Under Biden, the FTC and DOJ have fought more mergers than they have in decades, often targeting health care deals.
“What Harris could do is set the tone that she is going to continue this laser focus on competition and health care prices,” said Katie Gudiksen, a senior health policy researcher at University of California College of the Law, San Francisco.
The Harris campaign didn’t respond to a request for comment.
For decades, the health industry has undergone consolidation despite government efforts to maintain competition. When health systems expand, adding hospitals and doctor practices to their portfolios, they often gain a large enough share of regional health care resources to command higher prices from insurers. That results in higher premiums and other health care costs for consumers and employers, according to numerous studies.
Health insurers have also consolidated in recent decades, leaving only a handful controlling most markets.
Health care analysts say it’s possible for Harris to slow the momentum of consolidation by blocking future mergers that could lead to higher prices and lower-quality care. But many of them agree the consolidation that has already taken place is an inescapable feature of the U.S. health care landscape.
“It’s hard to unscramble the eggs,” said Bob Town, an economics professor at the University of Texas.
There were nearly 1,600 hospital mergers in the U.S. from 1998 to 2017 and 428 hospital and health system mergers from 2018 to 2023, according to a KFF study. The percentage of community hospitals that belong to a larger health system rose from 53 in 2005 to 68 in 2022. And in another sign of market concentration, as of January, well over three-quarters of the nation’s physicians were employed by hospitals or corporations, according to a report produced by Avalere Health.
Despite former President Donald Trump’s hostility to regulation as a candidate, his administration was active on antitrust efforts — though it did allow one of the largest health care mergers in U.S. history, between drugstore chain CVS Health and the insurer Aetna. Overall, Trump’s Justice Department was more aggressive on mergers than past Republican administrations.
Harris, as California’s attorney general from 2011 to 2017, jump-started health care investigations and enforcement.
“She pushed back against anticompetitive pricing,” said Rob Bonta, California’s current attorney general, who is a Democrat.
One of Harris’ most impactful decisions was a 2012 investigation into whether consolidation among hospitals and physician practices gave health systems the clout to demand higher prices. That probe bore fruit six years later after Harris’ successor, Xavier Becerra, filed a landmark lawsuit against Sutter Health, the giant Northern California hospital operator, for anticompetitive behavior. Sutter settled with the state for $575 million.
In 2014, Harris was among 16 state attorneys general who joined the FTC in a lawsuit to dismantle a merger between one of Idaho’s largest hospital chains and its biggest physician group. In 2016, Harris joined the U.S. Department of Justice and 11 other states in a successful lawsuit to block a proposed $48.3 billion merger between two of the nation’s largest health insurers, Cigna and Anthem.
Attempts to give the state attorney general the power to nix or impose conditions on a wide range of health care mergers have been fiercely, and successfully, opposed by California’s hospital industry. Most recently, the hospital industry persuaded state lawmakers to exempt for-profit hospitals from pending legislation that would subject private equity-backed health care transactions to review by the attorney general.
A spokesperson for the California Hospital Association declined to comment.
As attorney general of California, Harris’ work was eased by the state’s deep blue political hue. Were she to be elected president, she could face a less hospitable political environment, especially if Republicans control one or both houses of Congress. In addition, she could face opposition from powerful health care lobbyists.
Though it often gets a bad rap, consolidation in health care also confers benefits. Many doctors choose to join large organizations because it relieves them of the administrative headaches and financial burdens of running their own practices. And being absorbed into a large health system can be a lifeline for financially troubled hospitals.
Still, a major reason health systems choose to expand through acquisition is to accumulate market clout so they can match consolidation among insurers and bargain with them for higher payments. It’s an understandable reaction to the financial pressures hospitals are under, said James Robinson, a professor of health economics at the University of California-Berkeley.
Robinson noted that hospitals are required to treat anyone who shows up at the emergency room, including uninsured people. Many hospitals have a large number of patients on Medicaid, which pays poorly. And in California, they face a series of regulatory requirements, including seismic retrofitting and nurse staffing minimums, that are expensive. “How are they going to pay for that?” Robinson said.
At the federal level, any effort to blunt anticompetitive mergers would depend in part on how aggressive the FTC is in pursuing the most egregious cases. FTC Chair Lina Khan has made the FTC more proactive in this regard.
Last year, the FTC and DOJ jointly issued new merger guidelines, which suggested the federal government would scrutinize deals more closely and take a broader view of which ones violate antitrust laws. In September, the FTC filed a lawsuit against an anesthesiology group and its private equity backer, alleging they had engaged in anticompetitive practices in Texas to drive up prices.
In January, the agency sued to stop a $320 million hospital acquisition in North Carolina.
Still, many transactions don’t come to the attention of the FTC because their value is below its $119.5 million reporting threshold. And even if it heard about more deals, “it is very underresourced and needing to be very selective in which mergers they challenge,” said Paul Ginsburg, a professor of the practice of health policy at the University of Southern California’s Sol Price School of Public Policy.
Khan’s term ends in September 2024, and Harris, if elected, could try to reappoint her, though her ability to do so may depend on which party controls the Senate.
Harris could also promote regulations that discourage monopolistic behaviors such as all-or-nothing contracting, in which large health systems refuse to do business with insurance companies unless they agree to include all their facilities in their networks, whether needed or not. That behavior was one of the core allegations in the Sutter case.
She could also seek policies at the Department of Health and Human Services, which runs Medicare and Medicaid, that encourage competition.
Bonta, California’s current attorney general, said that, while there are bad mergers, there are also good ones. “We approve them all the time,” he said. “And we approve them with conditions that address cost and that address access and that address quality.”
He expects Harris to bring similar concerns to the presidency if she wins.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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By: Bernard J. Wolfson and Phil Galewitz, KFF Health News
Title: Harris’ California Health Care Battles Signal Fights Ahead for Hospitals if She Wins
Sourced From: kffhealthnews.org/news/article/kamala-harris-california-hospitals-health-care-antitrust-ftc/
Published Date: Mon, 05 Aug 2024 09:00:00 +0000
Kaiser Health News
Urgent Care or ER? With ‘One-Stop Shop,’ Hospitals Offer Both Under Same Roof
Phil Galewitz, KFF Health News
Fri, 02 Aug 2024 09:00:00 +0000
JACKSONVILLE, Fla. — Facing an ultracompetitive market in one of the nation’s fastest-growing cities, UF Health is trying a new way to attract patients: a combination emergency room and urgent care center.
In the past year and a half, UF Health and a private equity-backed company, Intuitive Health, have opened three centers that offer both types of care 24/7 so patients don’t have to decide which facility they need.
Instead, doctors there decide whether it’s urgent or emergency care —the health system bills accordingly — and inform the patient of their decision at the time of the service.
“Most of the time you do not realize where you should go — to an urgent care or an ER — and that triage decision you make can have dramatic economic repercussions,” said Steven Wylie, associate vice president for planning and business development at UF Health Jacksonville. About 70% of patients at its facilities are billed at urgent care rates, Wylie said.
Emergency care is almost always more expensive than urgent care. For patients who might otherwise show up at the ER with an urgent care-level problem — a small cut that requires stitches or an infection treatable with antibiotics — the savings could be hundreds or thousands of dollars.
While no research has been conducted on this new hybrid model, consumer advocates worry hospitals are more likely to route patients to costlier ER-level care whenever possible.
For instance, some services that trigger higher-priced, ER-level care at UF Health’s facilities — such as blood work and ultrasounds — can be obtained at some urgent care centers.
“That sounds crazy, that a blood test can trigger an ER fee, which can cost thousands of dollars,” said Cynthia Fisher, founder and chair of PatientRightsAdvocate.org, a patient advocacy organization.
For UF Health, the hybrid centers can increase profits because they help attract patients. Those patient visits can lead to more revenue through diagnostic testing and referrals for specialists or inpatient care.
Offering less expensive urgent care around-the-clock, the hybrid facilities stand out in an industry known for its aggressive billing practices.
On a recent visit to one of UF Health’s facilities about 15 miles southeast of downtown, several patients said in interviews that they sought a short wait for care. None had sat in the waiting room more than five minutes.
“Sometimes urgent care sends you to the ER, so here you can get everything,” said Andrea Cruz, 24, who was pregnant and came in for shortness of breath. Cruz said she was being treated as an ER patient because she needed blood tests and monitoring.
“It’s good to have a place like this that can treat you no matter what,” said Penny Wilding, 91, who said she has no regular physician and was being evaluated for a likely urinary tract infection.
UF Health is one of about a dozen health systems in 10 states partnering with Intuitive Health to set up and run hybrid ER-urgent care facilities. More are in the works; VHC Health, a large hospital in Arlington, Virginia, plans to start building one this year.
Intuitive Health was established in 2008 by three emergency physicians. For several years the company ran independent combination ER-urgent care centers in Texas.
Then Altamont Capital Partners, a multibillion-dollar private equity firm based in Palo Alto, California, bought a majority stake in Intuitive in 2014.
Soon after, the company began partnering with hospitals to open facilities in states including Arizona, Indiana, Kentucky, and Delaware. Under their agreements, the hospitals handle medical staff and billing while Intuitive manages administrative functions — including initial efforts to collect payment, including checking insurance and taking copays — and nonclinical staff, said Thom Herrmann, CEO of Intuitive Health.
Herrmann said hospitals have become more interested in the concept as Medicare and other insurers pay for value instead of just a fee for each service. That means hospitals have an incentive to find ways to treat patients for less.
And Intuitive has a strong incentive to partner with hospitals, said Christine Monahan, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University: Facilities licensed as freestanding emergency rooms — as Intuitive’s are — must be affiliated with hospitals to be covered by Medicare.
At the combo facilities, emergency room specialists determine whether to bill for higher-priced ER or lower-priced urgent care after patients undergo a medical screening. They compare the care needed against a list of criteria that trigger emergency-level care and bills, such as the patient requiring IV fluids or cardiac monitoring.
Inside its combo facilities, UF posts a sign listing some of the urgent care services it offers, including treatment for ear infections, sprains, and minor wounds. When its doctors determine ER-level care is necessary, UF requires patients to sign a form acknowledging they will be billed for an ER visit.
Patients who opt out of ER care at that time are charged a triage fee. UF would not disclose the amount of the fee, saying it varies.
UF officials say patients pay only for the level of care they need. Its centers accept most insurance plans, including Medicare, which covers people older than 65 and those with disabilities, and Medicaid, the program for low-income people.
But there are important caveats, said Fisher, the patient advocate.
Patients who pay cash for urgent care at UF’s hybrid centers are charged an “all-inclusive” $250 fee, whether they need an X-ray or a rapid strep test, to name two such services, or both.
But if they use insurance, patients may have higher cost sharing if their health plan is charged more than it would pay for stand-alone urgent care, she said.
Also, federal surprise billing protections that shield patients in an ER don’t extend to urgent care centers, Fisher said.
Herrmann said Intuitive’s facilities charge commercial insurers for urgent care the same as if they provided only urgent care. But Medicare may pay more.
While urgent care has long been intended for minor injuries and illnesses and ERs are supposed to be for life- or health-threatening conditions, the two models have melded in recent years. Urgent care clinics have increased the scope of injuries and conditions they can treat, while hospitals have taken to advertising ER wait times on highway billboards to attract patients.
Intuitive is credited with pioneering hybrid ER-urgent care, though its facilities are not the only ones with both “emergency” and “urgent care” on their signs. Such branding can sometimes confuse patients.
While Intuitive’s hybrid facilities offer some price transparency, providers have the upper hand on cost, said Vivian Ho, a health economist at Rice University in Texas. “Patients are at the mercy of what the hospital tells them,” she said.
But Daniel Marthey, an assistant professor of health policy and management at Texas A&M University, said the facilities can help patients find a lower-cost option for care by avoiding steep ER bills when they need only urgent-level care. “This is a potentially good thing for patients,” he said.
Marthey said hospitals may be investing in hybrid facilities to make up for lost revenue after federal surprise medical billing protections took effect in 2022 and restricted what hospitals could charge patients treated by out-of-network providers, particularly in emergencies.
“Basically, they are just competing for market share,” Marthey said.
UF Health has placed its new facilities in suburban areas near freestanding ERs owned by competitors HCA Healthcare and Ascension rather than near its downtown hospital in Jacksonville. It is also building a fourth facility, near The Villages, a large retirement community more than 100 miles south.
“This has been more of an offensive move to expand our market reach and go into suburban markets,” Wylie said.
Though the three centers are not state-approved to care for trauma patients, doctors there said they can handle almost any emergency, including heart attacks and strokes. Patients needing hospitalization are taken by ambulance to the UF hospital about 20 minutes away. If they need to follow up with a specialist, they’re referred to a UF physician.
“If you fall and sprain your leg and need an X-ray and crutches, you can come here and get charged urgent care,” said Justin Nippert, medical director of two of UF’s combo centers. “But if you break your ankle and need it put back in place it can get treated here, too. It’s a one-stop shop.”
——————————
By: Phil Galewitz, KFF Health News
Title: Urgent Care or ER? With ‘One-Stop Shop,’ Hospitals Offer Both Under Same Roof
Sourced From: kffhealthnews.org/news/article/urgent-emergency-care-combo-centers-intuitive-health-jacksonville-florida/
Published Date: Fri, 02 Aug 2024 09:00:00 +0000
Did you miss our previous article…
https://www.biloxinewsevents.com/since-fall-of-roe-self-managed-abortions-have-increased/
Kaiser Health News
Since Fall of ‘Roe,’ Self-Managed Abortions Have Increased
Sarah Varney, KFF Health News
Fri, 02 Aug 2024 09:00:00 +0000
The percentage of people who say they’ve tried to end a pregnancy without medical assistance increased after the Supreme Court overturned Roe v. Wade. That’s according to a study published Tuesday in the online journal JAMA Network Open.
Tia Freeman, a reproductive health organizer, leads workshops for Tennesseans on how to safely take medication abortion pills outside of medical settings.
Abortion is almost entirely illegal in Tennessee. Freeman, who lives near Nashville, said people planning to stop pregnancies have all sorts of reasons for wanting to do so without help from the formal health care system — including the cost of traveling to another state, challenge of finding child care, and fear of lost wages.
“Some people, it’s that they don’t have the support networks in their families where they would need to have someone drive them to a clinic and then sit with them,” said Freeman, who works for Self-Managed Abortion; Safe and Supported, a U.S.-based project of Women Help Women, an international nonprofit that advocates for abortion access.
“Maybe their family is superconservative and they would rather get the pills in their home and do it by themselves,” she said.
The new study is from Advancing New Standards in Reproductive Health, a research group based at the University of California-San Francisco. The researchers surveyed more than 7,000 people ages 15 to 49 from December 2021 to January 2022 and another 7,000-plus from June 2023 to July 2023.
Of the respondents who had attempted self-managed abortions, they found the percentage who used the abortion pill mifepristone was 11 in 2023 — up from 6.6 before the Supreme Court ended federal abortion rights in 2022.
One of the most common reasons for seeking a self-administered abortion was privacy concerns, said a study co-author, epidemiologist Lauren Ralph.
“So not wanting others to know that they were seeking or in need of an abortion or wanted to maintain autonomy in the decision,” Ralph said. “They liked it was something under their control that they could do on their own.”
Kristi Hamrick, vice president of media and policy at Students for Life Action, a national anti-abortion group, said she doesn’t believe the study findings, which she said benefit people who provide abortion pills.
“It should surprise no one that the abortion lobby reports their business is doing well, without problems,” Hamrick said in an emailed statement.
Ralph said in addition to privacy concerns, state laws criminalizing abortion also weighed heavily on women’s minds.
“We found 6% of people said the reason they self-managed was because abortion was illegal where they lived,” Ralph said.
In the JAMA study, women who self-managed abortion attempts reported using a range of methods, including using drugs or alcohol, lifting heavy objects, and taking a hot bath. In addition, about 22% reported hitting themselves in the stomach. Nearly 4% reported inserting an object in their body.
The term “self-managed abortion” may conjure images of back-alley procedures from the 1950s and ’60s. But OB-GYN Laura Laursen, a family planning physician in Chicago, said self-managed abortions using medication abortion — the drugs mifepristone and misoprostol — are far safer, whether done inside or outside the health care system.
“They’re equally safe no matter which way you do it,” Laursen said. “It involves passing a pregnancy and bleeding, which is what happens when you have a miscarriage. If your body doesn’t have a miscarriage on its own, these are actually the medications we give women to pass the miscarriage.”
Since Roe‘s end, more than 20 states have banned or further restricted abortion.
——————————
By: Sarah Varney, KFF Health News
Title: Since Fall of ‘Roe,’ Self-Managed Abortions Have Increased
Sourced From: kffhealthnews.org/news/article/self-managed-abortions-increase-post-roe-dobbs-privacy-concerns/
Published Date: Fri, 02 Aug 2024 09:00:00 +0000
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