Out-Of-Pocket Costs Put HIV Prevention Drug Out Of Reach For Many At Risk | California Healthline

It’s getting increasingly difficult for patients to afford Truvada, also known as pre-exposure prophylaxis, or PrEP, because of the drug’s high price and insurance company efforts to restrict the use of coupons that shield patients from it.

Public health officials are expanding efforts to get the HIV prevention pill into the hands of those at risk, in a nationwide effort to curb infections. But they’re hitting roadblocks, including the drug’s surging price tag and growing out-of-pocket costs for patients.

Since brand-name Truvada was approved for HIV prevention six years ago, its average wholesale price has increased by about 45 percent. Now, the drug — which rakes in billions of dollars in annual global revenue for its manufacturer, Gilead Sciences — carries a list price of close to $2,000 for a 30-day supply.

Most insurers cover the pill, also known as pre-exposure prophylaxis, or PrEP. It has been shown to be more than 90 percent effective in HIV prevention when taken daily. But private health plans are making patients responsible for a larger share of drug costs. And more are restricting use of the “copay coupons” that pharmaceutical companies have used to shield patients from out-of-pocket expenses.

Insurers say the drug companies use coupons to steer consumers toward pricier meds, so one way they are limiting the use of coupons is by no longer allowing them to count toward patients’ deductibles.

“If there is any example of the dysfunction in the American pharmaceutical system, it is this case,” said James Krellenstein, a member of the AIDS advocacy group ACT UP New York. “We have the most effective tool for ending the HIV epidemic, and one reason we’re unable to scale up is because it costs so [much] unnecessarily.”

HIV provider groups in California are trying to figure out which health plans are making the changes and the impact they have on people taking PrEP, said Courtney Mulhern-Pearson, a senior director at the San Francisco AIDS Foundation.

Many people on PrEP are healthy other than their HIV risk, and are likely to have high-deductible plans, said Anne Donnelly, director of health care policy at Project Inform, a San Francisco advocacy organization.

If patients can’t use the copay card, “there will come a point when people won’t be able to pick up PrEP,” she said.

Jared Wile, who lives in Chicago, started taking PrEP about three years ago, when he was dating someone with HIV. Wile, who has a $2,750 deductible, used a coupon to obtain the drug. He never paid anything out-of-pocket, he said, because Gilead waives up to $4,800 in out-of-pocket expenses for commercially insured patients.

That changed for Wile in May, when he learned the coupon no longer counted toward his deductible and that he would have to pay the full cost of the prescription — $1,600 per month — until he hit his deductible. Wile said he felt “blindsided” and stopped taking the medication.

Gilead spokesman Ryan McKeel said the company helps patients overcome financial barriers so more people can access the medication. He cited assistance programs for uninsured and underinsured people.

“We have designed our assistance programs with the intent that people can benefit from their full value, and we cannot control the actions or decisions of health insurers,” McKeel said in an emailed statement.

The federal Centers for Disease Control and Prevention estimates that more than 1 million people are at high risk of contracting HIV, but Gilead says only about 167,000 people currently take PrEP.

Beyond The Money Crunch

Price is one of many barriers — alongside patients’ lack of awareness and doctors’ hesitation to prescribe — that threaten to exacerbate the already stark disparities in PrEP use and HIV infection rates.

One major disparity is along geographic lines. The South, for example, accounts for over half of new HIV diagnoses but only about 30 percent of new PrEP users, according to data from AIDSVu, which maps HIV disease and PrEP use. HIV rates and PrEP use also vary by race and ethnicity.

Gilead has recently gone all-in with advertising to reach people at risk, including print campaigns and TV ads that will air through the summer. Since 2012, it has spent $28 million to fund U.S. organizations that seek to raise awareness of HIV, McKeel, the company spokesman, said.

“We recognize that many people who are at high risk for HIV infection still face challenges in accessing Truvada for PrEP, and we are in regular dialogue with public health officials, advocates and physicians to better understand and, where possible, help to address these challenges,” he added.

Some states — California and Florida among them — have launched PrEP assistance programs that can help patients cover the cost of the medication, along with required lab work and medical visits.

California’s program, run by the state Department of Public Health, helps low-income residents cover the drug costs.

Beyond these state-based programs, some public health departments and HIV service organizations are hiring PrEP navigators to help patients navigate the maze of copays 

A Complex Solution, And No Competition

The complexity of this problem is not unique in a dysfunctional American health care system.  The Affordable Care Act has done little to address these issues and is thwarted by pharma and other suppliers for health care.

PrEP is only one part of HIV prevention, so help paying for the pill is only one piece of the puzzle.

Patients also need regular HIV testing and medical care, which add to the cost borne both by patients and the health system. Some experts warn that Truvada’s high price point could financially undermine such broad prevention efforts.

Competition could help.

A generic version of the drug, manufactured by Teva Pharmaceuticals, is available abroad and gained approval for use last year from the federal Food and Drug Administration. When it becomes available in the United States, it could bring down prices, though it’s unclear when that will happen. Gilead’s own forecasts reflect that expectation, showing declines in future revenue from Truvada.

For now, though, Truvada is the only PrEP option available in the U.S., said David Howard, a health economist and professor at Emory University, who previously worked in the pharmaceutical industry. “From a company standpoint … their best strategy is to make as much money as they can.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Out-Of-Pocket Costs Put HIV Prevention Drug Out Of Reach For Many At Risk | California Healthline:

State Prisons Fail To Offer Cure To 144,000 Inmates With Deadly Hepatitis C

State prisons across the U.S. are failing to treat at least 144,000 inmates who have hepatitis C, a curable but potentially fatal liver disease, according to a recent survey and subsequent interviews of state corrections departments.

Many of the 49 states that responded to questions about inmates with hepatitis C cited high drug prices as the reason for denying treatment. The drugs can cost up to $90,000 for a course of treatment.

Nationwide, roughly 97 percent of inmates with hepatitis C are not getting the cure, according to the survey conducted for a master’s project at the Toni Stabile Center for Investigative Journalism at Columbia University’s Graduate School of Journalism.

Advocates say this ignores a 1976 Supreme Court ruling that determined an inmate’s medical care is a constitutional right.

In California, more than 16,000 prisoners — or about 12 percent of the prison population — have tested positive for chronic hepatitis C, according to the state Department of Corrections and Rehabilitation. Between July 2017 and April of this year, 1,580 prisoners with the disease received treatment, the department said.

Since late 2013, new hepatitis C drugs with a success rate of more than 95 percent have become available. But they come with sticker prices of $40,000 to $90,000 for the daily tablet regimen of eight to 12 weeks. These drugs replaced previous therapies that cost around $70,000 for 48 weeks of treatment with a much lower cure rate.

Rates of treatment vary from state to state. 

Methodology

The figures in this story came from a survey sent to the departments of corrections in 50 states and the District of Columbia, between October 2017 and March 2018. Some states responded to the survey without FOIA or Open Records requests, and others required a formal request.

The survey asked for: (1) the state prison policy on testing and treating HCV, (2) the HCV drugs in their formulary, (3) the number of inmates with HCV, or the prevalence rate of HCV in the state prisons, and (4) the number of inmates with HCV who were treated in the previous year, or the most recent data available. For states that required records requests, a question about the amount of budget spent on treating inmates with HCV was added to the survey.

Forty-nine states and D.C. responded to the survey in some form; North Carolina did not respond to repeated emails and phone calls. Forty-five states gave complete answers for both the numbers of inmates diagnosed and treated. Arkansas, Hawaii and Missouri responded only to either the prevalence rate or the number of inmates treated. South Carolina and D.C. denied the FOIA requests.

The overall numbers are estimates, and some states provided only estimates. Additionally, not every state prison performed testing during intake or does routine testing. For example, Georgia tested only 4 percent of its inmates but reported that 727 inmates have HCV, meaning that almost 1 in 3 of the people who were tested had the virus.

The policies on testing and treating varies greatly by state; some are more restrictive than others in terms of treatment eligibility, giving access to those in advanced stages of disease. Alaska, Georgia, Maine and South Dakota did not have clear written rules for testing or treating HCV. Mississippi had a policy that dated to 2005, almost a decade before the current drugs were introduced.

The current HCV medications come in at least eight brands. Not every prison system had these treatments in their formularies; physicians prescribing non-formulary HCV drugs need approval from the department of corrections. At least nine states did not include any of the HCV drugs in their prescription lists.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Thanthong-Knight reported this story as part of his master’s project for the Toni Stabile Center for Investigative Journalism at Columbia University Graduate School of Journalism.















http://tinyurl.com/y7caslv6

Success of blood test for autism affirmed

One year after researchers published their work on a physiological test for autism, a follow-up study confirms its exceptional success in assessing whether a child is on the autism spectrum.

First physiological test for autism proves high accuracy in second trial

A physiological test that supports a clinician's diagnostic process has the potential to lower the age at which children are diagnosed, leading to earlier treatment. Results of the study, which uses an algorithm to predict if a child has autism spectrum disorder (ASD) based on metabolites in a blood sample, published online today, appear in the June edition of Bioengineering & Translational Medicine.

Rather than search for a sole indicator of ASD, the approach Hahn developed uses big data techniques to search for patterns in metabolites relevant to two connected cellular pathways (a series of interactions between molecules that control cell function) with suspected links to ASD.

This study confirmed the original findings that were found several years ago by a prior group of investigators at the Rennselear Polytechnic Institute. 

"We looked at groups of children with ASD independent from our previous study and had similar success. We are able to predict with 88 percent accuracy whether children have autism," said Juergen Hahn, lead author, a systems biologist, professor, head of the Rensselaer Polytechnic Institute Department of Biomedical Engineering, and member of the Rensselaer Center for Biotechnology and Interdisciplinary Studies (CBIS). "This is extremely promising."

It is estimated that approximately 1.7 percent of all children are diagnosed with ASD, characterized as "a developmental disability caused by differences in the brain," according to the Centers for Disease Control and Prevention. Earlier diagnosis is generally acknowledged to lead to better outcomes as children engage in early intervention services, and an ASD diagnosis is possible at 18-24 months of age. However, because diagnosis depends solely on clinical observations, most children are not diagnosed with ASD until after 4 years of age.

Journal Reference:

1. Daniel P. Howsmon, Troy Vargason, Robert A. Rubin, Leanna Delhey, Marie Tippett, Shannon Rose, Sirish C. Bennuri, John C. Slattery, Stepan Melnyk, S. Jill James, Richard E. Frye, Juergen Hahn. Multivariate techniques enable a biochemical classification of children with autism spectrum disorder versus typically-developing peers: A comparison and validation study. Bioengineering & Translational Medicine, 2018; DOI: 10.1002/btm2.10095

https://www.sciencedaily.com/releases/2018/06/180619122434.htm

Egg Freezing: How Much It Costs and How Women Afford It | Money

So you want to freeze your eggs ??

An increasing number of women are choosing to freeze their eggs at high costs. Here's how they afford it and how much they have to spend.

You should do a deep-dive into it before you plunk your money into it, especially if you are borrowing to finance this crap-shoot. You might have better luck on the slots or the tables at your local casino.

Much information is available that supports this statement.

WATCH: The Cost of Trying for a Baby

Women Are Spending Up to $20,000 to Freeze Their Eggs. Is It Worth It?

Assisted reproductive technology isn’t new. In vitro fertilization (IVF)—a procedure that takes eggs from a woman’s ovaries and combines them with sperm in a little petri dish—has been around since 1981, when the first “test tube baby” was born in the U.S. But egg freezing, which stores the eggs for future fertilization, sort of like IVF on retainer, is still a new frontier.

The American Society for Reproductive Medicine (ASRM) dropped the “experimental” label from the procedure in 2012—so there’s not a lot of data about how many women are actually doing it. But the evidence is everywhere.

Today, more women like Meg are having frank, open discussions about reproductive health than ever before. They’re sharing their “fertility goals” on public forums like Instagram, Facebook, and family planning websites like The Bump, JustMommies, Eggsurance. And they’re shelling out thousands of dollars—sometimes tens of thousands of dollars—to bring those goals to fruition.

A single cycle of egg freezing starts at about $5,000 to $8,000. To get a viable number of eggs, some women need to undergo multiple rounds, paying double, or even triple, that price. The hormone prescriptions, injected daily into a patient’s abdomen for at least a week prior to the procedure, can add thousands of dollars to the bill. So can doctor’s visits and storage fees. And that’s just the first part of the process: Most women are on the hook for at least another $10,000 when they thaw and implant the eggs down the line. If you’re lucky, insurance might cover one or two consultations with a fertility doctor, but most patients have to pay for the procedure out of pocket, with the help of credit card debt, medical loans, and clinic-specific payment plans.

Those are hefty price tags for what basically amounts to a gamble. The odds an egg freezing patient will have a successful pregnancy varies, but research from the Society for Assisted Reproductive Technology (SART) shows that each frozen egg only has about a 4.5% to 12% chance of becoming a baby.  The odds a woman will actually use that egg are just as slim. The majority of egg freezing patients never return for the implantation: Studies published in 2017 in the academic journals Fertility and Sterility and Human Reproductionput that number at less than 10%.

All of this adds up to a big, open-ended question bubbling among twenty- and thirty-something women: How much is your fertility worth?

There’s still a lot of uncertainty about who, exactly, is a good candidate for egg freezing. Type “should I freeze my eggs?” into Google, and you’ll get bombarded with page after page of conflicting advice. Biology is mostly to blame here; the speed at which a woman’s eggs deplete depends almost entirely on her own genetic makeup. Fertility testing can give doctors a snapshot of what her odds of conceiving might be, but not a complete picture.

Paying for the procedure is the next big question mark.

Unlike IVF, egg freezing is an expense a woman usually has to navigate on her own, without help from a partner’s income. It comes with a laundry list of fees most patients don’t know about until they’re in the thick of it—like prescription costs ($3,000 and up) and “cryobank” storage fees (about $300 to $1,000 each year).

Still, for women considering taking the plunge, there are more financing options than ever before. Tech companies like Apple and Facebook have started covering the cost as an employee perk. And new, millennial-friendly clinics have popped up with new, millennial-friendly marketing grabs. This past March, the San Francisco–based clinic Spring Fertility sponsored a “Golden Egg Hunt,” which sent about 100 participants on scavenger hunt–style challenges, like belting out Frozen lyrics and hopping like rabbits up a flight of stairs. The grand prize? A free egg freezing cycle and, per Spring’s website, “priceless peace of mind.”

Angella Nguyen, a 38-year-old Los Angeles resident, did a staggering amount of research before freezing her eggs in February. The Bay Area clinic she chose, Zouves Fertility Center, offers financial assistance, as did the pharmaceutical companies that make some of the prescriptions she was required to take beforehand.

Even with these discounts—which required applications and mailed-in tax returns—Nguyen spent about $13,000 out of pocket. If she chooses to thaw and implant the eggs down the line, she’ll have to fork over even more money. But ideally, Nguyen says, she won’t need to.

“I still want to have a natural birth,” she says. “This is plan B to the plan B.”

Some women who can’t afford the hefty price tag borrow money from places like LendingClub, which doles out “fertility loans” with interest rates that swing from 3.99% to 24.99% (the average rate is about 10%, according to a company spokesman). In recent years, fertility clinics have started offering payment plans directly through their facilities, and it’s paid off. Shady Grove Fertility, a national clinic with 31 offices throughout the U.S., saw a 19% spike in women interested in egg freezing after it launched a $195 monthly payment option, a spokeswoman says.

Shady Grove is one of the few companies that charts its pregnancy success rates publicly, on its website. For patients younger than 38, freezing 20 eggs equates to a roughly 80% chance of at least one live birth, according to the clinic. Ten eggs give them a 50/50 chance. This isn’t a magic wand: Like the larger egg freezing population, most of Shady Grove’s patients never return for IVF (of the 875 women the clinic drew that sample from, only 117, or about 13%, came back for implantation). But it does put things into perspective.

“We want people to be educated when they’re doing this,” says Joseph Doyle, a doctor at Shady Grove’s Rockville, Md., office. “It’s a big investment.”

Egg Freezing: How Much It Costs and How Women Afford It 

Don't worry Doc, I've got two

Our system is based on sickness, not health, so expensive procedures are favored over preventing those procedures from happening in the first place.

That statement from a recent patient was a summary to me of what is bad in our health care “system.”  It’s a terrible summary of what is seen all over this country with people who must make the choice between financial solvency and health.

Here’s what happened:  It was a new patient I saw, who is a veteran who owns two businesses.  He went out on his own when he “kept getting laid off.”  He has largely been successful in what he’s doing, but as is the case with many these days, he couldn’t afford health insurance.  This was especially bad because he had a heart attack last year, which required stenting and a significant hospital stay.  He didn’t fill me in on the financial details, but there’s no doubt that this hurt him significantly.

Unfortunately, he has another problem: glaucoma.  His glaucoma is bad enough to need surgery done to avoid losing vision in one eye.  Sadly, he can’t afford that surgery.  We talked about the difficult choices he had to make with his health and his money.  “It seems to me that the eye problem is the most urgent problem you have.  You don’t want to lose your vision,” I told him.

That’s when he smiled, waved his hand over his right eye and said, “Don’t worry, doc.  It’s just one eye.  I’ve got two.”

My stomach lurched to hear this statement.  A guy who has done nothing wrong aside from choosing self-employment (and perhaps inheriting less-than-stellar genes) is left with the choice: financial devastation or blindness in one eye.  He works hard, has served the country, didn’t complain to me at all, yet here he is about to be swallowed by the ever-widening maw of impossible medical expense.

How can we help people in this situation?  How can we care for those who need care without increasing already out of control spending?  There are many who give simplistic answers to that question, but most of them ignore the cause of our problems: the out-of-control cost of care.

As a retired ophthalmologist, this scenario seems all too real. The reality depends upon how old is the patient ?  Most patients who develop cataract are over 65 and qualify for Medicare reimbursement. Cataracts develop very gradually and can wait to be removed. However other serious conditions such as glaucoma and/or macular degeneration must be treated early to avoid permanent loss of eye sight.

There is no one single reason for medical financial stress, much of it depends upon the status of employment, disability or others, too numerous to mention.  There are circumstances where I  could waive a copay, however Medicare would penalize me for doing so. The rule is buried somewhere in my participating provider agreement with CMS.  If faced with the option of performing a surgery on a medicare payment, would I collect a copayment from a patient if necessary?  Would I refuse to treat a patient who did not pay a co-payment? No, I would not.  If read correctly the rule says that I should attempt to collect a co-payment at the time of visit.  My front office asks the patient for the co-payment. If they do not pay or cannot pay, it is waived. (quietly) . I am sure some physicians have been audited and warned.  Perhaps Medicare does not yell 'fraud' at this deception.  I expect the CMS budget, already stressed, could not afford to prosecute these 'misdemeanors'.  There is enough real fraud perpetrated. However, if the sum total amount exceeds $ 10,000 a perpetrator could be accused of a felony.

How can we help people in this situation?  How can we care for those who need care without increasing already out of control spending?  There are many who give simplistic answers to that question, but most of them ignore the cause of our problems: the out-of-control cost of care. My colleague who wrote the original article is a primary care physician (family medicine, ob/gyn, or internal medicine).  These physicians are at the gateway at the entry point to the health system. Ninety-nine percent of their patients do not require inpatient or complicated treatments.

My colleagues, as well as others, have developed a new model for medical expense.  

In his practice, which is (by the way) a direct primary care practice, where he does not accept payment from insurance companies but rather is paid by patients in the form of a low ($35 to $70) monthly payment.  Because he is paid directly by my patients, he is motivated to save them money whenever possible, as it justifies paying me the monthly fee.  Also, me being much less busy (I see between 5 and 12 patients on a normal day), he can work to find ways to avoid unnecessary care.  This is especially important because many of my patients don’t have insurance and those who do have high-deductible plans. Direct payment avoids almost all the overhead of having an insurance department and personel to collect payment.

This patient experienced this aspect of my care on this same visit.  He was also interested in being screened for colon cancer.  Some friends had urged him to do so.  “But when I called to find out what a colonoscopy costs, they said it would be more than $6,000!  I can’t afford that!”  I sent a quick message to my nurse and she relayed that there is a gastroenterologist in town who can do a colonoscopy for $1,600 (extra for biopsies, of course).

He was impressed by this, as are many of my patients when we do lab tests for more than 80 percent discount, dispense medications that are more than 70 percent cheaper than the average discounted price from GoodRx, and when we know where to get $100 ultrasounds, $250 CT scans, and $450 MRI scans.  These prices are out there for any doctor to use, but my business model makes it to my advantage to give patients the best value possible.  So there are ways to cut the cost of care for many people.  Unfortunately, not many doctors use these resources, much less know about them.  Few, if any specialists use this model of a deep discount for cash at the front desk.

A deeper question in this man’s case is the fact that his heart disease was treated at a local hospital which specializes in heart disease.  While much of the public may see this as a positive thing, those who know health care realize that these hospitals are very quick to do procedures that are not always necessary.  In his case, he had a stent placed on a 65 percent lesion, which doesn’t have great evidence supporting its placement.  Much of interventional cardiology treads the ground lightly in the area of solid epidemiological evidence of benefit for some very expensive procedures.  It seems to be based largely on the visceral response all of us (me included) would have: “It could only help to stent the 65 percent lesion, wouldn’t it?   What will it hurt?”  It turns out that the evidence for much of this is light.

In this case, the stenting of a 65 percent lesion could result in blindness, as the money he would have spent on eye surgery was instead paid to the interventional cardiologist and the “heart specialty” hospital.

A patient is left with a choice: financial devastation or blindness: 

Online Pharmacy's have broken through the 'glass ceiling'

This morning Amazon broke the news that it is acquiring virtual pharmacy PillPack. With this, the online retail giant that has made itself famous for “one-click shopping” for consumer goods is positioning to expand its services to include prescription medication. 

Do you remember when ordering prescriptions from Canadian online pharmacies and ordering contract lenses online was considered  'UnAmerican?  Today if you are not purchasing items, medications, or dog food online you may be considered a  Luddite. 

The recent announcement that Berkshire Hathaway and Amazon would partner to improve health care and reduce cost is becoming a reality very quickly.

A week after appointing a CEO for its healthcare joint venture with Berkshire Hathaway and JPMorgan, Amazon  today announced an acquisition that underscores how it also hopes to have a more direct — and more commercial — role in the world of healthcare in the coming years. The company has purchased PillPack, an online pharmacy the lets users buy medications in pre-made doses.

The move (and that reported valuation hike) signal how heated the e-health market is becoming, and also how Amazon views it as a key frontier in its bid to be the go-to place for anything a consumer (or medical organization) might want or need in the area of healthcare.

The might of Amazon in commerce plays a massive role in how the market is poised to develop: it buying the company is not only a signal of how PillPack will likely get scaled out (not least through Amazon’s healthcare JV) but also because of how other pharmacy companies will have to respond. So far, the market is punishing the rest for not already being where Amazon appears to be going.

“PillPack’s visionary team has a combination of deep pharmacy experience and a focus on technology,” Jeff Wilke, CEO of Amazon Worldwide Consumer, said in a statement. “PillPack is meaningfully improving its customers’ lives, and we want to help them continue making it easy for people to save time, simplify their lives, and feel healthier. We’re excited to see what we can do together on behalf of customers over time.”

Amazon, Berkshire Hathaway and JPMorgan announced the eagerly-anticipated head of their joint venture on Wednesday: Atul Gawande, MD. 

Gawande has worn many hats over his distinguished career: surgeon at Brigham and Women’s Hospital, a professor at Harvard's T.H. Chan School of Public Health, staff writer at The New Yorker, best-selling author.

The precise nature of the new venture, which the three companies announced earlier this year, is still largely shrouded in mystery. It doesn't even have a name yet. 

But today three new facts emerged: It will be based in Boston. It will be an "independent entity that is free from profit-making incentives and constraints." And Gawande will lead it, starting on July 9. The New England-based startup delivers medications in pre-sorted dose packaging, coordinates refills and renewals, and ensures that shipments are sent on time, according to a statement. The service targets people who take multiple daily prescriptions. While terms of the deal have not yet been released,  

The synergy of Amazon and Berkshire Hathaway funding the venture along with a visionary CEO, who has a credible and altruistic vision of how health care must change to deliver quality care. 

http://tinyurl.com/y8u86x5q

Game Changer for non weight bearing replaces the crutch

Game Changer

Doctors aren't top opioid prescribers in NH | New Hampshire

The highest-volume prescribers of opioids in New Hampshire are not doctors, but nurse practitioners and physician assistants who work at specialty pain clinics, according to Medicare and Medicaid data reviewed by the New Hampshire Union Leader.

The data show that the top 25 prescribers of oxycodone HCL and Oxycontin wrote more than 22,500 prescriptions for the two drugs for Medicare and Medicaid patients in 2013. 

None of the top five had a doctor’s license. Four of the five worked at specialty pain clinics. And one — physician assistant Christopher Clough — was permanently banned from prescribing narcotics and working in the pain care field by the state Board of Medicine earlier this year.

The data come from two sources. Data from Part D Medicare billings were obtained through ProPublica, a non-profit journalism website that has compiled publicly available data from the Center for Medicare and Medicaid Services. The New Hampshire Union Leader obtained digital Medicaid billing records from the New Hampshire Department of Health and Human Services.


The most recent ProPublica data are for 2013, which is more than a year before the heroin and opioid abuse crisis rose to prominence in the Granite State. Of the top 25 prescribers, nine are physicians, 12 are nurse practitioners, four are physician assistants.

New Hampshire law allows nurse practitioners to work independently and issue prescriptions without physician oversight; physician assistants must be overseen by a doctor.



Kelly Doherty, a nurse practitioner of 15 years, issued more Medicare prescriptions for oxycodone HCL than anyone else in New Hampshire. Doherty, who now heads the palliative care program at Cornerstone VNA, said she was working in 2013 at Interventional Spine Medicine, a specialty pain clinic in Barrington.

She said her job was to manage medications at the practice, a job that involves drug testing, calling patients randomly to count their pill supply, and other efforts to discourage abuse.

She was not surprised at the findings. And she disputed contentions that prescription opioids are responsible for the heroin epidemic.

“Even Tylenol can be addicting. Any pain medicine can cause addiction when used inappropriately,” she said.

“I believe the heroin epidemic is due to the government’s lack of initiative in mental health treatment. It does not start with me prescribing drugs to people who need it.”







Doctors aren't top opioid prescribers in NH | New Hampshire

Death Panels: What Physicians are doing to protect Patient rights

Many years ago when HMOs and the Affordable Care Act were embryonic some proposed end of life management by committee.  In most cases the issue resolved around the costs of end of life and near death expense to the health finance system. 
Expensive life-extending treatments would require a review by a committee.  In most cases, the treatment reviews would take place by administrators in health plans and/or government programs.
No one can dispute the inflation of health care expense. Many solutions have been proposed and initiated with varying success or even paradoxical increases in cost and bureaucracy

In California on Friday, the California Medical Association killed Assembly Bill 3087 (Kalra) – dangerous legislation that would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California. that would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California. Due in large part to staunch opposition led by CMA, the bill died in the Assembly Appropriations Committee.The California Assembly struggles to contain it's health care costs for Medi-caid. This proposed bill would have extended far beyond the reach of government programs.Through CMA’s Grassroots Action Center, thousands of physician members contacted their legislators because AB 3087 would have:

• Decimated California’s health care delivery system.

• Disrupted care and limited choice for millions of California patients.

• Caused 175,000 health care workers to lose their jobs.

• Forced hospitals to close and pushed health care providers into early retirement

• Caused a “brain drain” of talented medical students and residents fleeing California for more ideal working conditions.

California Medical Association Mission Statement

May 29, 2018 - 2018 - California Medical Association

The Ebola superhighway: Why the new outbreak terrifies public health authorities | TheHill

A new outbreak of the Ebola virus that has killed at least two dozen people has sent public health officials scrambling to contain the epidemic as it threatens to spread far beyond the remote jungles of the Congo River Basin — and raises new questions about the World Health Organization’s (WHO) preparations for the next killer virus.

EBOLA spread follows the rivers, which are transportation corridors in the jungles of the Congo

How Ebola got its name.

The U.S. government is preparing its most direct response yet to the outbreak that appears to have begun in April, readying staffers from the Centers for Disease Control and Prevention (CDC) to deploy to multiple communities in Congo.

Ministry of Health officials first identified cases of viral hemorrhagic fever when it reached the town of Bikoro earlier this month. On Thursday, officials said a new case had been identified in Mbandaka, a city of 1.2 million.

The new case in Mbandaka has raised the alarm among public health officials because it is the first time the virus has ever landed in a city that sits directly on the Congo River.

In all eight of the previous known Ebola outbreaks in Congo, the virus has been contained within remote jungle villages or relatively small towns, where isolated populations are less likely to spread the disease.

But the Congo River is effectively the region’s highway system. Barges and boats travel from Kisangani in the east through major cities including Bumba, Mbandaka — and eventually Kinshasa, the capital of Congo and home to more than 11 million people, as well as Brazzaville, the capital of the Republic of Congo.

“The Congo River connects three national capitals and multiple other large cities,” said Jeremy Konyndyk, who led the U.S. Agency for International Development’s Office of Foreign Disaster Assistance during the 2014-2015 outbreak. “The fact that there are now several cases in an urban center of more than a million people underscores the potential for this outbreak to get out of control.”

If the Ebola virus traveled upriver from Bikoro to Mbandaka, some officials wonder, has it also traveled downstream toward Kinshasa, which offers direct air traffic to cities including Brussels, Paris, Dubai and Lagos, Nigeria?

“We don't know what's happening along the river, because the river is used by a lot of barges,” said Pierre Rollin, one of the world’s leading experts on the Ebola virus at the CDC. “None of the outbreaks have been by the river or in the big towns. So we have a lot of caution before claiming we know what's going on.”

Previous outbreaks have been snuffed out in the Congo, Rollin said, because the area is so remote that humans did not have a chance to travel far enough to transmit the virus before succumbing.

That was not the case four years ago in West Africa, where the virus spread widely across international boundaries. Commercial and cultural travel throughout Guinea, Liberia and Sierra Leone — across borders drawn a century and a half ago by colonizers with little regard for traditional tribal boundaries — is far more common than it is in Congo.

The present outbreak has raised anew questions about WHO and its capacity to respond to deadly viral threats. Following the West Africa outbreak, when the ill-prepared WHO endured withering criticism for its lackluster response to the initial round of cases, the agency has undergone a remarkable round of self-flagellation, reorganizing to prioritize emergency preparedness and response while cutting bureaucracy.

“We’ve seen WHO activate much more quickly, at much larger scale, and in more effective partnership with players like” Doctors Without Borders, said Konyndyk, who sat on an independent panel that advised WHO on reforming its emergency functions after the West Africa outbreak.

The first WHO investigative team arrived in Bikoro on May 5, about a month after the first suspected cases are likely to have emerged in Ikoko Impenge. A logistics team arrived on May 9, and the United Nations began daily flights carrying supplies and personnel between Kinshasa and Mbandaka on May 13. 

Tedros Adhanom Ghebreyesus, the WHO’s director general, visited Bikoro on May 13, in part to show the urgency of the situation.

“A major lesson learnt from the West Africa Ebola outbreak was that WHO needed a flexible fund to rapidly respond to outbreaks and emergencies,” Tarik Jasarevic, a WHO spokesman, said in an email from Geneva. The agency’s new Contingency Fund for Emergencies, already activated in Congo, has made cash available to responders far more quickly than in the West Africa case.

Still, some wonder why it took the Congolese Ministry of Health and the WHO a month to spot the virus in the first place.

“We are doing better at response, but not much better at rapid detection, which is important,” said Tom Frieden, a former CDC director who now runs the public health organization Resolve to Save Lives. “This was spreading for a while before [it was] recognized.”

Aiding the response further is a new vaccine, finalized in the last days of the West Africa outbreak. About 4,000 doses of the vaccine are headed to the epicenter of the new outbreak, where they will be used in two ways: First, health-care workers, those most vulnerable to exposure, will be vaccinated. Then, those who have come into contact with anyone infected, and the contact’s contacts, will be vaccinated, a practice known as ring vaccination.

“That part should really add another arm to the response. It's not the response by itself, because you still have to do all the rest,” Rollin said.

Congo is also far more prepared to respond to an Ebola outbreak because the virus is known to be endemic to the region. The first modern outbreak of the Ebola virus occurred in the village of Yambuku, about 370 miles from the site of the present one, back in 1976.

The Ebola superhighway: Why the new outbreak terrifies public health authorities | TheHill