I had a brother who basically tried to destroy our family with his drinking and his use of drugs. I remember having to home from college and medical school to rescue him many times after my parents were feed up with his abuses and problems with the police. Finally he and his girlfriend wrapped his car around a telephone phone resulting his death. So, I understand the opioid problem but have minimal empathy. We all make our own choices in life and need to stop blaming everyone else but those that use, steal, lie and continue to use opioids. Now, what are the real numbers?
Blake Farmer reported that while thousands of cities and counties have banded together to sue opioid makers and distributors in a federal court, another group of plaintiffs has started to sue on their own: hospitals.
Hundreds of hospitals have joined up in a handful of lawsuits in state courts, seeing the state-based suits as their best hope for winning meaningful settlement money.
“The expense of treating overdose and opioid-addicted patients has skyrocketed, straining the resources of hospitals throughout our state,” said Lee Bond, chief executive officer of Singing River Health System in Mississippi in a statement. His hospital is part of a lawsuit in Mississippi.
Hospitals may find there are downsides to getting involved in litigation, says Paul Keckley, an independent health analyst.
“The drug manufacturers are a soft target,” he says. But the invasive nature of litigation may generate “some unflattering attention” for hospitals, he adds. They’d likely have to turn over confidential details about how they set their prices, as well as their relationships with drug companies.
So despite representing the front lines of the opioid epidemic, most hospitals have been hesitant to pile on.
Just about every emergency room has handled opioid overdoses, which cost hospitals billions of dollars a year, since so many of the patients have no insurance. But that’s just the start. There are also uninsured patients, like Traci Grimes of Nashville, who end up spending weeks being treated for serious infections related to their IV drug use.
“As soon as I got to the hospital, I had to be put on an ice bath,” Grimes says of her bout with endocarditis over the summer, when bacteria found its way to her heart. “I thought I was going to die, literally. And they said I wasn’t very far away from death.”
Grimes is in recovery from her opioid addiction but still getting her energy back after spending a month being treated through a special intravenous line to her heart at Vanderbilt University Medical Center. Most patients could be sent home with a PICC line, but not someone with a history of illicit IV drug use who could misuse it to inject other substances. Vanderbilt and other academic medical centers have recognized this problem and established special clinics to manage these complex patients.
Grimes, 37, says she’s grateful for the care she received, which also included multiple procedures and treatment for pneumonia, hepatitis A and hepatitis C. But like most patients in her situation, she’s uninsured and strapped for cash.
“I can’t pay a thing. I don’t have a dime,” she says. “So they do absorb all that cost.”
Hospitals estimate treating complicated patients like Grimes costs an average of $107,000 per person, according to court documents. The total costs to U.S. hospitals in one year, 2012, exceeded $15 billion, according to a report cited in the suits. And most patients either couldn’t pay or were covered by government insurance programs.
The expense is a leading reason cited by the hospitals that’ve banded together in a handful of lawsuits in Tennessee, Texas, Arizona, Florida, Kentucky, Mississippi and West Virginia. These suits are all separate from the big consolidated federal case in Ohio that includes cities and counties around the country. But the most prominent hospitals in those states, like Vanderbilt, have opted not to join the litigation.
West Virginia University President Gordon Gee, who oversees the state’s largest hospital system, has been urging others to join the suits. He and former Ohio Governor John Kasich established an organization meant to highlight the harm done to hospitals by the opioid crisis.
“I think the more hospitals we have that want to be involved in this in some way, the better off we are,” he says. “You know, there’s always safety in mass.”
By “safety,” Gee acknowledges a central concern for hospitals weighing the risk versus reward of going to court. They may have the tables turned on them by the pharmaceutical companies, since until recently, patients in the hospital were often prescribed large quantities of opioids, contributing to the epidemic.
“I suspect there are some hospitals … who are afraid that if they get into it, those who on the defense side will point out, well, maybe hospitals were really the problem,” he says.
The lead defendant in the suits, Purdue Pharma, did not respond to requests for comment.
Gee says hospitals can claim they were victims of dubious opioid marketing.
Still many high-profile hospitals are sitting out the lawsuits, even though they’re typically the ones that treat the most complicated and expensive patients.
Paul Keckley says if hospitals join the litigation, they may be forced to cough up actual totals for their opioid-related financial damages. That could force hospitals to reveal how much more they charge for some services, compared to the actual costs of providing the care.
“Hospitals basically have charged based on their own calculations and the underlying cost of delivering that care has been virtually non-transparent,” Keckley says. “Then you open a whole new can of worms.”
Keckley says especially big academic medical centers have relationships with drugmakers that they may not want publicly highlighted.
Still, hospitals might benefit without having to put their names on lawsuits and exposing themselves to risk. In Oklahoma, the state won an early opioid lawsuit in August. The payout does not direct money to hospitals, per se. However, Patti Davis, president of the Oklahoma Hospital Association, says they’re happy to see some of the money was earmarked for treatment.
“When we see treatment, we get very excited because it’s our hospitals providing a lot of the treatment,” she says.
But nationally, hospitals can’t count on potential settlement money to trickle down to their bottom lines, says attorney Don Barrett. He’s a Mississippi litigator helping hospitals sue in state courts.
Two decades ago, when the target of litigation was Big Tobacco, Barrett was working for states. He says hospitals didn’t join in, to his surprise. And when the states won those suits and started getting paid damages, hospitals missed out. Only about a third of the money was even spent on health or tobacco control, according to one watchdog’s estimate.
“I guess they thought that the states were going to take care of them, that these local governments were going to take this money and give it to the hospitals where it would do some good,” he says. “Of course, they didn’t give them a damn penny.”
Some states did set up trust funds that might help patients in the hospital stop smoking. But many are using the money to fill potholes, pay teachers and otherwise close gaps in state budgets.
Though not detailed in the lawsuits, many of the participating hospitals are in varying levels of financial distress, and not always primarily because of the opioid epidemic. Facilities owned by Community Health Systems make up a large share of the hospitals suing in Alabama, Florida, Mississippi, Tennessee and Texas. The investor-owned hospital chain, based in Franklin, Tenn., has been struggling mostly because of an outsized debt load taken on during a rapid period of expansion.
A CHS spokesperson declined to comment, citing a policy not to talk about pending litigation.
But Barrett says he expects more hospitals to join the cause rather than relying on states to determine how settlement money is spent.
“We’re not going to allow that to happen this time,” he says. “We can’t afford to allow it to happen this time.”
The Real Cost Of The Opioid Epidemic: An Estimated $179 Billion In Just 1 Year
SelenaSimmons-Duffin reported that there’s a reckoning underway in the courts about the damage wrought by the opioid crisis and who should pay for it.
Thousands of cities and counties are suing drugmakers and distributors in federal court. One tentative dollar amount floated earlier this week to settle with four of the companies: $48 billion. It sounds like a lot of money, but it doesn’t come close to accounting for the full cost of the epidemic, according to recent estimates — let alone what it might cost to fix it.
Of course, there’s a profound human toll that dollars and cents can’t capture. Almost 400,000 people have died since 1999 from overdoses related to prescription or illicit opioids. Since 2016, the number of opioid deaths per year rivals or has exceeded the number from traffic accidents. These are lives thrown into chaos, families torn apart — you can’t put a dollar figure on those things.
But the economic impact is important to understand. The most recent estimate of those costs comes from the Society of Actuaries and actuarial consulting firm Milliman in a report published this month.
“We pride ourselves that this is objective, nonpartisan research,” says Dale Hall, managing director of research at the Society of Actuaries. He adds, “We’re not here to influence any court proceedings.” As actuaries, they calculate financial numbers associated with risks, for instance, for insurance companies.
So how much did the epidemic cost in just one year, 2018? The total number they came to was $179 billion. And those are costs borne by all of society — both by governments providing taxpayer-funded services (estimated to be about a third of the cost) and also individuals, families, employers, private insurers and more.
When you start to break that number apart, a picture emerges of how opioid addiction ripples out into communities and across generations.
Overdose deaths: $72.6 billion
It makes sense that the biggest contributor to the costs of the epidemic comes from overdose deaths, according to Stoddard Davenport of Milliman, one of the report’s authors.
“When you think about the course of a person’s life that struggles with opioid use disorder, early mortality is the most significant adverse event that can happen, and I think that bears out when you look at the economic impact,” he says.
Every day, 130 people die from opioid overdoses. Most of them are in the 25-55-age range, right in the middle of their prime working years, and lost earning potential accounts for most of those costs.
“The mortality costs have a small component of end of life health care, coroner expenses and things like that,” he says. “The grand majority of it, however, is composed of lost lifetime earnings.”
Preliminary data suggest overdose deaths dipped in 2018 for the first time in years, but many experts say it’s too early to say whether that marks a turnaround.
Hall points out that whether the annual death toll stays as high as 47,000 in coming years “will be certainly a driver of what these overall economic costs will be.”
Health care: $60.4 billion
The next biggest amount comes from health care costs. The researchers took several large databases of insurance claims that had been scrambled to hide the identity of the patients and flagged people who had been coded as having opioid use disorder. Then the researchers calculated their overall health care costs — not just directly related to their addiction, but any additional costs — and compared them to similar patients without addiction.
Nearly one-third ($60.4 billion) of the estimated economic burden of the opioid
“Looking at the difference in costs gives us a sense for how much more complicated is their overall health care picture and what those additional expenses look like for two otherwise comparable people,” Davenport explains.
Opioid addiction is linked to other health problems. Patients might have chronic pain or mental illness that underlies their addiction; infectious diseases like HIV and hepatitis C can spread among injection drug users; and there can also be higher costs for other conditions like anemia, liver disease, and pulmonary heart disease, according to another Milliman analysis from earlier this year.
There are also health costs for people who live in the same household as someone with an opioid use disorder — their lives might be more complicated and their mental and physical health can suffer as a result.
Then there are the costs for infants born dependent on opioids — what’s called neonatal abstinence syndrome. “The epidemic effect is starting to create a second generation that extends down to children and unfortunately newborns as well,” Hall says. In 2018 those costs were $800 million, but they estimate this year they could be almost $1 billion.
There are still more costs the report could not capture, including elevated costs for patients whose opioid use disorder is undiagnosed and potential ongoing expenses for children born with neonatal abstinence syndrome as they grow up.
Lost productivity: $26.5 billion
When someone is addicted to opioids, they might not be able to apply for or hold down a job, or they might be incarcerated and unable to work. The researchers broke this section out into reduced labor force participation, absenteeism, incarceration, short and long term disability, and workers’ compensation.
“What we’re trying to capture is the amount of time that folks are spending not doing economically productive activities,” Davenport says. Other productivity costs — like “presenteeism,” when someone shows up at work but isn’t as productive as they otherwise would be — were not included here.
It’s also worth noting, many of these costs fall to private employers, for instance, and families who have a family member not bringing home income.
“It’s around 30% falling on the federal state and local governments,” he says. “The rest [falls to] the private sector and then of course to individuals.”
Criminal justice: $10.9 billion
Measuring this part of the costs of the epidemic is a different beast. The researchers captured costs related to police, court cases, correctional facilities and property lost to crime, Davenport explains. They drilled down into criminal justice expenses to see “what proportion of those total budgets involve substance use disorders, and then what proportion of that is represented by opioids.”
Having an opioid addiction dramatically increases the chance of being caught up in the criminal justice system. As NPR has reported, only 3% of the general population reported being recently arrested, on parole or on probation. For people with opioid use disorder, that jumped up to nearly 20%.
Child and family assistance and education: $9 billion
The team took a similar approach to calculate the costs for things like food assistance, child welfare, income, and housing assistance, and education. They took those total costs, figured out what portion was related to substance use, and what part of that was related to opioid use.
The epidemic has a profound impact on families and communities — parents with opioid use disorder have to navigate treatment and sometimes battle for custody of their kids; the state has to handle child welfare cases and find new homes for foster kids; and schools are providing counseling for kids with addicted parents.
“Typically an epidemic will start in one place but then it broadens out,” says Hall. “We’re starting to see a broadening out of the impact of the opioid epidemic into some second-generation effects.”
Hall adds there are also “the costs of educating people about the epidemic and ways to prevent future opioid use disorder.” Those costs — mostly from federal grants for elementary and secondary education programs — came out to $1.2 billion last year.
What’s missing: Turning the crisis around
These are some solid numbers that capture the current economic burden of the epidemic. Estimating what it’s going to cost to fix the crisis — to treat those who are addicted, to reduce overdose deaths, and more — is another story.
“The notion of abatement is that we want to deal with the problem that exists but also to begin to remedy it,” says Christopher Ruhm, professor of public policy and economics at the University of Virginia. He worked for several years on a 30-year abatement plan for Oklahoma as part of that state’s case against several drug companies.
For Oklahoma, Ruhm estimated treatment; prevention, education and surveillance for one year would cost $836 million. The judge in the case made his own calculations and ordered Johnson & Johnson to pay $572 million, though the amount has since been adjusted, and the case is currently being appealed.
If you scale Ruhm’s numbers up from that one state to the whole country, you get $69 billion to fund a year’s worth of abatement programs.
“I’m not saying that’s an appropriate calculation in the sense that things could be different in Oklahoma from other places,” Ruhm cautions. There are also costs that might come up on the federal level that wouldn’t be factored in for Oklahoma, such as research into effective addiction treatments.
Still, it gives you a rough idea, as society starts to take stock of what this epidemic is costing already, how much it will cost to try to fix it and who should ultimately pay.
Why Are Insurance Executives Treating Our Patients?
Kevin Campbell believes that peer-to-peer consults waste time and harm patients, I’m wondering where this opinion comes from, his medical degree?
Kevin Campbell reported that in two recent surveys, physicians said that pre-authorizations are burdensome to their practice and that they could lead to adverse patient outcomes. Kevin Campbell, MD, agrees that the insurance companies shouldn’t be part of patient practice, and says that the peer-to-peer review process is even worse.
The opinions expressed in this commentary are those of the author. The following transcript has been edited for clarity.
Insurance companies have been granted far too much control over patient care over the last several decades. Nowhere is it more apparent than when physicians are asked to obtain “pre-approval” for guideline-based, medically necessary procedures. According to one survey from the Medical Group Management Association, 83% of those surveyed said prior authorizations are “very” or “extremely” burdensome to their practice and their staff. Another survey conducted of physicians found that nearly one-third of doctors believe that spending time obtaining pre-authorizations actually led to adverse patient outcomes.
Ninety percent of those practice managers have indicated that the amount of pre-authorizations have significantly increased over the last year. To illustrate the sheer volume of this work, there were 182 million pre-authorization transactions conducted last year alone.
While Congress has given lip service to this issue by hosting a hearing with doctors in September, no real changes have occurred. In fact, the insurance companies have lobbied Congress that these pre-authorizations are needed to reduce costs and prevent unneeded treatments.
I find this practice offensive. Who are insurance executives to decide who needs or does not need a procedure? Who are they to determine the appropriateness of a procedure? Did they go to medical school? Have they ever looked a patient in the eyes and told them they cannot have a life-saving procedure done because it costs too much?
Worse than the pre-authorization is the peer-to-peer consultations. As an electrophysiologist, I spent nearly a decade training at Duke in order to become an expert in the implantation of pacemakers and ICDs and performing ablations. When I have a pre-auth denied, I have to get on the phone and argue my case for the procedure — which is based on ACC and HRS guidelines — to someone who has NEVER even seen a pacemaker, and almost always does not even understand how a pacemaker functions! Often these are retired pathologists, pediatricians, or other non-specialists that are making decisions about MY clinical judgment. In fact, an EP colleague of mine recently told me that he had to do a peer-to-peer consult to argue the appropriateness of an ICD implantation. When he began the consultation, the insurance company representative, who was supposedly an MD, said that he could not justify putting ACID into a patient. The trick here is that this guy did not even know that it was an AICD or a defibrillator and not ACID. This just illustrates the level of incompetence of the reviewing doctors that insurance companies hire to review the appropriateness of procedures.
We cannot stand for this any longer. Insurance companies are working around the clock to avoid paying for care. Our patients and our employers pay insurance companies for coverage. The physicians that care for patients every day — by and large — provide evidence-based care and do what is indicated for patients based on guidelines. It is insulting and frankly disgusting to have someone who has no knowledge of a particular specialty making a determination of care appropriateness on a patient that they have never evaluated and with no expert knowledge on the topic. Moreover, these reviewing MDs are actually compensated for NOT approving procedures.
Our patients are suffering. Our staff is becoming overworked in dealing with pre-authorizations. Our doctors are wasting valuable time on the phone arguing with ignorant MD reviewers employed and incentivized by insurance companies. Let’s take medicine back — contact your congressman or congresswoman today.
Verma to Democrats: Some insurance ‘better than no insurance at all’
Michael Brady noted that CMS Administrator Seema Verma on Wednesday defended the Trump administration’s actions on healthcare, telling the U.S. House of Representatives’ Energy and Commerce Committee that her agency is trying to provide greater access to care in the face of rising healthcare costs.
Verma touted the CMS’ efforts on a range of healthcare issues from health IT interoperability to opioid abuse throughout her testimony, but the committee’s Democratic members met her with fierce criticism. They said that under the Trump administration, the healthcare system is heading in the wrong direction and that the Affordable Care Act is succeeding “despite” the administration’s best efforts to undermine it.
The Democrats were especially concerned about the CMS’ expansion of short-term, limited-duration insurance, a recent drop in the number of people with insurance, waivers for Medicaid work requirements and the administration’s unwillingness to share information about what it’ll do if a court throws out the ACA.
The CMS loosened restrictions on short-term, limited-duration insurance last year to provide more affordable coverage options to consumers who don’t have employer-sponsored insurance but earn too much to receive subsidies for plans offered through ACA exchanges or qualify for federal programs like Medicaid. Unlike plans sold on the exchanges, they don’t have to meet the ACA’s mandates.
Critics, including the committee’s Democratic members, argue that these plans are affordable because they don’t cover as much as ACA-approved plans that have caps of cost-sharing and require payers to cover people with pre-existing conditions. Throughout the hearing, several committee members called them “junk” health plans. And the representatives repeatedly confronted Verma on the lack of ACA protections for consumers.
“What are people with these junk plans supposed to do when they need vital healthcare services that are not covered by these junk plans?” said Rep. Paul Tonko (D-N.Y.).
Verma responded that when the other plans available to people are unaffordable, the short-term plans are “better than no insurance at all.”
“If there were more affordable options available under Obamacare, people wouldn’t have to make compromises,” Verma said.
Several committee members also took aim at the Trump administration for a recent falloff in the number of people who have health insurance. Nearly 2 million more people lacked health insurance in 2018 compared with the year before, according to a report from the U.S. Census Bureau. The report showed that a dropoff in Medicaid coverage caused most of the decline.
“Under this administration, thousands of children and families have lost coverage of basic health services … the numbers just don’t lie,” said Rep. Diana DeGette (D-Colo.).
But the worries about Medicaid weren’t limited to Democrats; Republicans had concerns too.
“How do we ensure that the populations, some of the most vulnerable in our communities, are actually getting the care that we have promised to them?” said Rep. Cathy McMorris Rodgers (R-Wash.).
Committee Democrats also brought up the administration’s approval of Medicaid work requirement waivers, which seem increasingly likely to get struck down by the courts because of HHS’ failure to consider their effects on coverage. Low-income, working-age adults in Arkansas were less likely to have health insurance, work or participate in community engagement activities after the state’s work requirement went into effect, according to a recent study in the New England Journal of Medicine. That’s despite Arkansas’ unemployment rate declining over that period.
“Can you point me to one study that says a work requirement makes people healthier?” asked Rep. Joe Kennedy III (D-Mass.). “Healthier people might work, but working doesn’t necessarily make people healthier.”
Several members of the committee also wanted to know what the administration would do if the 5th U.S. Circuit Court of Appeals were to uphold a lower court ruling that would invalidate the ACA entirely. They were especially frustrated that HHS had “stonewalled” them on their requests for documents about the administration’s contingency plans, especially those related to likely coverage losses and protections for pre-existing conditions.
Committee members also wanted to know why the administration didn’t ask the courts to safeguard the parts of the law that the administration says it supports. They asked about protections for pre-existing conditions or allowing kids to stay on their parents’ health insurance until they are 26 years old.
“Did the administration file some kind of motion in the Texas case to say that the pre-existing conditions should be maintained?” DeGette asked.
“We will maintain what works and we will try to address the problems that we’re having with the ACA,” Verma replied.
She added that people with pre-existing conditions “don’t have the protections today” if they can’t afford the coverage.
“Where is the plan?” asked Rep. Jan Schakowsky (D-Ill.).
An analysis by the left-leaning Urban Institute estimates that roughly 20 million people will lose coverage if the courts toss out Obamacare altogether.
And hopefully, we will hear from Ms. Warren regarding how she proposes to pay for Medicare for All, her answer for the Democrats’ new health care system. I can’t wait to hear how all their plans are going to be paid for.
Happy Halloween to All you Goblins, Devils, Witches and Yes you Politicians that act like Goblins and Devils and Witches and Donkeys!