Opioids After Surgery Left Her Addicted. Is That A Medical Error?


In April this year, Katie Herzog checked into a Boston teaching hospital for what turned out to be a nine-hour-long back surgery.

The 68-year-old consulting firm president left the hospital with a prescription for Dilaudid, an opioid used to treat severe pain, and instructions to take two pills every four hours as needed. Herzog took close to the full dose for about two weeks.

Then, worried about addiction, she began asking questions. “I said, ‘How do I taper off this? I don’t want to stay on this drug forever, you know? What do I do?’” Herzog said, recalling conversations with her various providers.

She said she never got a clear answer.

So she turned to Google to try to figure out how  to wean herself off the Dilaudid. She eventually found a Canadian Medical Association guide to tapering opioids.

“So I started tapering from 28 [milligrams], to 24 to 16,” Herzog said, scrolling through a pocket diary with red cardinals on the cover that she used to keep track.

About a month after surgery, she had a follow-up visit with her surgeon. She had reached the end of her self-imposed tapering path the day before and at the doctor’s, she recalls feeling quite sick.

“I was teary, I had diarrhea, I was vomiting a lot, I had muscle pains, headache, I had a low-grade fever,” Herzog recalled.

The surgeon thought she had a virus and told her to see her internist. Her internist came to the same conclusion.

She went home and suffered through five days of what she came to realize was acute withdrawal, and two more weeks of fatigue, nausea and diarrhea.

“I had every single symptom in the book,” Herzog said. “And there was no recognition by these really professional, senior, seasoned doctors at Boston’s finest hospitals that I was going through withdrawal.”

Herzog did not name any of the providers who had something to do with her pain management or missed signs of withdrawal. She said she sees this as a system-wide problem. Herzog did share medical records that support her story. After the withdrawal, she did not crave Dilaudid and she manages any lingering pain with Tylenol. She has since returned to her providers, who’ve acknowledged that she was in withdrawal.

Not An Isolated Incident

Herzog’s story is one doctors are hearing more and more. “We have many clinicians prescribing opioids without any understanding of opioid withdrawal symptoms,” said Dr. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and co-director of the Opioid Policy Research Collaborative at Brandeis University’s Heller School. One reason, Kolodny said, is that doctors don’t realize how quickly a patient can become dependent on drugs like Dilaudid.

Sometimes that dependence leads to full-blown addiction. About half of street drug users say they switched to heroin after prescribed painkillers became too expensive.

Now, a handful of doctors and hospital administrators are asking, if an opioid addiction starts with a prescription after surgery or some other hospital-based care, should the hospital be penalized? As in: Is addiction a medical error along the lines of some hospital-acquired infections?

Writing for the blog and journal Health Affairs, three physician-executives with the Hospital Corporation of America argue for calling it just that.

“It arises during a hospitalization, is a high-cost and high-volume condition, and could reasonably have been prevented through the application of evidence-based guidelines,” write Drs. Michael SchlosserRavi Chari and Jonathan Perlin.

The authors admit it would be hard for hospitals to monitor all patients given an opioid prescription in the weeks and months after surgery, but they say hospitals need to try.

“Addressing long-term opioid use as a hospital-acquired condition will draw a clear line between appropriate and inappropriate use, and will empower hospitals to develop evidenced-based standards of care for managing post-operative pain adequately while also helping protect the patient from future harm,” said Schlosser in an emailed response to questions.

Kolodny said it’s an idea worth considering.

“We’re in the midst of a severe opioid epidemic, caused by the over-prescribing of opioids,” Kolodny said. “Putting hospitals on the hook for the consequences of aggressive opioid prescribing makes sense to me.”

Potential Addiction Vs. Pain Management Awareness

But penalizing hospitals for patients who become addicted to opioids conflicts with payments tied to patient satisfaction surveys. Hospitals that do not adequately address patients’ pain may lose money for low patient satisfaction scores. In response to the opioid epidemic, patient surveys are shifting from questions like, “Did the hospital staff do everything they could to help you with your pain?” to questions that emphasize talking to patients about their pain. But physicians may still prescribe more, rather than fewer, opioids to avoid complaints from dissatisfied patients.

“This is a real concern that patients who may feel that their pain is under-managed may take that out in these patient report cards,” said Dr. Gabriel Brat, a trauma surgeon at Beth Israel Deaconess Medical Center who studies the use of opioids after surgery at Harvard Medical School.

Most patients leave the hospital with more pain meds than they need. Studies show that between 67 and 92 percent of patients have opioid pills left over after common surgical procedures.

One reason that may contribute to over-prescribing is that patients vary a lot. Brat said about 10 percent of patients need intense pain management, but it’s difficult to identify who will be that 10 percent.

“Many surgeons are still prescribing opioids for the subset of patients that have higher requirements, as opposed to for the majority of patients who are taking a very small percentage of the pills that they are prescribed,” Brat explained.

There are no firm guidelines for which opioids to prescribe after surgery, at what dose or for how long. The CDC released opioid prescribing guidelines for chronic pain in 2016, but it included only brief references to acute pain.

Some opioid prescribing guidance for surgeons is emerging. A study published in September reviewed surgical records for 215,140 patients. It found that the optimal opioid prescription following general surgery is between four to nine days.

This story is part of a reporting partnership with NPR, WBUR and Kaiser Health News.

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Lil Peep’s Cause Of Death Confirmed: Toxicology Report Points The Finger At Fentanyl, Xanax

Lil Peep in the music video for “Awful Things.”
Photo Credit Lil Peep | YouTube

The cause of the untimely death of young rapper, Lil Peep, has been released to the public.

Over three weeks after reports of his death, the Pima County Medical Examiner has released the toxicology report that reveals that Peep (born Gustav Ahr) died from an overdose of Fentanyl and Xanax. The report also confirmed that the death was accidental.

A Deadly Mix

While fairly safe to use, Fentanyl and Alprazolam are a dangerous mix. Alprazolam, the generic name of Xanax, is a well-known anti-anxiety drug.

According to Drugs.com, mixing fentanyl with alprazolam (and other drugs that cause central nervous system depression) is fatal. Other side effects include respiratory distress and coma.

At the time of his death, Lil Peep’s older brother, Karl Aher, suspected that the pill the rapper took might have been laced.

“We [the family] have heard there was some sort of substance he did not expect to be involved in the substance he was taking,” Oskar told People. “He thought he could take what he did, but he had been given something and he didn’t realize what it was.”

He also mentioned that his brother, Karl, had a healthy relationship with drugs. Moreover, there was no reason for the rapper, who was also a model and fashion icon, to take his own life.

“He was super happy with where he was in life,” Oskar added.

Authorities found drug paraphernalia and evidence of an overdose at the scene. No foul play was suspected.

Drug Cocktail

TMZ reported that the medical examiner also found traces of other recreational drugs in his system. Lil Peep tested positive for marijuana and cocaine. The YouTube star also tested positive for the painkiller Tramadol and other powerful opiates such as Hydrocodone, Hydromorphone, Oxycodone, and Oxymorphone.

The medical examiner, however, did not find any traces of alcohol in his system at the time of his death.

Untimely Death

Lil Peep was found lifeless inside his tour bus on Nov. 16, hours before he was scheduled to perform at a nightclub in Tucson, Arizona. He was laid to rest in a quiet memorial held in his hometown of Long Beach, California on Dec. 12.

The music industry is mourning the untimely death of the emerging rapper who, a few months ago, has released his first and only studio album, Come Over When You’re Sober (Part One). Fellow musicians such as Diplo, Sam Smith, and Pete Wentz of Fall Out Boy have paid tribute to the young artist. His ex-girlfriend, actress Bella Thorne, also expressed her grief on her personal Twitter and Instagram accounts.


© 2017 ENSTARZ, All rights reserved. Do not reproduce without permission.

Could IdealShake be the Best Meal Replacement Shake to Help You Drop Pounds This Winter?

There are always a couple things you want to look for in the best meal replacement shake, but the most important qualities have to be:

  • Plenty of protein to flood your body with necessary resources to recover from grueling workouts while starving the fat creation components of your body 
  • The right amount of effortlessly digestible carbohydrates to give you the energy you need to get through the day without fueling fat creation 
  • A flavor and consistency that isn’t going to have you shying away from meal replacement shakes and towards unhealthy snacks that aren’t going to help you get the results you are looking for

The IdealShake formula covers all of the above bases and then some, giving you the opportunity to lose weight faster than you would have been able to otherwise while at the same time making sure you lead a healthy and productive lifestyle along the way.

If you have been thinking about taking the plunge with what you think is the best meal replacement shake solution, but aren’t quite sure of whether or not it is really right for you, check out the inside information we are able to share below.

Proven formula designed to help you decrease fat

Right out of the gate, you’re going to appreciate the fact that the IdealShake formula includes everything you need to start burning fat a lot faster than you would have been able to with traditional meals – keeping your calories restricted while filling you up and flooding you with all of the protein you need without bogging you down with all kinds of carbohydrates and sugar.

Each and every single serving of the IdealShake comes in at about 100-110 calories, with 11g of high quality protein in just 2g or less of sugar. The formulation also includes a number of hunger blockers designed to cut down on your cravings while making you feel full, giving you a big boost when it comes to portion control.

Tastes so good you’ll replace meals with no trouble at all

Of course, even the best meal replacement shake isn’t going to be able to help you out at all unless you are excited to replace actual meals with it – and that’s only going to happen when you are dealing with a meal replacement shake that’s tasty enough to get you to skip some of your favorite meals.

The IdealShake comes in a variety of different flavors, each and every one of them delicious, but a lot of people consider the Chocolate version of the IdealShake to be the very best of the bunch. It is almost impossible to imagine any weight loss journey being easier than the one where you get to enjoy a delicious chocolate shake that helps you melt fat at the same time!

Won’t risk your short or long-term health

Of course, you need to make sure that you aren’t getting conned with modern-day snake oil peddled by less than ethical marketers these days – which proves more difficult than most anticipate, considering just how insidious some of the weight loss companies out there can be.

Thankfully though, the folks behind the IdealShake formulation aren’t ever going to risk putting your short or long-term health in jeopardy. The formulation is proven, safe, and free of nasty chemicals that can derail your health and wellness, and is instead loaded with ingredients designed to support your weight loss journey while making you feel – and look – better every step of the way.

Closing thoughts

At the end of the day, you’ll have plenty of different options to pick and choose from when it comes time to start your weight loss journey this winter.

But if you’re serious about accelerating your rate of weight loss while at the same time enjoying one of the most delicious meal replacement shakes that’s been proven time and time again to provide you with results you can depend on, you need look no further than the IdealShake formulation.

Some other options to find the best meal replacement shake include 310 Shake, Vega One Shake and the Orgain Shake if you want to look into some more.

Fergie Reveals Details About Her Addiction To Crystal Meth: ‘I Was Suffering From Psychosis And Dementia’

Fergie opened up about her struggles with crystal meth addiction. The 42-year-old popstar said she suffered from symptoms of psychosis and dementia as a result of the drug abuse.
Photo Credit Kevin Winter | Getty Images

Fergie has achieved chart success as the female vocalist of the hip-hop group, The Black Eyed Peas, as well as a solo artist.

The 42-year-old singer, who recently released her first studio album in 11 years, is also considered as one of the most popular solo female artists in the world today. However, her journey to stardom includes a battle with drug addiction that not many people know about.

Fergie Talks Crystal Meth Addiction

In a recent interview with British publication iNews, the Double Duchess hitmaker, Fergie candidly opened up about her past struggle with crystal meth addiction and the serious implications it had on her health.

The “Fergalicious” singer said that before she found fame with Black Eyed Peas, she was severely addicted to crystal meth. Her addiction was so bad that she started having hallucinations every day.

“At my lowest point, I was [suffering from] chemically induced psychosis and dementia,” she revealed. “I was hallucinating on a daily basis. It took a year after getting off that drug for the chemicals in my brain to settle so that I stopped seeing things. I’d just be sitting there, seeing a random bee or bunny.”

‘The Hardest Boyfriend’

Fergie pointed out that the intensity of her visions reached a point where she actually thought that the CIA, FBI, and the SWAT were following her. She then recalled one encounter when she tried to find comfort in a church but was chased away because of her crazy antics inside the place of worship.

She further said that although the drug phase was “a lot of fun,” it was the lowest point in her life. However, she is grateful that it happened because she used it as a learning experience.

This isn’t the first time Fergie has spoken about her history of drug use in the hopes that her story can help others. In 2006, she referred to her addiction as “the hardest boyfriend” she had to part ways with.

Split With Josh Duhamel

In September, Fergie and husband Josh Duhamel announced via a joint statement that they were splitting up after eight years of marriage. The former Hollywood couple shares a 4-year-old son named Axl Jack.

In her interview, she also touched on life as a single mother, how she’s managing work and dealing with her separation from the Transformers actor at the same time.

© 2017 ENSTARZ, All rights reserved. Do not reproduce without permission.

From Not To Hot: Mama June Sets Sights On Pageant Queen Dream After Losing 300 Pounds


Mama June has set her sights on becoming a pageant queen after an impressive 300-pound weight loss. The Mama June: From Not To Hot star documented her journey on the reality TV show.

Mama June Wants To Become A Pageant Queen

In the Season 2 trailer of Mama June: From Not To Hot, Mama June revealed that one of her biggest dreams is to join a beauty pageant.

“I’ve been always on the other side of pageant world… I have not talent,” said Mama June.

Her daughter, Alana Thompson, also known as Honey Boo Boo, will be teaching her mom how to walk on the runway. The 12-year-old is worried that her mom won’t be able to win her much-desired crown because she’s a newbie in the pageant world.

However, Mama June won’t stop at anything so she could bring home the crown, even though some of her friends think that she’s already too old to join the competition.

Elsewhere, the second season of Mama June: From Not To Hot will also feature Mama June’s health struggles. Despite her 300-pound weight loss, the 38-year-old Georgia native tells the cameras that she’s going through tough times.

In one of the scenes, Honey Boo Boo’s older sister asks her to hurry up because they need to take their mom to the hospital. While there, Mama June is attached to tubes, and she dozes off while her family awaits news on what they should do next.

Mama June’s Weight Loss Update

Last month, a photo of the reality TV star surfaced online and it’s evident that Mama June managed to maintain her 300-pound weight loss for the past seven months.

The reality TV star previously weighed 460 pounds. Mama June underwent gastric sleeve surgery, breast augmentation, and loose skin removal. She spent $75,000 for all of the procedures and managed to weigh 137 pounds afterward.

Also in Mama June: From Not To Hot, Mama June will find out that one of her daughters is pregnant. Her ex-boyfriend, Mike Thompson who is also known as Sugar Bear, will make an appearance in the second season of the We TV series.

Earlier this year, Mama June accused Sugar Bear of physically and emotionally abusing her and her children.

“It’s time the world sees him for what he is. Lauryn ‘Pumpkin’ Shannon’s eye buckle was caused by him… because he got mad. So many emotional and physical scars with the kids,” said Shannon.

© 2017 ENSTARZ, All rights reserved. Do not reproduce without permission.

Stopping Opioid Addiction At One Key Source: The Hospital

It may not be rocket science, but a group of surgeons at the University of Michigan’s Michigan Medicine have devised a strategy to curb the nation’s opioid epidemic — starting at their own hospital.

Their findings appeared online Wednesday in the journal JAMA Surgery.

Opioid addiction has been deemed a “national emergency.” It’s estimated to have claimed 64,000 lives in 2016 alone. And research shows that post-surgical patients are at an increased risk of addiction because of the medication they receive to help manage pain during recovery.

It’s a simple enough idea: Surgeons should give patients fewer pills after surgery — the time when many people are first introduced to what can be highly addictive painkillers. They should also talk to patients about the proper use of opioids and the associated risks.

That seemingly small intervention could lead to significant changes in how opioids are prescribed and make inroads against the current epidemic, said the researchers.

“The way we’ve been prescribing opioids until this point is we’ve basically been taking a guess at how much patients would need,” said Jay Lee, a research fellow and general surgery resident at the University of Michigan, and one of the paper’s authors. “We’re trying to prevent addiction and misuse by making sure patients themselves who are receiving opioids know how to use them more safely — that they are getting a more consistent amount and one that will reduce the risk of them getting addicted.”

The researchers identified 170 patients who underwent gallbladder surgery and surveyed them within a year of the operation — asking how many pills they actually used, what pain they experienced after surgery and whether they had used other painkillers, such as ibuprofen.

They used those findings to create new hospital guidelines that cut back the standard opioid prescription for gallbladder surgeries.

Then, they analyzed how patients fared under the new guidelines, tracking 200 new surgery patients who received substantially fewer pills — an average of 75 milligrams, compared with 250 mg previously. Despite getting less medication, patients didn’t report higher levels of pain, and they were no more likely than the previously studied patients to ask for prescription refills. They were also likely to actually use fewer pills.

The takeaway: After surgery, patients are getting prescribed more opioids than necessary and doctors can reduce the amount without experiencing negative side effects.

Within five months of the new guidelines taking effect at Michigan Medicine, surgeons reduced the volume of prescribed opioids by about 7,000 pills. It’s now been a year since the change took effect, and the researchers estimate they have curbed prescriptions by about 15,000 pills, said Ryan Howard, a general surgery resident and the paper’s lead author.

That has real implications. Studies have found that overprescribing opioids helps drive the epidemic. It can put patients at risk of addiction. And it endangers friends and family, who can easily acquire unused excess pills in, for instance, an unsecured medication cabinet. Reducing prescriptions altogether makes that less likely.

“This really shows in a very methodological way that we are dramatically overprescribing,” said Michael Botticelli, who spearheaded drug-control policy under the Obama White House, including the administration’s response to the opioid crisis.

“Not only do we have to reduce the supply to prevent future addiction, but we really have to minimize opportunities for diversion and misuse,” he said.

More hospitals are starting to turn in this direction, Botticelli said. He now runs the Grayken Center for Addiction at Boston Medical Center, which is also trying to systematically reduce opioid prescriptions after patients have surgery.

Meanwhile, 24 states have passed laws to limit how many pills a doctor can prescribe at once, according to the National Conference of State Legislatures.

“Those limits are just sort of generic limits across the board,” said Chad Brummett, an anesthesiology professor at the University of Michigan and another co-author of the paper. Their concept, he added, “is a step even further beyond what some of these policymakers are trying to do, and it’s one I think surgeons are more likely to adopt.”

The researchers also created a set of talking points for doctors and nurses to use with patients based on “fairly common sense” measures, Lee said. They include:

  • Encouraging patients to use lower-strength, non-addictive painkillers first;
  • Warning them about the risks of addiction; and
  • Reminding them that even a sufficient opioid prescription would leave them feeling some pain.

The talking points also offer tips for patients on safely storing and disposing of extra pills.

“So much of this problem can be addressed with solutions that are not complicated … like telling patients what to do with the medications when they’re finished using them,” said Julie Gaither, an instructor at Yale School of Medicine. Gaither has researched the opioid epidemic’s consequences, though she was not involved with this study.

The Michigan team is pushing its new prescribing guidelines online, in hopes of encouraging other hospitals to adopt similar practices. It also has started implementing the change in other hospitals around the state.

Still, this gets at only a small part of the problem, noted Jonathan Chen, an assistant professor of medicine at Stanford University, who has also researched opioid abuse and addiction. The bulk of opioid prescriptions are written by family doctors and general internists, he said.

“This won’t solve every problem — but nothing ever does,” said Chen, who was not involved with this study. “It’s one concrete area, and a natural place to start.”

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Choosing a Plant-Based Meal Replacement Shake to Get Fit This Winter

Trying to lose weight on your own is nowhere near as simple, straightforward, or easy as a lot of people make it out to be!

Believe it or not, a lot more has to go on than just “eating better and moving more” if you’re going to burn fat from your body as quickly and as permanently as possible. Thankfully though, the best meal replacement shake, and specifically products like the Vega Shake have been designed to provide you with an almost unfair advantage against fat – helping you break down and destroy fat wherever it is found in the body much faster than you would have been able to otherwise.

On top of that, the Vega Shake formulation gives everyone the opportunity to enjoy a quality meal replacement solution – even if you are vegetarian or vegan!

One of the few 100% plant-based meal replacement shake options on the planet today, the Vega Shake formulation is everything you need to jumpstart your weight loss journey and enjoy the kinds of body transformation results you deserve. You’ll be able to clean up your diet much faster than you ever thought possible, all while enjoying one of the most delicious meal replacement solutions available on the market.

Let’s learn a little bit more about why many people consider the Vega Shake to be the best meal replacement shake available to help you lose weight this winter.

100% plant-based so that everyone can use it

The coolest thing about the Vega Shake formulation is the fact that it uses real plant-based food ingredients as opposed to animal ingredients or synthetic ingredients cooked up in some laboratory somewhere.

People are really starting to understand and embrace the fact that they have different dietary restrictions than others, and some are making lifestyle decisions that do not allow them to eat animal products or dairy quite as casually as others are willing to.

With Vega Shakes, you won’t ever have to worry about compromising any of your principals or any of your dietary restrictions just to take advantage of a meal replacement solution that actually works. Utilizing soy ingredients and a whole host of other plant-based materials loaded with all the nutrients you need to recover and accelerate your weight loss results, Vega Shakes have what it takes to get the job done effectively and efficiently.

A whole lineup of Vega nutrition products to get you the results you are after

On top of the Vega Shake options, there are also a whole host of other Vega Nutrition products available on the market today that are going to be able to accelerate the results that you would have received with just Vega Shakes – really kicking your body into high gear and providing you with the jumpstart you need to lose weight faster.

We’re talking about Vega meal replacement bars, nutritional supplements, fat burners, and more – each and every one created specifically to “play nicely” with every other Vega option so that you’re able to lose weight, build muscle, and lead a happier and healthier lifestyle.

All-natural compounds guaranteed you don’t deal with nasty side effects

If you’ve been paying attention to the weight loss world for any amount of time you’ve no doubt discovered that many of the meal replacement shakes available for sale these days are sometimes anything but safe and anything but guaranteed to produce the results you are looking for – giving you all the more reason to decipher the best meal replacement shake from the bunch.

But because the Vega Shake formulation doesn’t use fake, phony, or synthesized materials in ingredients, you don’t have to worry about your body rejecting this nutritional supplement, nasty side effects rearing their ugly head and causing all kinds of pain, and being dissatisfied with the rate of weight loss you have been hoping for.

These shakes have been shown to work, and when combined with a clean, healthy, and improved daily diet and moderate exercise throughout the week you’re going to be able to shave pounds off of your figure faster than you ever would have thought possible. You’ll be able to melt fat all winter long and come out in the spring with a beach body ready for the heart of summer! 

If Your Insurer Covers Few Therapists, Is That Really Mental Health Parity?

That’s the conclusion of a report published Thursday by Milliman Inc., a national risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.

Among the findings:

  • In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.
  • Insurers pay primary care providers 20 percent more for the same types of care as they pay addiction and mental health care specialists, including psychiatrists.
  • State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington D.C., the figure was 63 percent.

The researchers at Milliman examined two large national databases containing medical claims records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and the District of Columbia from 2013 to 2015.

“I was surprised it was this bad. As someone who has worked on parity for 10-plus years, I thought we would have done better,” said Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company. “This is a wake-up call for employers, regulators and the plans themselves that whatever they’re doing, they’re making it difficult for consumers to get treatment for all these illnesses. They’re failing miserably.”

The high proportion of out-of-network behavioral care means mental health and substance-abuse patients were far more likely to face the high out-of-pocket costs that can make treatment unaffordable, even for those with insurance.

In a statement issued with the report, the coalition of mental health groups, including Mental Health America, the National Association on Mental Illness, and The Kennedy Forum, called on federal regulators, state agencies and employers to conduct random audits of insurers to make sure they are in compliance with the parity law.

Harbin, now a consultant on parity issues, said the report’s finding that mental health providers are paid less than primary care providers is a particular surprise. In nine states, including New Hampshire, Minnesota, Vermont, Maine and Massachusetts, payments were 50 percent higher for primary care providers when they provided mental health care.

Because of such low reimbursement rates, he said, mental health and substance abuse professionals are not willing to contract with insurers. The result is insurance plans with narrow behavioral health networks that do not include enough therapists and other caregivers to meet the demands of patients.

For years, insurers have maintained that they are making every effort to comply with the Mental Health Parity and Addiction Equity Act, which was intended to equalize coverage of mental health and other medical conditions. And previous research has found that they have gone a long way toward eliminating obvious discrepancies in coverage. Most insurers, for example, have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.

Still, discrepancies appear to continue in the more subtle ways that insurers deliver benefits, including the size of provider networks.

Kate Berry, a senior vice president at America’s Health Insurance Plans, the industry’s main trade group, said the real problem is the shortage of behavioral health clinicians.

“Health plans are working very hard to actively recruit providers” and offer telemedicine visits in shortage areas, said Berry. “But some behavioral health specialists opt not to participate in contracts with providers simply because they prefer to see patients who are able to pay out of their pocket and may not have the kind of severe needs that other patients have.”

“This is a challenge that no single stakeholder in the health care infrastructure can solve,” she added.

Carol McDaid, who runs the Parity Implementation Coalition, countered that insurers have been willing and able to solve provider shortages in other fields. When there was a shortage of gerontologists, for example, McDaid said, insurers simply increased the rates and more doctors joined the networks. “The plans have the capacity to do this; I just think the will hasn’t been there thus far,” she said.

The scarcity of therapists who accept insurance creates a care landscape that is difficult to navigate for some of the most vulnerable patients.

Ali Carlin, 28, said she used to see her therapist in Richmond, Va., every week, paying a copay of $25 per session. But in 2015, the therapist stopped accepting her insurance, and her rate jumped to $110 per session.

Carlin, who has both borderline personality disorder and addiction issues, said she called around to about 10 other providers, but she couldn’t find anyone who accepted her insurance and was taking new patients.

“It’s such a daunting experience for someone who has trouble maintaining their home and holding a job and friendships,” said Carlin. “It makes me feel like no one can help me, and I’m not good enough, and it’s not an attainable goal.”

In Virginia, the Milliman report found that 26 percent of behavioral health office visits were out-of-network — more than seven times more than for medical care.

With no alternative, Carlin stuck with her old therapist but must save up between sessions. She has just enough to cover a visit once every few months.

“I make $30,000 a year. I can’t afford an out-of-pocket therapist or psychiatrist,” said Carlin. “I just can’t afford it. I’m choosing groceries over a therapist.”

Angela Kimball, director of advocacy and public policy at the National Alliance on Mental Illness, said she worries many patients like Carlin simply forgo treatment entirely.

“One of the most common reasons people give of not getting mental health treatment is the cost. The other is not being able to find care,” she said. “It’s hurting people in every corner of this nation.”

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Hospitals With History Get A Second Life

When Laura Kiker rented a new apartment in September a few blocks from the U.S. Capitol in Washington, she knew she was moving into a historical neighborhood.

She had no idea, though, that her new home at 700 Constitution Ave. Northeast was a former hospital dating back nearly a century.

Today, she loves living in what used to be a patient room, in a four-story building with wide hallways, high ceilings and restored post-World War II-style architecture. A spacious rooftop deck, yoga studio and indoor dog wash are added bonuses for Kiker, and her dog, Stella. “There is so much history in this town, it’s nice to live in a place that has its own,” said Kiker, 30, a management consultant.

Across the country, hospitals that have shut their doors are coming back to life in various ways: as affordable senior housing, as historical hotels and as condos, including some costing tens of millions in the heart of New York’s Greenwich Village.

A wing of Specialty Hospital Capitol Hill found new life as an apartment house at 700 Constitution Ave. Northeast — reflecting its storied architecture. (Courtesy Borger Management)

The trend of converting hospitals to new uses has accelerated as real estate values have soared in many U.S. cities. At the same time, the demand for inpatient beds has declined, with the rise of outpatient surgery centers and a move toward shorter hospital stays.

As health systems consolidate for financial reasons, they might prefer that patients visit their flagship hospital while buildings related to smaller hospitals in their orbit get sold off — especially if the latter have a disproportionate share of indigent patients.

David Friend, chief transformation officer at the consulting firm BDO in Boston, noted that real estate is one of urban hospitals’ most valuable assets. “A hospital could be worth more dead than alive,” he said.

The number of hospitals in the U.S. has declined by 21 percent over the past four decades, from 7,156 in 1975 to 5,627 in 2014, according to the latest federal data.

Even when the conversions make medical sense, they pull at the heartstrings of communities whose residents have an emotional attachment to hospitals where family members were born, cured or died. But they sometimes create health deserts in their wake.

St. Vincent’s Hospital in New York treated survivors of the Titanic’s sinking in 1912, the first AIDS patients in the 1980s and victims of the 9/11 terrorist attacks in 2001, went bankrupt and closed seven years ago. Developer Rudin Management bought it for $260 million and transformed it into a high-end condo complex, which opened in 2014. Earlier this year, former Starbucks CEO Howard Schultz reportedly bought one of the condos for $40 million.

New York’s St. Vincent’s Hospital, a Greenwich Village institution for 160 years, closed permanently on April 30, 2010, after an unsuccessful search to find a way out of its estimated $700 million debt. It was transformed into luxury town homes. (Photo by Mario Tama/Getty Images)

Developers turned the old St. Vincent’s Hospital site into town houses, some of which sell for tens of millions of dollars today. (Courtesy of Greenwich Lane)

Jen van de Meer, an assistant professor at the Parsons School for Design in New York, who lives in the neighborhood, said residents’ protests about the conversion were not just about the optics of a hospital that had long served the poor being repurposed. “Now, if you are in cardiac arrest, the nearest hospital could be an hour drive in a taxi or 20 minutes in an ambulance across the city,” van de Meer said.

St. Vincent’s is one of at least 10 former hospitals in New York City that have been turned into residential housing over the past 20 years.

What’s next, a pet-icure? Leo gets pampered at the indoor dog wash at 700 Constitution, a hospital-turned-apartment house in Washington, D.C. (Phil Galewitz/KHN)

Closing a hospital and converting it to another use is not exactly like renovating an old Howard Johnson’s, said Jeff Goldsmith, a health industry consultant in Charlottesville, Va. “A hospital in a lot of places defines a community — that’s why it’s so hard to close them,” said Goldsmith, who noted that after Martha Jefferson Hospital closed its downtown facility in 2009 to move closer to the interstate highway, an apartment building took its place.

But many older hospitals are too outmoded to be renovated for today’s medical needs and patient expectations. For example, early 20th-century layouts cannot accommodate large operating room suites and private rooms, said Friend.

Real estate investors say the location of many older hospitals — often in city centers near rail and bus lines — makes them attractive for redevelopment. The buildings, with their wide hallways and high ceilings, are often easy to remake as luxury apartments.

Spurring Development

In some circumstances, a conversion provides a much-needed lift for the community. New York Cancer Hospital, which opened on Central Park West in 1887 and closed in 1976, was an abandoned and partially burned-out hulk by the time it was restored as a condo complex in 2005. Developer MCL Companies paid $24 million for the property, branded 455 Central Park West.

“The building itself is fantastic and a landmark in every sense of the word,” said Alex Herrera, director of technical services at the New York Landmarks Conservancy. He noted that it retained some of its original 19th-century architecture.

The Eastern Dispensary Casualty Hospital, shown here in 1936, was founded in 1888 in southeast Washington, D.C. It eventually was developed into Specialty Hospital Capitol Hill. (Courtesy Library of Congress)

Nicky Cymrot, president of the Capitol Hill Community Foundation in Washington, D.C., a neighborhood group, said that when Specialty Hospital Capitol Hill sold off a little-used 100,000-square-foot wing of its facility that became 700 Constitution, neighbors weighed in with concerns about aesthetics and traffic. The building was first known as Eastern Dispensary Casualty Hospital, which opened in 1905.

But by the time the condominium opened early this year after a five-year, $40 million renovation, the response was positive.

Sophie White, 28, who moved into 700 Constitution this summer, watched the building’s transformation and renovation from a rental property a few blocks away. “It used to be a blight on the neighborhood with unsavory people milling around it,” she said. “Now, it’s a bright spot and with its dog park out front, it’s really a cool place to live.”

Nearly half of the 139-unit building, where one-bedroom apartments rent for nearly $2,600 per month, is already leased. Asked why former hospitals are being bought and redeveloped as housing: “It’s all about location, location, location,” said Terry Busby, CEO of Arlington-based Urban Structures.

Columbia Hospital for Women, in the heart of Washington, D.C., was built in 1915 and shuttered in 2002.
(Courtesy of Library of Congress)

The developer paid more than $30 million for the old hospital property and turned it into an upscale 225-unit luxury condominium community near George Washington University. (Courtesy of Trammell Crow Company)

Likewise Columbia Hospital for Women, which had delivered more than 250,000 babies since it opened shortly after the Civil War, closed in 2002 and reopened in 2006 as condos with a rooftop swimming pool in the city’s fashionable West End.

Some former hospitals are used for purposes other than housing.

In Santa Fe, N.M., St. Vincent Hospital moved into a new facility in 1977 and the old structure downtown was reborn as a state office building. Later, it was abandoned and locals listed it as one of the spookiest places in town. In 2014, the building reopened yet again as the 141-room Drury Plaza Hotel.

‘A Building With Tremendous History’

After Linda Vista Community Hospital, in L.A.’s Boyle Heights neighborhood, closed in the 1990s, the abandoned six-story building fell into disrepair — its empty patient rooms, discarded medical equipment and aging corridors serving as sets for movies such as “Pearl Harbor” and “Outbreak.” Amcal Multi-Housing Inc. bought the property in 2011 and redeveloped it into a low-income senior apartment house called Hollenbeck Terrace.

In 2011, the six-story Linda Vista Community Hospital in East Los Angeles was transformed into apartments for seniors. (Courtesy Amcal Multi-Housing Inc.)

The developer aimed to preserve some of the historical charm of the old hospital building in the Hollenbeck Terrace design. (Heidi de Marco/KHN)

“They really rescued a building with tremendous history … while providing really needed low-income senior housing,” said Linda Dishman, CEO of the Los Angeles Conservancy, a group dedicated to preserving and revitalizing historical structures. “It is such an iconic building in the neighborhood.”

Gorman reported from Los Angeles.

KHN’s coverage in California is supported in part by Blue Shield of California Foundation.


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Doctors Make Big Money Testing Urine For Drugs, Then Ignore Abnormal Results

Some of the seized records would show that Campbell endangered patients by prescribing opiates without any medical need, according to federal prosecutors. Campbell, who collected millions of dollars from Medicare for urine tests run at his office lab, also failed to act when test results revealed patients were abusing prescription and illegal drugs, according to a government medical expert’s report.

Four patients died from drug-related causes under his watch, the report said. Others flunked two dozen or more urine tests, but the clinic kept prescribing them pills. One patient with a history of overdoses failed 46 urine tests and was never confronted about it. Campbell denied wrongdoing.

The nation’s opioid crisis has prompted an explosion in urine testing. The scourge has driven huge profits for many pain clinics across the U.S., an ongoing Kaiser Health News investigation shows. Spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year — more than the entire budget of the Environmental Protection Agency, according to a KHN analysis of billing data from Medicare and private insurance billing from the Mayo Clinic.

Medicare and other insurers pay for urine tests with the expectation that clinics will use the results to detect and curb dangerous abuse. But some doctors have taken no action when patients are caught misusing pharmaceuticals, or taking street drugs such as cocaine or heroin. Federal pain guidelines say doctors should discuss test results with patients and taper medication if necessary.

A lab technician inspects a urine sample at the Comprehensive Pain Specialists lab in Brentwood, Tenn., in February. (Heidi de Marco/KHN)

Medicare and private insurers acknowledge that they lack the resources to routinely verify that doctors who order a high volume of drug-related tests do so to improve patient care, not fatten the bottom line.

“This is a big issue,” said Louis Saccoccio, who heads the National Health Care Anti-Fraud Association, a group formed by private insurers and government officials. “There are abusive practices out there.”

­In nearly a dozen recent criminal cases, prosecutors have cited evidence that doctors supplied opiates to patients with repeated abnormal urine test results.

One such doctor was Alabama pain specialist Shelinder Aggarwal, who billed Medicare and private insurers over $9 million for urine tests solely “because he served to profit,” according to prosecutors in Alabama. He pleaded guilty to illegal prescribing and health care fraud. Earlier this year, a judge sentenced him to 15 years in prison.

Theodore Parran, who has served as an expert witness for the federal government, predicted more doctors could face fraud charges, or discipline by state medical licensing boards, over lab testing that appears to be profit-motivated.

“This is certainly on their radar,” Parran, a professor of medical education at Case Western Reserve University School of Medicine, said in an interview. Ignoring repeated abnormal urine tests “is bad medicine” that “endangers the safety of the patients and the community.”

The KHN investigation earlier this year found that dozens of pain doctors with their own labs took in $1 million or more in 2015 from Medicare for running urine and, in some cases, genetic drug tests. Some doctors derived at least 80 percent of their Medicare income this way.

Campbell’s office was among the clinics billing Medicare the most in the country, according to KHN’s data analysis of Medicare billing records.

Campbell and his staff at Physicians Primary Care PLLC billed the government agency a total of nearly $6 million for urine testing during 2014 and 2015, according to the KHN analysis.

John Kuhn Jr., U.S. attorney for the Western District of Kentucky, in July announced a range of health care fraud indictments, part of a nationwide sweep that charged hundreds of defendants. (Courtesy of the U.S. Department of Justice)

In June, more than three years after the Indiana raid, a federal grand jury in Kentucky indicted Campbell and two associates. The charges — which were announced July 13 as part of a national health care fraud sweep — include multiple counts of illegally distributing prescription drugs and health care fraud; one fraud count accuses Campbell of ordering costly genetic tests through an outside lab that were “not medically necessary and never interpreted.” All of the defendants pleaded not guilty.

Neither Campbell nor his attorney, Page Pate, would comment for this story. However, in an interview with KHN several months before his indictment, Campbell said the government’s case was “without merit.” He denied he ran a “pill mill” and said he relied on his “state-of-the-art” lab, which serves the Jeffersonville clinic and a branch just across the Ohio River in Louisville, to help keep patients safe.

“We do a lot of drug testing for patients and we do it appropriately,” Campbell said.

Indeed, deciding how often to order these tests, and for which patients and drugs, can be a judgment call. Doctors also sometimes disagree over what action they should take against patients with “dirty” urine: Some doctors kick out drug abusers, while others argue that is unethical. Instead, doctors should counsel these patients and refer them for substance abuse treatment, they say.

(Garth Superville for KHN)

Donald White, a spokesman for the U.S. Department of Health and Human Services’ Office of the Inspector General, said if test results are disregarded, “why is the test being ordered in the first place?”

“When abnormal urine drug test results are not acted upon by the physician who ordered the test, it raises concerns not only that the testing itself is not medically reasonable and necessary, but also that the doctor’s treatment of the patient may fall below the standard of care,” White said.

Prosecutors say Campbell kept them at bay for years by asserting that records seized in the raid, including computers and emails, contained privileged attorney communications. Clearing that hurdle delayed them from sending medical records to an outside expert for review, prosecutors said.

Indiana anesthesiologist Timothy King, who wrote the government medical expert’s report in the Campbell case, examined 19 patient files this year for his report. He concluded that Campbell “fails to practice medicine according to generally accepted medical principles and standards of care,” and “routinely” prescribed opiates “without a medical purpose.”

King said Campbell gave four patients a brew of pills known as the “Holy Trinity,” which King called “a street-popular combination of opiate, sedative and muscle relaxant that produces a heroin-like euphoria.”

These four patients were prescribed refills despite repeated abnormal urine tests. Two failed two dozen or more urine screens, according to King’s report.

All 19 patients repeatedly failed their tests, which King described as an obvious warning sign that they were ingesting prohibited drugs, or possibly peddling unused pills on the street.

“Urine drug screens are routinely inconsistent— [which can indicate] medication misuse, abuse and diversion,” the expert concluded.

The four people who died showed telltale signs of trouble such as admitting they had diverted some of their medicine, or had been visiting other doctors to feed pill habits according his report.

A 25-year-old woman identified only by the initials “CM” had “vague” complaints of lower-back pain and used drugs “for purposes of abuse and diversion,” according to King. She died three days after the clinic issued her a prescription for painkillers methadone and hydrocodone, King wrote. “EL,” who was homeless and disabled, died from a drug overdose in July 2014, also three days after her office visit, according to the report.

King also said Campbell appeared to order unnecessary tests, including X-rays, “to optimize billing.”

Less than a month after prosecutors received King’s report, a federal grand jury in Louisville indicted Campbell and nurse practitioners Dawn Antle and Mark Dyer.

All have pleaded not guilty. No trial date has been set.

Indiana officials quickly suspended their licenses to practice.

Prosecutors also are seeking forfeiture of Campbell’s Jeffersonville office building and other proceeds.

Attorneys for Antle and Dyer also had no comment. In the earlier interview with KHN, Campbell argued his practice attracts many difficult patients who have “no other option” to seek relief from pain. “Nobody else will see these people,” he said.

He ordered tests for a slew of substances because none of his drug-abusing patients “ever just uses one drug. They use everything they can get their hands on.”

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.


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