Markian Hawryluk, Author at KFF Health News

As Foundation for ‘Excited Delirium’ Diagnosis Cracks, Fallout Spreads

Renuka Rayasam and Markian Hawryluk and Samantha Young — Wed, 13 Dec 2023 10:00:00 +0000

When Angelo Quinto’s family learned that officials blamed his 2020 death on “excited delirium,” a term they had never heard before, they couldn’t believe it. To them, it was obvious the science behind the diagnosis wasn’t real.

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Why Do We Pay For so Much Worthless Health Care?

Markian Hawryluk — Fri, 17 Nov 2023 14:08:16 +0000

Medical advances are expensive. Take Wegovy, the wildly successful obesity drug that we learned last week may also reduce the risk of heart disease. If just 10 percent of Medicare beneficiaries start taking the drug, taxpayers could be on the hook for nearly $27 billion a year.

So how can the country afford the latest and greatest in medicine? One possibility: Stop paying billions of dollars a year for stuff that doesn’t help patients and might even harm them. As much as 30 percent of the $3 trillion we spend on health care annually goes to such low-value care, as I reported in this story.

Some examples: Doctors continue to prescribe unneeded opiates or antipsychotics, routinely screen for vitamin D deficiency, and order cancer-screening tests late in life when they are unlikely to provide much benefit. Treatments like those raise costs, lead to health complications and interfere with the delivery of more appropriate care.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

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But the fee-for-service health system in the United States rewards doctors for providing more care rather than the right care, and that has made it maddeningly difficult to stop such waste. And even when doctors have no financial incentives to order additional tests or services, low-value care is hard to stamp out.

A recent analysis in Colorado, for example, found that patients and private and public payers in the state spent $134 million on unnecessary care in 2021. And despite a more than decade-long campaign called Choosing Wisely to identify unnecessary services, spending on low-value care has barely budged.

In some places, defensive medicine plays a role, as doctors in highly litigious states order extra lab tests or imaging in fear of malpractice suits. And sometimes, low-value services just get ingrained in the culture and become almost impossible to eliminate.

As Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design,put it, “There’s a culture of more is better. And ‘more is better’ is very hard to overcome.”

Some individual institutions have been able to reduce low-value care. Children’s Hospital Colorado slashed the number of abdominal CT scans in kids by having surgeons come to the emergency room and help estimate how likely they were to have appendicitis. And a Los Angeles safety-net health system operating on a fixed budget was able to eliminate unnecessary testing before cataract surgeries. But these efforts are more the exception than the rule.

Fendrick has been beating the drum that eliminating low-value services is the only viable way to pay for all the advances in medicine, such as the new anti-obesity drugs like Wegovy. A provision in the Affordable Care Act already provides a means to do that. Buried deep in the law, Section 4105 (which Fendrick jokes only about eight people actually know about) gives the health and human services secretary authority to not cover any service to which the U.S. Preventive Services Task Force assigns a D rating, meaning it offers little or no benefit and isn’t recommended.

Several years ago, at the request of then-House Democratic leadership staffers, Fendrick calculated that Medicare could save $5 billion over 10 years by not paying for the seven most common D-rated services. And that reflects only the services themselves, not the cascade of unnecessary care they often precipitate.

Spoiler alert: Medicare is still paying for them.

“You could cover insulin. You could buy a lot of obesity drugs,” Fendrick told me. “That’s not enough — maybe a month of obesity drugs — but you know what I mean.”

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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Why It’s So Tough to Reduce Unnecessary Medical Care

Markian Hawryluk — Mon, 13 Nov 2023 10:00:00 +0000

The U.S. spends huge amounts of money on health care that does little or nothing to help patients, and may even harm them. In Colorado, a new analysis shows that the number of tests and treatments conducted for which the risks and costs exceed the benefits has barely budged despite a decade-long attempt to tamp down on such care.

The state — including the government, insurers, and patients themselves — spent $134 million last year on what is called low-value care, according to the report by the Center for Improving Value in Health Care, a Denver nonprofit that collects billing data from health plans across Colorado. The top low-value items in terms of spending in each of the past three years were prescriptions for opiates, prescriptions for multiple antipsychotics, and screenings for vitamin D deficiency, according to the analysis.

Nationwide, those treatments raise costs, lead to health complications, and interfere with more appropriate care. But the structure of the U.S. health system, which rewards doctors for providing more care rather than the right care, has made it difficult to stop such waste. Even in places that have reduced or eliminated the financial incentive for additional testing, such as Los Angeles County, low-value care remains a problem.

And when patients are told by physicians or health plans that tests or treatments aren’t needed, they often question whether they are being denied care.

While some highly motivated clinicians have championed effective interventions at their own hospitals or clinics, those efforts have barely moved the needle on low-value care. Of the $3 trillion spent each year on health care in the U.S., 10% to 30% consists of this low-value care, according to multiple estimates.

“There’s a culture of ‘more is better,’” said Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design. “And ‘more is better’ is very hard to overcome.”

To conduct its study, the Center for Improving Value in Health Care used a calculator developed by Fendrick and others that quantifies spending for services identified as low-value care by the Choosing Wisely campaign, a collaborative effort of the American Board of Internal Medicine Foundation and now more than 80 medical specialty societies.

Fendrick said the $134 million tallied in the report represents just “a small piece of the universe of no- and low-value care” in Colorado. The calculator tracks only the 58 services that developers were most confident reflected low-value care and does not include the costs of the cascade of care that often follows. Every dollar spent on prostate cancer testing in men over 70, for example, results in $6 in follow-up tests and treatments, according to an analysis published in JAMA Network Open in 2022.

In 2013, Children’s Hospital Colorado learned it had the second-highest rate of CT abdominal scans — a low-value service — among U.S. children’s hospitals, with about 45% of kids coming to the emergency room with abdominal pain getting the imaging. Research had shown that those scans were not helpful in most cases and exposed the children to unnecessary radiation.

Digging into the problem, clinicians there found that if ER physicians could not find the appendix on an ultrasound, they swiftly ordered a CT scan.

New protocols implemented in 2016 have surgeons come to the ER to evaluate the patient before a CT scan is ordered. The surgeons and emergency doctors can then decide whether the child is at high risk of appendicitis and needs to be admitted, or at low risk and can be sent home. Within two years, the hospital cut its rate of CT scans on children with abdominal pain to 10%, with no increase in complications.

“One of the hardest things to do in this work is to align financial incentives,” said Lalit Bajaj, an emergency physician at Children’s Colorado who championed the effort, “because in our health care system, we get paid for what we do.”

Cutting CT scans meant less revenue. But Children’s Colorado worked with an insurance plan to create an incentive program. If the hospital could hold down the rate of high-cost imaging, saving the health plan money, it could earn a bonus from the insurer at the end of the year that would partly offset the lost revenue.

But Bajaj said it’s tough for doctors to deal with patient expectations for testing or treatment. “It’s not a great feeling for a parent to come in and I tell them how to support their child through the illness,” Bajaj said. “They don’t really feel like they got testing done. ‘Did they really evaluate my child?’”

That was a major hurdle in treating kids with bronchiolitis. That respiratory condition, most often caused by a virus, sends thousands of kids every winter to the ER at Children’s, where unneeded chest X-rays were often ordered.

“The data was telling us that they really didn’t provide any change in care,” Bajaj said. “What they did was add unnecessary expense.”

Too often, doctors reading the X-rays mistakenly thought they saw a bacterial infection and prescribed antibiotics. They would also prescribe bronchodilators, like albuterol, they thought would help the kids breathe easier. But studies have shown those medicines don’t relieve bronchiolitis.

Bajaj and his colleagues implemented new protocols in 2015 to educate parents on the condition, how to manage symptoms until kids get better, and why imaging or medication is unlikely to help.

“These are hard concepts for folks,” Bajaj said. Parents want to feel their child has been fully evaluated when they come to the ER, especially since they are often footing more of the bill.

The hospital reduced its X-ray rate from 40% in the 17 months before the new protocols to 29% in the 17 months after implementation, according to Bajaj. The use of bronchodilators dropped from 36% to 22%.

Part of the secret of Children’s success is that they “brand” their interventions. The hospital’s quality improvement team gathers staff members from various disciplines to brainstorm ways to reduce low-value care and assign a catchy slogan to the effort: “Image gently” for appendicitis or “Rest is best” for bronchiolitis.

“And then we get T-shirts made. We get mouse pads and water bottles made,” Bajaj said. “People really do enjoy T-shirts.”

In California, the Los Angeles County Department of Health Services, one of the largest safety-net health systems in the country, typically receives a fixed dollar amount for each person it covers regardless of how many services it provides. But the staff found that 90% of patients undergoing cataract surgery were getting extensive preoperative testing, a low-value service. In other health systems, that would normally reflect a do-more-to-get-paid-more scenario.

“That wasn’t the case here in LA County. Doctors didn’t make more money,” said John Mafi, an associate professor of medicine at UCLA. “It suggests that there’s many other factors other than finances that can be in play.”

As quality improvement staffers at the county health system looked into the reasons, they found the system had instituted a protocol requiring an X-ray, electrocardiograms, and a full set of laboratory tests before the surgery. A records review showed those extra tests weren’t identifying problems that would interfere with an operation, but they did often lead to unnecessary follow-up visits. An anomaly on an EKG might lead to a referral to a cardiologist, and since there was often a backlog of patients waiting for cardiology visits, the surgery could be delayed for months.

In response, the health system developed new guidelines for preoperative screenings and relied on a nurse trained in quality improvement to advise surgeons when preoperative testing was warranted. The initiative drove down the rates of chest X-rays, EKGs, and lab tests by two-thirds, with no increase in adverse events.

The initiative lost money in its first year because of high startup costs. But over three years, it resulted in modest savings of about $60,000.

“A fee-for-service-driven health system where they make more money if they order more tests, they would have lost money,” Mafi said, because they make a profit on each test.

Even though the savings were minimal, patients got needed surgeries faster and did not face a further cascade of unnecessary testing and treatment.

Fendrick said some hospitals make more money providing all those tests in preparation for cataract surgery than they do from the surgeries themselves.

“These are older people. They get EKGs, they get chest X-rays, and they get bloodwork,” he said. “Some people need those things, but many don’t.”

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Doctors Abandon a Diagnosis Used to Justify Police Custody Deaths. It Might Live On, Anyway.

Markian Hawryluk and Renuka Rayasam — Mon, 16 Oct 2023 09:00:00 +0000

Brooks Walsh hadn’t questioned whether “excited delirium syndrome” was a legitimate medical diagnosis before the high-profile police killings of Elijah McClain in Colorado in 2019 and George Floyd in Minnesota in 2020.

The emergency physician in Bridgeport, Connecticut, was familiar with the term from treating patients who were so severely agitated and combative that they needed medication just to be evaluated.

But it gave him pause when excited delirium — and not the restraint tactics used by arresting police officers — was mentioned as a possible factor in the deaths of those two Black men. That’s when Walsh took a closer look at the American College of Emergency Physicians’ 2009 position paper on excited delirium, which he and other physicians had relied on to treat such patients, then decided something needed to be done.

“I was disappointed by a lot of stuff in that paper: the quality of the evidence that they cite and just, frankly, odd language,” Walsh said.

Excited delirium is not listed in the standard reference book of mental health conditions, nor does it have its own diagnostic code under a system used by health professionals to identify diseases and disorders. No blood test or other diagnostic test can confirm the syndrome. Most major medical societies, including the American Medical Association and the American Psychiatric Association, no longer recognize excited delirium as a legitimate medical condition. One of the last medical holdouts, the National Association of Medical Examiners, rejected excited delirium as a cause of death this year.

But the American College of Emergency Physicians, the medical society representing Walsh and more than 36,000 other doctors, still hadn’t disavowed its report that gave excited delirium much of its legitimacy — until this month. On Oct. 12, the group approved a resolution that Walsh co-authored to withdraw the 2009 white paper on excited delirium, removing the only remaining official medical pillar of support for a theory, which despite being based primarily on discredited research and racial biases, has played a key role in absolving police of culpability for in-custody deaths.

“This is the membership of ACEP saying we recognize that this was wrong,” said Sophia Spadafore, an emergency physician at Mount Sinai Hospital in New York City. “And now, as an organization, we need to reckon with our history and try to make up for some of the mistakes that were made and repair some of the damage that we did.”

The vote brought some vindication to Verdell and William Haleck, whose son Sheldon died in 2015 after being pepper-sprayed, shocked with a Taser, and restrained. The Utah family lost its civil case against Honolulu police officers, whose lawyers argued the 38-year-old former Hawaii Air National Guardsman had experienced excited delirium. Watching defense experts paint their son as responsible for his own death was excruciating, his parents said.

“We were right all along,” Verdell Haleck said in response to the ACEP vote. “Now our hopes are that the term can never be used again to cause pain and suffering for another family in their pursuit of justice.”

And momentum is building. Just before the vote, California became the first state to ban excited delirium as a diagnosis and cause of death on death certificates, autopsy reports, and police reports, as well as in civil court proceedings.

Backers of the emergency physicians’ resolution hope such disavowals of the term will lead to better training and greater accountability of paramedics and police when they interact with people in mental health crises.

But it is unlikely the doctors’ vote can affect past wrongful death and criminal cases against police. And it remains unclear whether renouncing the 2009 document will prevent defense lawyers in future cases from using similar victim-blaming concepts — just with alternative terminology.

‘This Drastically Affected Our Lives’

Nearly 14 years ago, Patrick Burns, 50, died after sheriff’s deputies hogtied him and shocked him multiple times with Tasers in Sangamon County, Illinois, according to court documents. A medical examiner concluded the official cause of death was excited delirium.

That diagnosis in Burns’ death stymied the family’s lawsuit against the county officers, which ended in a $40,000 settlement in 2015, said Richard Burns, one of Patrick’s brothers. The label also helped law enforcement create a picture of him as someone who was “out of control,” which ruined his brother’s reputation, Richard said. “That picture is implanted on who my brother was, and that’s not the truth.”

The term “excited delirium” dates back decades but has never been supported by rigorous scientific studies. Still, the term persisted as some of its early researchers earned money for testifying as expert witnesses in cases involving law enforcement and the company now called Axon Enterprises, which makes the Taser stun gun.

The theory suggested that agitated, delirious individuals were dying not because they had been shocked by stun guns, restrained with chokeholds, or held facedown so they couldn’t breathe, but because of this unexplained medical condition that could lead to sudden death.

Funding from Taser International, Axon’s former company name, sponsored some of the research forming the basis of ACEP’s white paper supporting the excited delirium theory, according to a 2017 Reuters investigation. The 19-person task force that drafted the 2009 paper included three people who provided paid testimony or performed consulting work for Taser, that report found. KFF Health News called eight of the task force members but none agreed to interviews. Axon executives did not respond to calls or emails seeking comment on the white paper.

That ACEP paper described patients with excited delirium as having superhuman strength, being impervious to pain, exhibiting aggressive behavior, and making guttural sounds. To Walsh and other doctors behind the push to reject the diagnosis, those descriptions reflected age-old racist tropes of Black men as being stronger than white men or being animalistic. The incorrect notion that Black people feel less pain persists in modern medicine and has led to disparities in pain treatment.

Indeed, excited delirium has been cited more often in cases involving people of color. According to a Virginia Law Review article, at least 56% of police custody deaths from 2010 to 2020 attributed to excited delirium involved Black and Latino victims. Reviews of deaths attributed to excited delirium also found they overwhelmingly occurred when people were being restrained.

Yet the authority of the esteemed doctors group and its position paper helped cement an alternative cause of death that defense attorneys for police argued in court. And now, it’s likely too late for families who lost cases based on an excited delirium defense. Even with ACEP’s disavowal, courts may be reluctant to reopen resolved cases, said Jim Davy, a civil rights lawyer in Philadelphia.

In June, just months after the National Association of Medical Examiners decided excited delirium should no longer be listed as a cause of death, the county coroner changed Patrick Burns’ official manner of death to homicide. The coroner concluded he had suffered brain damage due to a lack of oxygen after being restrained on his stomach, not from excited delirium.

But the Illinois state attorney declined to pursue new charges against the deputies in Burns’ death.

“It’s more than just an unfortunate story,” Richard Burns said. “This drastically affected our lives.”

Racial Reckoning Sparks Shift

At a 2020 American Medical Association policy conference, medical students spurred by the racial reckoning in the wake of the police-involved deaths of Floyd and many others introduced a series of resolutions around combating racism in medicine, including one against excited delirium. But emergency physicians, who also belong to that broader physician group, objected.

“They’re regarded as the content experts on the issue, and so I think it was hard for us to combat some of those counterarguments at that time,” said Rohan Khazanchi, a medical resident and a researcher with the FXB Center for Health and Human Rights at Harvard University.

Emergency physicians see patients with agitation and delirium more often than clinicians in other specialties do and oversee emergency medical technicians and paramedics who encounter such individuals outside of a hospital.

The AMA decided to study the issue. Its subsequent report firmly sided with the medical students and, in 2021, the AMA delegates issued a strong condemnation of excited delirium as a clinical diagnosis.

But ACEP, which represents a predominantly white specialty, dragged its feet in addressing its problematic paper. Instead, the group released a new policy statement in 2021 using the term “hyperactive delirium,” saying the guidance was not meant as an update or refutation of the paper.

Jeffrey Goodloe, an emergency physician in Tulsa, Oklahoma, and one of the authors of the 2021 policy statement, said ACEP didn’t want to issue a statement without providing a clinical document to help guide physicians. And since the task force wanted to focus on clinical considerations, he said, it avoided addressing “excited delirium,” which had been under fire.

“It was being used in nonclinical ways, which no one ever really thought that it would be,” he said. “It was becoming at times a flashpoint between law enforcement and the community at large.”

This spring, the group issued a statement saying it no longer recognized excited delirium as a diagnosis but stopped short of retracting the 2009 white paper. And until this month’s vote, it hadn’t taken any steps to prevent its name and policy statement from being used by defense attorneys defending police in court cases involving in-custody deaths.

Goodloe, who now chairs the ACEP board, said it was hard for ACEP to track individual court cases and what expert witnesses were saying, especially if they were not ACEP members.

“We can’t ensure how nonmedical professionals use a document that is designed to inform and guide medical care,” he said. “I would hope that they would continue to recognize the primary intent of the paper and be very meticulous about avoiding misquoting or mischaracterizing what that paper is for.”

New Terms Arise

The remaining defenders of the term insist that excited delirium is a real condition that puts patients, physicians, and first responders at risk.

One of the 2009 white paper’s co-authors, Deborah Mash, a retired professor of neurology at the University of Miami, declined an interview but wrote in an email that the task force that penned the white paper included some of the most respected thought leaders in emergency medicine at the time, who sought to suggest best practices for treating patients with such symptoms.

Since then, she said, “banning the use of the ‘term’ has caught on with the anti-police movement.”

Mash has testified about excited delirium as an expert witness for the defense in wrongful death claims filed against Axon over the use of its Tasers.

Some lawyers who bring in-custody death cases on behalf of families believe the ACEP reversal will help wipe out a major police defense tactic.

“It has a huge impact on cases going forward, because the white paper was the main vehicle for trying to legitimize excited delirium,” said Julia Sherwin, a civil rights attorney who is representing the family of Mario Gonzalez, who died in police custody in California in 2021.

But eradicating the term “excited delirium” may not stop police from trying to use the theory behind it to justify the deaths of suspects in custody: The Minneapolis Star-Tribune reported last year that a training for the Minneapolis Police Department, which was involved in Floyd’s death, used PowerPoint slides with the words “excited delirium” crossed out and replaced with the term “severe agitation with confusion (delirium).”

Clinical documents from ACEP and other organizations have described the same cluster of symptoms at various times as hyperactive delirium, agitated delirium, or restraint-related cardiac arrest. Defense lawyers might argue the same concept using those terms or rely on other medical conditions to explain a death rather than law enforcement officials’ use of force.

“It’s so easy for them, once the excited delirium argument is dismissed, to use another kind of medical argument that’s quite similar,” said Justin Feldman, a social epidemiologist at Harvard University who studies patterns of in-custody deaths.

In April 2021, Gonzalez died after police officers in Alameda, California, restrained him on his stomach, handcuffed him, and placed their weight on him. The county coroner listed his death as a homicide. But ACEP member Gary Vilke, one of the co-authors of the 2009 white paper, said in a September 2023 deposition he believed that Gonzalez died of cardiac dysrhythmia, an irregular heartbeat.

Vilke testified in the deposition that he could make up to $50,000 as a defense expert in the case, which is set to go to trial later this year, and that he has testified in restraint or law enforcement-related cases 58 times over the past four years. Vilke declined to comment to KFF Health News on the white paper.

California’s new law lists alternative terms — hyperactive delirium, agitated delirium, and exhaustive mania — that will be restricted along with excited delirium starting in January. Nothing in the law prevents defense experts from using other medical explanations, such as cardiac dysrhythmia, for the deaths.

“People in agitated states due to cocaine, methamphetamine or untreated psychiatric illness still require help which is provided by police and first responders,” Mash, who helped create the 2009 paper, wrote in an email. “These individuals are at increased risk of sudden death regardless of what you call it.”

Still, Richard Burns, the Halecks, and others whose loved ones died during police encounters hope the ACEP vote prevents future abuses, pushes more states to follow California’s lead, and boosts police accountability.

“What needs to happen is to focus on the why, the reason, the cause,” said Burns. “The cause is the police brutality, which gets minimized when it’s being able to be hidden behind these terms.”

Chris Vanderveen, KUSA-TV’s director of special projects, contributed to this report.

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Police Blame Some Deaths on ‘Excited Delirium.’ ER Docs Consider Pulling the Plug on the Term.

Markian Hawryluk and Renuka Rayasam — Mon, 02 Oct 2023 09:00:00 +0000

The way Sheldon Haleck’s parents see it, the 38-year-old’s only crime was jaywalking. But that March night in 2015, after Honolulu police found him behaving erratically, they pepper-sprayed him, shocked him with a Taser, and restrained him. Haleck became unresponsive and was taken to a hospital. Before his parents could get from their home in Utah to Hawaii, the former Hawaii Air National Guardsman was taken off life support.

“Nobody’s supposed to die from something like this,” said Haleck’s father, William.

An initial autopsy ruled Haleck’s death a homicide and his family filed a civil lawsuit in federal court against the three officers who tried to remove him from the street. The case should have been “one of the easiest wrongful death cases” to win, said Eric Seitz, an attorney who represented Haleck’s family.

But the officers’ attorneys seized on a largely discredited, four-decade-old diagnostic theory called “excited delirium,” which has been increasingly used over the past 15 years as a legal defense to explain how a person experiencing severe agitation can die suddenly through no fault of the police. “The entire use of that particular theory, I think, is what convinced the jury,” Seitz said.

Haleck’s case is just one legal battle in which the theory of excited delirium exonerated law enforcement despite mounting opposition to the term among most prominent medical groups. The theory has been cited as a defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California. It figures in a criminal trial against two police officers involved in the 2019 death of Elijah McClain in Aurora, Colorado, now underway. It has allowed defense attorneys to argue that individuals in police custody died not of restraint, not of a Taser shock, but of a medical condition that can lead to sudden death.

But now, the American College of Emergency Physicians will vote at an October meeting on whether to formally disavow its 2009 position paper supporting excited delirium as a diagnosis that helped undergird those court cases. The draft resolution also calls on ACEP to discourage physicians who serve as expert witnesses from promoting the theory in criminal and civil trials.

“It’s junk science,” said Martin Chenevert, an emergency medicine physician at UCLA Santa Monica Medical Center, who often testifies as an expert witness. The theory has been used to provide a cover for police misconduct, he said. “It had an agenda.”

Passing the resolution wouldn’t bring Haleck back, but his parents hope it would prevent other families from experiencing their agony. “May that excited delirium die here,” said his mother, Verdell.

Democratic California Gov. Gavin Newsom is considering signing into law a bill passed Sept. 12 that would do much of the same in his state.

“If we don’t fully denounce this now, it will be there for the grasping, again,” said Jennifer Brody, a physician with the Boston Health Care for the Homeless Program, who co-authored a 2021 editorial calling on organized medicine to denounce excited delirium. “Historically, we know what happens: The pendulum swings the other way.”

Most major medical societies, including the American Medical Association and the American Psychiatric Association, don’t recognize excited delirium as a medical condition. This year, the National Association of Medical Examiners rejected excited delirium as a cause of death. No blood test or other diagnostic test can confirm the syndrome. It’s not listed in the Diagnostic and Statistical Manual of Mental Disorders, a reference book of mental health conditions, nor does it have its own diagnostic code, a system used by health professionals to identify diseases and disorders.

But the argument’s pervasiveness in excessive-use-of-force cases has persisted in large part because of the American College of Emergency Physicians’ 2009 white paper proposing that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die from the condition.

The ACEP white paper has been cited in cases across the U.S., and lawyers who file police misconduct cases said that courts and judges accept the science without sufficient scrutiny.

ACEP’s position “has done a lot of harm” by justifying first responder tactics that contribute to a person’s death, said Joanna Naples-Mitchell, an attorney who worked on a Physicians for Human Rights review of excited delirium. The term has also been used in cases in Australia, the United Kingdom, Canada, and other countries, according to the group.

“This is a really important opportunity for ACEP to make things right,” she said of the upcoming vote.

ACEP officials declined KFF Health News requests for an interview.

Starting in the mid-1990s, the leading proponents of excited delirium produced research with funding from Taser International, a maker of stun guns used by police, which later changed its name to Axon. The research purported to show that the technique of prone restraint, in which suspects are lying face down on the ground with the police officer’s weight on top of them, and Taser shocks couldn’t kill someone. That research formed the basis of the white paper, providing an alternative cause of death that defense attorneys could argue in court. Many emergency physicians say the ACEP document never lived up to the group’s standard for clinical guidelines.

Axon officials did not respond to a call or email seeking comment on the white paper or the upcoming ACEP vote. In 2017, Taser officials used the American College of Emergency Physicians’ position on excited delirium as evidence that it is a “universally recognized condition,” according to Reuters.

A recent review published in the journal Forensic Science, Medicine, and Pathology concluded no scientific evidence exists for the diagnosis, and that the authors of the 2009 white paper engaged in circular reasoning and faulty logic.

“Excited delirium is a proxy for prone-related restraint when there is a death,” said Michael Freeman, an associate professor of forensic medicine at Maastricht University in the Netherlands, who co-authored the review. “You don’t find that people get ‘excited delirium’ if they haven’t also been restrained.”

Between 2009 and 2019, Florida medical examiners attributed 85 deaths to excited delirium, and at least 62% involved the use of force by law enforcement, according to a January 2020 report in Florida Today. Black and Hispanic people accounted for 56% of 166 deaths in police custody attributed to excited delirium from 2010 to 2020, according to a December 2021 Virginia Law Review article.

This year, ACEP issued a formal statement saying the group no longer recognizes the term “excited delirium” and new guidance to doctors on how to treat individuals presenting with delirium and agitation in what it now calls “hyperactive delirium syndrome.” But the group stopped short of retracting the 2009 white paper. For the past 14 years, ACEP took no steps to withdraw the document or to discourage defense attorneys from using it in court.

Even now, lawyers say, they must continually debunk the theory.

“Excited delirium has continued to come up in every single restraint asphyxia case that my partner and I have handled,” said Julia Sherwin, a California civil rights attorney. “Instead of acknowledging that the person died from the police tactics, they want to point to this alternate theory of deaths.”

Now, plaintiffs’ attorneys say, if ACEP passes the resolution it would be the most meaningful step yet toward keeping the theory out of the courtroom. The resolution calls on ACEP to “clarify its position in writing that the 2009 white paper is inaccurate and outdated,” and to withdraw approval for it.

Despite the theory’s lack of scientific underpinning, backers of the ACEP resolution expect heated debate before the vote scheduled for the weekend of Oct. 7-8. Emergency physicians often encounter patients with agitation and delirium, they say, and are sympathetic to other first responders who share the challenge of managing such patients. While they have tools like sedation to help them in the emergency room, law enforcement officials must often subdue potentially dangerous individuals without such help.

Most people won’t die as a result of police tactics such as prone restraint or Taser use, but a small fraction do.

“It’s a crappy, crappy situation, when you have someone who’s out of control, who can’t make decisions for himself, and is potentially a threat somewhere,” said Jared Strote, an emergency medicine professor at the University of Washington. “It’s not like they have a sticker on their head that says, ‘Hey, I’m at high risk. If you hold me down, then I could go into sudden cardiac arrest.’”

Nonetheless, sentiment is growing among emergency physicians that the 2009 ACEP white paper has resulted in real harm and injustices, and it’s time to set it aside.

“We’ll be able to close the chapter on it and move forward to recognize explicitly that this was in error,” said Brooks Walsh, an emergency physician from Bridgeport, Connecticut, and a key player in bringing the resolution up for a vote. “We definitely have an ethical responsibility to address mistakes or evolutions in medical thinking.”

Chris Vanderveen, KUSA-TV’s director of special projects, contributed to this report.

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Pot Boom Wakes Sleepy Dinosaur, Colorado

Markian Hawryluk — Mon, 25 Sep 2023 09:00:00 +0000

DINOSAUR, Colo. — There isn’t much to this town a short drive from the national monument of the same name. A couple of gas stations, a liquor store, and a small motel line the two main drags, Brontosaurus Boulevard and Stegosaurus Freeway.

But this community of about 315 and its four marijuana dispensaries — one shop for every 79 residents — is a contender for the title of cannabis capital of Colorado.

Dinosaur, nestled in the northwestern corner of the state, is a five-minute drive to the Utah line and a couple of hours away from Wyoming, both states where recreational marijuana use is illegal.

Dinosaur lies at the intersection of U.S. Highway 40 (that’s Brontosaurus Boulevard) and Colorado Highway 64 (Stegosaurus Freeway). The crossroads had long been a stop where truckers filled their fuel tanks and their bellies. But until weed came to town, there was little to sustain the local economy.

It’s a classic story of a border town prospering from differing laws state to state, and how arbitrary lines drawn through a desolate landscape drive economic patterns. Coloradans from Dinosaur cross the border to get groceries and health care. Utahans come to Dinosaur for lottery tickets, liquor, and pot.

The four cannabis stores, which opened after the passage of a 2016 ballot measure, have changed the fortunes of a town that made repeated losing bets on other commodities before finally hitting the jackpot with marijuana.

“You’d be shocked how much money comes through here,” said Jim Evans, the town’s treasurer. “There’s money running out of our ears.”

Lando Blakley, who has lived in Dinosaur most of his life, opened the town’s third retail store, Dino Dispensary, in 2018. He estimates that 95% of his business comes from out-of-state customers, some from as far away as North Dakota.

“Right now, cannabis is Dinosaur’s lifeblood,” he said.

Utah has legalized medical marijuana, but with tight restrictions and few places to buy it. So, patients may have to travel hours to outlets in Salt Lake City or Ogden for an in-state supplier. But for those living in Vernal or other eastern towns, Dinosaur is the closest place to buy cannabis in person.

“If anyone had to travel in the wintertime to go to a dispensary in Salt Lake City, they’re not going to do it,” said Michael, a 37-year-old who, like most pot-shop customers who spoke with KFF Health News, declined to give his last name after buying marijuana at one of the stores. “Why drive 300 miles and put your life at risk, when you can drive 30?”

It is illegal to bring marijuana over the border to Utah, but multiple customers said they’ve never had a problem. Still, a traffic stop for other reasons could have more serious consequences if police find marijuana in the car.

Utah residents Jackson and Chelsea order their cannabis online from Rocky Mountain Cannabis, located, appropriately, at 420 E. Brontosaurus Blvd. (420 is shorthand for smoking marijuana), and drive across the state line to pick it up.

“Everybody in Utah goes and gets their green card and then comes here and gets their marijuana,” Jackson said.

The cards, carried by people registered with Utah’s medical marijuana program (about 70,000 of the state’s 3.4 million residents), provide cover in case they get pulled over. Other customers say it’s not worth the hassle to apply for a card and pay the $15 annual fee when none of that is required in Colorado.

At least two other Colorado towns rival Dinosaur in per capita retail cannabis outlets. Moffat in south-central Colorado boasts four marijuana stores in a town and surrounding area of just 818 people, due to a massive cannabis growing operation.

Sedgwick is another border town that has banked on weed, with three stores and a population of 172. The town sits in the northeastern corner of the state, less than 10 minutes from Nebraska, where marijuana is illegal for both medical and recreational use.

Some border towns opted against allowing marijuana stores, such as Rangely, from which residents now make the 18-mile trip to Dinosaur to buy cannabis.

The four stores in Dinosaur are bunched on the east side of town, just off Highway 40, pretty much the only locations that satisfy the town mandate to be at least 1,000 feet from a school. Most outlets want to be along the highway, to capture customers passing through. Someone could easily walk to all four stores, and some people do just that to dodge the state’s daily 1-ounce purchase limit.

To say that cannabis has transformed the appearance of town would be a stretch. It remains a sleepy little town, with little else to drive its economy. Despite the thriving marijuana trade, there still seem to be more closed businesses than open ones.

In fact, the town isn’t quite sure what to do with all the money it collects. It once limped along with an annual budget of $100,000 or less, but Dinosaur now rakes in that much each month in cannabis revenue alone.

In 2021, the town collected about $1.4 million in cannabis-related taxes and licensing fees.

When it first approved cannabis sales, the town collected a 5% tax that flowed into its general revenue fund. Residents voted to add a second 5% tax earmarked for infrastructure projects. It collects licensing fees from the retail stores and a marijuana grow operation and gets a portion of the cannabis revenue collected by the state.

That money has allowed the town to build new sewage ponds, repaint the inside of its water tank, and add new housing lots with paved roads and sewer and water connections. The town is in the midst of a beautification project, planting trees and flowers, and is refurbishing the former school building into a community recreation center. Where the town previously relied on the county sheriff for law enforcement and suffered through long response times, it has now hired three marshals of its own.

And last year, for the first time in decades, the town revived its annual festival, now called the Dinosaur Stone Age Stampede, with food, games, and music.

But most of the marijuana tax revenue goes into savings. The town expects to have about $3.5 million in its coffers by year-end, and, Evans said, Dinosaur draws some $230,000 a year in interest alone.

Becoming a cannabis hot spot wasn’t a given. Heated debate erupted when the Town Council first considered allowing retail stores. Town leaders ultimately decided to let the residents choose at the polls. An initial ballot measure in 2010 failed.

By 2016, opinions changed as residents saw other border towns in Colorado flourishing while their town was quickly becoming … well, a dinosaur.

“People were seeing that the towns that had [legalized] was prospering,” said Mayor Richard Blakley, 70, who is the father of Dino Dispensary owner Lando Blakley. “And no real bad crime increase or stuff like that.”

The settlement that became Dinosaur was initially called Baxter Flats, but was established as a town in 1947, and named Artesia, a nod to the artesian wells in the surrounding hills. In 1966, the National Park Service told local leaders if they changed the name to Dinosaur, the town would prosper from its connection to the national monument known for its prehistoric fossils and petroglyphs.

Residents agreed and renamed their home and the streets. But prosperity never followed, in part because the Colorado side of the national monument has few dinosaur fossils. It’s mostly a showcase of geology.

“People come in and ask, ‘Where’s the museum? Where’s the skeletons?’” Evans said. Other than a few scientifically questionable dinosaur sculptures, there’s no Tyrannosaurus rex or Stegosaurus, no Velociraptor or Allosaurus.

As the national park rangers say, Utah has the bones, Colorado has the stones — or, as people say on the Utah side of the border, the stoned.

“We have a reputation,” Evans said. “You talk about Dinosaur in Utah, and it’s like, ‘Yeah, they’re all potheads and stuff.’”

The mayor said the town has seen few negative consequences from allowing marijuana, among them some people unprepared for the drug’s potency being sickened by it. The town is growing. The population, which had dropped to 243 residents in the 2020 census, has rebounded to about 315, Blakley said. Many people have also purchased vacant lots to take advantage of the relatively cheap cost of real estate, making it difficult to find land in town.

Blakley hopes the economic growth will bring a grocery store. Residents drive 40 minutes to Vernal, Utah, or two hours to Grand Junction, to stock up on food or to receive medical care. Children go to school in Rangely since Dinosaur’s school closed years ago. An urgent care clinic opened across from the town hall a few years ago, but it couldn’t make a go of it.

Even if Dinosaur continues to grow, it won’t add more cannabis stores. The Town Council capped the available licenses at four. And those four stores are now the essence of Dinosaur.

“Otherwise,” Evans, the treasurer, said, “this is a sad little town.”

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A Move to Cut Drug Prices Has Patients With Rare Diseases Worried

Markian Hawryluk — Wed, 30 Aug 2023 09:00:00 +0000

For people with cystic fibrosis, like Sabrina Walker, Trikafta has been a life-changer.

Before she started taking the drug, she would wind up in the hospital for weeks at a time until antibiotics could eliminate the infections in her lungs. Every day, she would wear a vest that shook her body to loosen the mucus buildup.

One particularly bad flare-up, known as a pulmonary exacerbation, had her coughing up blood in 2019, so she was put on the newly approved breakthrough medication.

Within a month, her lung function increased by 20%, she said, and her health improved. Before she started taking Trakafta, she could count on three to four hospitalizations a year. Over the four years on the medication, she has been hospitalized only once.

“I was spending hours a day doing airway clearance and breathing treatments, and that has been significantly reduced,” said the 37-year-old Erie, Colorado, mother. “I’ve gained hours back in my day.”

Now she runs and hikes in the thin Colorado air and works a full-time job. Other patients have seen similar gains with the drug therapy, allowing many to resume regular lives and even take themselves off waiting lists for a lung transplant. Yet Walker and scores of other Colorado patients with cystic fibrosis are worried they could lose access to that transformative medication.

A state board charged with addressing the affordability of the most expensive prescription drugs has chosen Trikafta among its first five drugs to review, and it could move to cut the medication’s average in-state annual price of approximately $200,000, accounting for both insurers’ contributions and patients’ out-of-pocket costs. Drugmakers, including Trikafta’s maker, Vertex Pharmaceuticals, have said payment limits could hurt innovation and limit access, stoking panic among patients that the drug might no longer be sold in Colorado.

Two of the drugs chosen by the state board, the rheumatoid arthritis treatment Enbrel and the psoriasis medication Stelara, also appear on the initial list of 10 drugs for which Medicare will negotiate prices. Any federally negotiated price reductions won’t go into effect until 2026, and it’s unclear how that effort will affect the Colorado board’s work in the interim.

The Colorado board’s choice of drugs to review elucidates one of the thorniest questions the board must wrangle with: Would lowering the price tag for rare-disease medications lead manufacturers to pull out of the state or limit their availability? State officials contend that the high cost of prescription drugs puts them out of reach for some patients, while patients worry that they’ll lose access to a life-changing therapy and that fewer dollars will be available to develop breakthrough medications. And with affordability boards in other states poised to undergo similar exercises, what happens in Colorado could have implications nationwide.

“It just puts Trikafta as a whole at risk,” Walker said. “It would start here, but it could create a ripple effect.”

Cystic fibrosis is a genetic condition that causes the body to produce thick, sticky mucus that clogs the lungs and digestive system, leading to lung damage, infections, and malnutrition. It is a progressive disease that results in irreversible lung damage and a median age of death of 34 years. There is no cure.

The rare disease affects fewer than 40,000 people in the U.S., including about 700 in Colorado. That means research and development costs are spread across a smaller number of patients than for more common conditions, such as the millions of people with heart disease or cancer.

Officials from Vertex Pharmaceuticals declined a request for an interview. But company spokesperson Sarah D’Souza emailed a statement saying that “the price of this medicine reflects its value to patients, the small number of people living with CF, the billions of dollars Vertex has invested to date to develop the first medicines to treat the underlying cause of CF, and the billions more we are investing in CF and other serious diseases.”

Setting an upper payment limit, the company said, could hinder access to drugs like Trikafta and curtail investment in scientific innovation and drug discovery.

State officials counter that Vertex and other drugmakers are resorting to fear-mongering to protect their profits.

Colorado Insurance Commissioner Michael Conway said that whenever the state talks about saving people money on health care, the affected entity — be it a hospital, insurance company, or drug manufacturer — cries foul and claims there will be an access problem.

“This is just, from my vantage point, the pharmaceutical industry trying to scare people,” he said.

Colorado’s Prescription Drug Affordability Board has been working for more than a year to sort through 604 drugs eligible for review, with 17 data points for each, to create a prioritized list. In the end, they decided to focus this year only on drugs that had no brand-name competition or generic alternatives that could lower costs.

Besides Trikafta, Enbrel, and Stelara, the board will review the affordability of the antiretroviral medication Genvoya, used to treat HIV, and another psoriasis treatment, Cosentyx.

Of those five, Trikafta had the highest average annual costs but the lowest five-year increase in price and the fewest patients taking it.

The board’s review of the five drugs will happen over its next three to four meetings this year and early next year, allowing all stakeholders — including patients, pharmacies, suppliers, and manufacturers — to provide feedback on whether the drugs are indeed unaffordable and what a reasonable price should be. Any cost limits wouldn’t take effect until next year at the earliest.

The board looked at what patients were paying out-of-pocket for their medicines, using a database that captures all the insurance claims in the state. But that data did not account for patient assistance programs, through which manufacturers reimburse patients for out-of-pocket costs. Such programs boost manufacturer sales of drugs because insurance covers most of the cost, and patients otherwise might not be able to afford them.

Through the first half of the year, Vertex reported profits of $1.6 billion, with 89% of its revenue coming from Trikafta (marketed as Kaftrio in Europe). At the beginning of the year, Vertex decreased copay assistance for people with cystic fibrosis, in what the company said was a response to insurers’ limiting patients’ ability to apply copay assistance to their deductibles.

Lila Cummings, director of the Colorado board, said its staff could not find any entity that collects data on patient assistance programs, so those figures were not available to the board. Once they begin reviewing the individual medications, board members will dig into what extra financial help patients are getting. Cummings also said the board is hoping manufacturers will convey in good faith what might prompt them to leave the Colorado market.

When Trikafta came up second on the Colorado board’s prioritized list of drugs eligible for review, patients and advocacy groups flooded the board with pleas to leave pricing for the medication and other drugs for rare diseases untouched.

“People are scared,” Walker said. “If you look at all the drugs out there, it’s one that has been so transformational that I think it will go down in history for how positively it’s impacted our population as a whole.”

According to the Cystic Fibrosis Foundation, lung exacerbations dropped 65% and lung transplants dropped 80% after the drug’s approval. More patients have been able to work, attend school, or start a family. Clinicians have reported a baby boom among patients who take Trikafta.

A study published this year showed that two-thirds of people with cystic fibrosis struggled with finances, experiencing debt, food insecurity, or trouble paying for household or health expenses. The survey was conducted in 2019, before the FDA approval of Trikafta.

Years ago, the Cystic Fibrosis Foundation invested in Aurora Biosciences, later acquired by Vertex Pharmaceuticals, to promote development of cystic fibrosis therapies. The foundation completed the sale of its royalty rights in 2020.

Mary Dwight, chief policy and advocacy officer for the Cystic Fibrosis Foundation, said the board should “ensure its review of Trikafta accounts for the overall value this drug has for someone with CF, including the impact on an individual’s long-term health and well-being.”

There is no guarantee that the Colorado board will take action on Trikafta. State officials have stressed that board members are solely focused on improving access and wouldn’t jeopardize the availability of the medication.

“We have a history of being able to save people money on health care that doesn’t lead to access problems,” Conway said. “We’re not talking about these companies losing money at all; we’re talking about making it more affordable so that more Coloradans can get access to the pharmaceutical needs that they have.”

But Walker remains unconvinced.

“They had so much testimony on their call and they still selected Trikafta,” she said. “Everyone was just saying how important this drug is, and it didn’t matter. It still got pushed through.”

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Community With High Medical Debt Questions Its Hospitals’ Charity Spending

Markian Hawryluk — Thu, 17 Aug 2023 09:00:00 +0000

PUEBLO, Colo. — As 41% of American adults face medical debt, residents of this southern Colorado city contend their local nonprofit hospitals aren’t providing enough charity care to justify the millions in tax breaks they receive.

The two hospitals in Pueblo, Parkview Medical Center and Centura St. Mary-Corwin, do not pay most federal or state taxes. In exchange for the tax break, they are required to spend money to improve the health of their communities, including providing free care to those who can’t afford their medical bills. Although the hospitals report tens of millions in annual community benefit spending, the vast majority of that is not spent on the types of things advocates and researchers contend actually create community benefits, such as charity care.

And this month, four U.S. senators called on the Treasury’s inspector general for tax administration and the Internal Revenue Service to evaluate nonprofit hospitals’ compliance with tax-exempt requirements and provide information on oversight efforts.

The average hospital in the U.S. spends 1.9% of its operating expenses on charity care, according to an analysis of 2021 data by Johns Hopkins University health policy professor Ge Bai. Last year, Parkview provided 0.75% of its operating expenses, about $4.2 million, in free care.

Centura Health, a chain of 20 tax-exempt hospitals, reports its community benefit spending to the federal government in aggregate and does not break out specific numbers for individual hospitals. But St. Mary-Corwin reported $2.3 million in charity care in fiscal year 2022, according to its state filing. The filing does not specify the hospital’s operating expenses.

The low levels of charity care have translated into more debt for low-income residents. About 15% of people in Pueblo County have medical debt in collections, compared with 11% statewide and 13% nationwide, according to 2022 data from the Urban Institute. Those Puebloans have median medical debt of $975, about 40% higher than in Colorado and the U.S. as a whole. And all of those numbers are worse for people of color.

“How far into debt do people have to go to get any kind of relief?” said Theresa Trujillo, co-executive director at the Center for Health Progress’ Pueblo office. “Once you understand that there are tens of millions of dollars every single year that hospitals are extracting from our communities that are meant to be reinvested in our communities, you can’t go back from that without saying, ‘Oh my gosh, that is a thread we need to pull on.’”

Trujillo is organizing a group of fed-up residents to engage both hospitals on their community benefit spending. The group of at least a dozen residents believe the hospitals are ignoring the needs identified by the community — things like housing, addiction treatment, behavioral health care, and youth activities — and instead spending those dollars on things that mainly benefit the hospitals and their staffs.

For the fiscal year ending June 2022, with total revenue of $593 million, Parkview reported $100 million in community benefit spending. But most of that — more than $77 million — represented the difference between the hospital’s cost of providing care and what Medicaid paid for it.

IRS guidelines allow hospitals to claim Medicaid shortfall as a community benefit, but many academics and health policy experts argue such balance sheet shifts aren’t the same as providing charity care to patients.

Parkview also reported $4.7 million for educating its medical staff and $143,000 in incentives to recruit health professionals as community benefit. The hospital spent only $44,000 on community health improvement projects, which appear to have consisted mainly of launching a new mobile app to streamline appointments and referrals.

Meanwhile, the hospital recently spent $58 million on a new orthopedic facility and $43 million on a new cancer center. Parkview also wrote off $39 million in bad debt in fiscal 2022, although that is different from charity care. The bad debt is money the hospitals tried to collect from patients and ultimately decided they’d never get. But by that time, those patients would likely have been sent to collections and potentially had their credit damaged. And outstanding debt often keeps patients from seeking other needed care.

There is a disconnect between what the community said its biggest health needs were and where Parkview directed its spending. The hospital’s community needs assessment pegged access to care as the top concern, and the hospital said it launched the phone app in response.

The second-largest perceived health need was addressing alcohol and drug use. Yet, the only initiative Parkview cited in response was posting preventive health videos online, including some on alcohol and drug use. Meanwhile, the hospital shut down its inpatient psychiatric unit.

Parkview declined to answer questions about its charity care spending, but hospital spokesperson Todd Seip emailed a statement saying the hospital system “has been committed to providing extensive charity care to our community.”

Seip noted that 80% of Parkview’s patients are covered by Medicare or Medicaid, which pay lower rates than commercial insurance. The hospital posted a net loss of $6.7 million in the 2022 fiscal year, although its charity care wasn’t appreciably higher in previous years in which it posted a net gain.

Centura St. Mary-Corwin reported $16 million in Medicaid shortfall and $2 million in medical staff education in 2022, according to its state filing. The hospital spent about $38,000 for its community health improvement projects, primarily on emergency medical services outreach programs in rural areas. The hospital provided another $96,000 in services, mainly to promote covid-19 vaccination.

Centura also declined to answer questions about its charity care spending. Hospital spokesperson Lindsay Radford emailed a statement saying St. Mary-Corwin was aligning its community health needs assessment process with the Pueblo Department of Public Health and Environment “to develop shared implementation strategies for our community benefit funds, ensuring the resources are targeting the highest needs.”

Trujillo questioned how the hospital has conducted its community health assessments, relying on a social media poll to identify needs. After community members identified 12 concerns, she said, hospital leaders chose their priorities from the list.

“They talk about a community garden like they’re feeding the whole south side of the community,” Trujillo said. The hospital established a community garden in 2021, with 20 beds that could be adopted by residents to grow vegetables. Trujillo did praise the hospital for providing part of its building for a community college nursing program.

Trujillo’s group has spent much of the summer researching hospital charity spending and showing up at public meetings to have their views heard. They are working to gain seats on hospital and other state boards that influence how community benefit dollars are spent, and are urging hospitals to reconfigure their boards to better represent the demographics of their communities.

“We’ve made folks now aware that we want to be a part of those processes,” Trujillo said. “We’re willing to help them reach deeper into the community.”

Tax-exempt hospitals have been under increased state scrutiny for their charitable spending, especially after the Affordable Care Act and Medicaid expansion drove down the uninsured rate. That in turn cut the amount of care hospitals had to provide without being paid, potentially freeing up money to help more people without insurance or with high-deductible plans.

In Colorado, hospitals’ charity care spending and bad debt write-offs dropped from an average of $680 million a year in the five years prior to the ACA being fully implemented in 2014 to an average of $337 million in the years after, according to the Colorado Healthcare Affordability and Sustainability Enterprise Board, a state advisory group.

In states like Colorado, which used federal funding to expand the number of people covered by Medicaid, hospitals shifted more of their community benefit spending to cover Medicaid reimbursement shortfalls.

A January report from Colorado’s Department of Health Care Policy & Financing concluded that payments from public and private health plans help the state’s hospitals make more than enough money to offset lower Medicaid rates and still turn a profit while providing more true charity care.

Colorado has enacted two bills in the past five years to increase the transparency of hospitals’ charitable efforts with new reporting requirements.

“I think overall, we’re pleased with the amount of money that hospitals are reporting they spent,” said Kim Bimestefer, the executive director of the Department of Health Care Policy & Financing. “Is that money being expended in meaningful ways, ways that improve health and well-being of the community? Our reports right now can’t determine that.”

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A menudo, adolescentes con adicciones pasan por el proceso de desintoxicación sin medicamentos

Markian Hawryluk — Fri, 04 Aug 2023 15:50:00 +0000

Denver, Colorado.— Cuando Denver Health quiso abrir una unidad de desintoxicación para adolescentes que sufren adicción a los opioides, los médicos buscaron por todas partes un modelo a seguir, pero no encontraron ninguno.

Los adolescentes que llegan a salas de emergencia por una sobredosis de opioides generalmente reciben naloxona para revertir los efectos de las peligrosas drogas en su sistema y se les proporciona una lista de lugares a los que pueden acudir para recibir atención de seguimiento.

Sin embargo, con demasiada frecuencia, nunca buscan ayuda adicional y quedan a merced de la agonía de la abstinencia sin medicamentos que alivien sus ansias. Como resultado, muchos de ellos vuelven a consumir opioides, algo que a menudo termina en tragedia.

Christian Thurstone, director de servicios de salud conductual del hospital de Denver, informó que seis de sus pacientes adolescentes han muerto por sobredosis de fentanilo en los últimos dos años. Denver Health ha inaugurado ahora lo que él cree que es la primera unidad de desintoxicación para adolescentes hospitalizados en el país.

“Llevo 20 años tratando a adolescentes con problemas de adicciones aquí en Denver”, dijo Thurstone. “No sabría a dónde enviar a alguien para una desintoxicación adolescente”.

Una nueva investigación ha descubierto que la mayoría de las áreas de Estados Unidos carecen de instalaciones que ofrezcan desintoxicación supervisada por personal médico para pacientes menores de 18 años. Con las sobredosis de adolescentes en aumento junto con el rápido crecimiento del uso intencional y no intencional de fentanilo, hay una notable falta de opciones para este grupo.

Investigadores de la Oregon Health & Science University se hicieron pasar por tíos de un adolescente que recientemente había sufrido una sobredosis. Los investigadores llamaron a todas las instalaciones de tratamiento de adicciones para adolescentes que pudieron encontrar en Estados Unidos para preguntar si su sobrino o sobrina podía ir allí para desintoxicarse y si la instalación ofrecía medicamentos para ayudar con el proceso.

De las 160 instalaciones de tratamiento residencial para adolescentes que contactaron, solo 63 dijeron que permitirían la desintoxicación de adolescentes en el lugar. De esos 63, solo 18 ofrecían buprenorfina, el único medicamento aprobado por la Administración de Alimentos y Medicamentos (FDA) para tratar el trastorno por uso de opioides en jóvenes de 16 años en adelante, y algunos de ellos no ofrecían medicamentos adicionales para controlar los síntomas de abstinencia.

“No estoy segura de si ‘inhumano’ es una palabra demasiado fuerte”, dijo Caroline King, residente de medicina de emergencia en la Universidad de Yale, quien se graduó de OHSU en 2023 y lideró la investigación. “No ofrecer nada, ni siquiera medicamentos para las náuseas o cosas realmente básicas, es realmente una tragedia”.

El personal de una instalación le dijo a los investigadores que no ofrecen medicamentos porque los niños son resilientes, insinuando que no sufren tanto como los adultos, o tal vez que merecen sufrir, dijo King. En otro establecimiento, los trabajadores dijeron a los investigadores que “intentan darles Gatorade y simplemente los acuestan”, comentó King.

King dijo que varios lugares respondieron que no podían pensar en un solo lugar en su estado en donde los jóvenes pudieran acudir para desintoxicarse.

“Es realmente terrible escuchar que esa es la situación”, dijo King.

La Sociedad Estadounidense de Medicina de Adicción está revisando sus estándares para el tratamiento del trastorno por uso de opioides en adultos (este año) y menores (en 2024). Sandra Gómez-Luna, directora médica de psiquiatría en la Escuela de Medicina de Yale, quien lidera el esfuerzo pediátrico, dijo que la mayoría de los adolescentes no experimentan síntomas significativos de abstinencia y que, en general, la abstinencia no es tan intensa para los adolescentes como lo es para los adultos.

“Eso no significa que no haya un grupo de adolescentes con trastornos por uso de sustancias que requerirán una desintoxicación con monitoreo médico”, dijo.

Gómez-Luna explicó que, debido a que los adolescentes generalmente no han consumido drogas durante tanto tiempo como los adultos, es posible que no sufran las consecuencias del uso crónico o tengan condiciones de salud que puedan dificultar la abstinencia o el tratamiento.

Pero el aumento en el uso de fentanilo, un opioide más potente, puede estar cambiando esa percepción.

“A medida que más y más adolescentes se involucren en el uso de fentanilo”, dijo Gómez-Luna, “habrá más adolescentes que requerirán una desintoxicación con monitoreo médico”.

Gómez-Luna dijo que el grupo de medicina de adicción también está preocupado por la escasez de instalaciones para adolescentes y la falta de personal especializado para tratarlos.

Scott Hadland, jefe de medicina para adolescentes y adultos jóvenes en el Hospital General de Massachusetts para Niños y la Escuela de Medicina de Harvard, dijo que hay menos instalaciones para adolescentes en parte porque a muchos de ellos nunca se los identifica como un paciente que necesita ayuda, a pesar del creciente número de sobredosis.

“El volumen de pacientes no siempre está ahí para respaldar un programa como éste, a pesar de que sabemos que es un gran problema de salud pública”, dijo Hadland. “Se vuelve financieramente difícil construir un programa cuya única línea de servicio sea proporcionar servicios de desintoxicación para jóvenes”.

Cuando no hay unidades de desintoxicación dedicadas disponibles, a los adolescentes a veces se los admite en un hospital, a menudo en la unidad de cuidados intensivos, donde hay más supervisión que en las plantas de hospitalización general. Pero eso también significa que es menos probable que los adolescentes reciban atención de un equipo especializado en medicina de adicción para adolescentes.

“Nuestra fuerza laboral pediátrica tradicionalmente no ha recibido una formación sólida en el manejo de la adicción”, dijo Hadland. “Cuando los pacientes van a instalaciones de hospitales pediátricos generales, es posible que no haya alguien allí que tenga la experiencia necesaria para manejar la atención de ese paciente”.

Thurstone dijo que el mayor obstáculo para poner en marcha la unidad de desintoxicación para adolescentes de Denver Health fue el personal. Les tomó más de un año encontrar a un especialista en adicciones certificado para dirigirla.

Especialistas en adicciones enfatizan que no todos los adolescentes con trastorno por uso de opioides necesitan una desintoxicación hospitalaria. La abstinencia se puede manejar en casa si los adolescentes tienen un entorno familiar estable que los apoye, y vigile sus síntomas.

Sin embargo, muchos adolescentes con trastornos por uso de opioides provienen de hogares quebrados, en los que los padres pueden estar luchando con adicciones ellos mismos. Y después de la pandemia, los especialistas también están viendo más adolescentes con este trastorno que tienen otros problemas psiquiátricos, como depresión, ansiedad, trastorno por déficit de atención e hiperactividad o trastornos alimentarios.

“Todas estas condiciones han aumentado por la pandemia, junto con el aumento de las sobredosis que estamos viendo”, dijo Hadland. “Parte del desafío de nuestra fuerza laboral pediátrica en este momento no es solo abordar la adicción, sino también los problemas subyacentes de salud mental con los que los jóvenes están lidiando”.

Thurstone dijo que a nivel nacional, aproximadamente la mitad de todos los adolescentes abandonan el tratamiento, pero que es peor en comunidades marginadas.

Denver Health reacondicionó camas de una unidad psiquiátrica para poner en marcha su programa de desintoxicación para adolescentes. La unidad atendió a su primer paciente en la primavera y ha estado admitiendo a aproximadamente un paciente por semana, en su mayoría adolescentes fentanilo-dependientes.

Los adolescentes reciben terapia asistida con medicamentos, generalmente buprenorfina, para abordar sus ansias, medicamentos adicionales para controlar cualquier efecto secundario de la abstinencia; y terapia cognitivo-conductual para ayudarlos en su recuperación. Una vez que se les puede dar el alta de manera segura, se los conecta con programas de tratamiento de adicciones en sus comunidades. Thurstone cree que proporcionar ese continuo de atención ayudará a reducir las sobredosis en adolescentes en la región de Denver.

“Podemos hacerlo mejor que una visita a la sala de emergencias y una lista de recursos para llamar”, apuntó.

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Teens With Addiction Are Often Left to Detox Without Medication

Markian Hawryluk — Fri, 04 Aug 2023 09:00:00 +0000

DENVER — When Denver Health wanted to open an inpatient opioid detox unit specifically for teens, doctors there searched high and low for a model to copy. They didn’t find one.

Teens who land in emergency rooms with an opioid overdose generally receive naloxone to reverse the effects of dangerous drugs in their system and are sent home with a list of places they can go for follow-up care. But too often, those teens never seek additional help. They are left to suffer through the agony of withdrawal with no medications to ease their cravings. As a result, many, seeking relief, go back to opioids, often with tragic consequences.

Christian Thurstone, the director of behavioral health services at the Denver hospital, said six of his teen patients have died of fentanyl overdoses in the past two years. Denver Health has now opened what he believes to be the nation’s first adolescent inpatient detox unit.

“I’ve been doing adolescent substance treatment here in Denver for 20 years,” Thurstone said. “I wouldn’t know where to send somebody for adolescent detox.”

New research has found that most areas of the U.S. lack facilities that offer medically managed withdrawal for patients under 18. With adolescent overdoses continuing to rise along with the rapid growth of intentional and unintentional fentanyl use, there is a stark lack of options for teens.

Researchers at Oregon Health & Science University posed as an aunt or uncle of a teen who recently overdosed. The researchers called every U.S. teen addiction treatment facility they could find to ask if their niece or nephew could go there to detox and whether the facility offered medications to help with the process.

Of the 160 adolescent residential treatment facilities they contacted, only 63 said they would allow adolescents to detox on-site. Of those 63, only 18 offered buprenorphine — the one medication that’s FDA-approved to treat opioid use disorder in kids as young as 16 — and some of those offered no additional medications to manage withdrawal symptoms.

“I’m not sure if inhumane is too strong of a word,” said Caroline King, an emergency medicine resident at Yale University, who graduated from OHSU in 2023 and led the research. “Offering nothing, offering no additional medication, even nausea medication or really basic things, is really a travesty.”

Staff members at one facility told the researchers they don’t offer medications because kids are resilient, implying they don’t suffer as much as adults, or perhaps that they deserve to suffer, King said. Workers at another told researchers they “try to push Gatorade down them and just lay them down in a cot,” she said.

King said multiple locations responded that they couldn’t think of a single place in their state where kids could go to detox.

“It’s just really terrible to hear that that’s the case,” King said.

The American Society of Addiction Medicine is revising its standards for treating opioid use disorder in adults (this year) and children (in 2024). Sandra Gomez-Luna, the chief medical officer for psychiatry at the Yale School of Medicine, who is leading the pediatric effort, said most adolescents do not experience significant withdrawal symptoms and that, in general, withdrawal isn’t as intense for teens as it is for adults.

“That doesn’t mean that there isn’t a portion of teens with substance use disorders that will require medically monitored withdrawal management,” she said.

Because teens usually haven’t been using drugs for as long as adults, Gomez-Luna said, they may not suffer the consequences of chronic use or have as many accompanying health conditions that can make withdrawal more difficult, or more complex to treat.

But the rise in the more potent opioid fentanyl may be changing that thinking.

“As more and more teens will get involved in fentanyl use,” Gomez-Luna said, “there will be more adolescents that will require medically monitored withdrawal.”

Gomez-Luna said the addiction medicine group is also concerned there are too few facilities for teens and a lack of specialized personnel to treat them.

Scott Hadland, chief of adolescent and young adult medicine at Mass General for Children and Harvard Medical School, said there are fewer facilities for adolescents in part because many teens are never identified as needing help or connected to care, despite the growing number of overdoses.

“The patient volume is surprisingly not always there to support a program like this, even though we know that this is a huge public health problem,” Hadland said. “It becomes financially difficult to build a program whose sole service line is to provide detoxification services for young people.”

When no dedicated detox units are available, teens sometimes get admitted to a hospital, often to the intensive care unit, where more monitoring is available than on regular inpatient floors. But that also means teens are less likely to be cared for by a team specializing in adolescent addiction medicine.

“Our pediatric workforce has not traditionally received strong training in the management of addiction,” Hadland said. “When patients do go to general pediatric hospital settings, it’s possible that there isn’t someone there who has the expertise needed to manage that patient’s care.”

Thurstone said the biggest hurdle in getting Denver Health’s teen detox unit running was staffing. It took more than a year to find a certified addiction specialist to run the unit.

Addiction specialists stress that not all teens with opioid use disorder need inpatient detox. Withdrawal can be managed at home if teens have a stable family environment to support them and monitor their symptoms. Many adolescents with opioid use disorders, however, come from broken homes in which the parents may be struggling with addiction themselves. And coming out of the pandemic, specialists are also seeing more teens with opioid use disorders who have other psychiatric problems, such as depression, anxiety, attention-deficit/hyperactivity disorder, or eating disorders.

“All of these conditions have been on the rise in the wake of covid, alongside the rise in overdoses that we’re seeing,” Hadland said. “Part of the charge of our pediatric workforce right now is not just to address addiction, but also to tackle the underlying mental health conditions that young people are working through.”

Thurstone said that nationwide about half of all adolescents drop out of treatment, but that it’s worse in marginalized communities.

Denver Health repurposed beds from an inpatient psychiatric unit to get its teen detox program running. The unit saw its first patient this spring and has been admitting about one patient a week, mostly teens with a fentanyl dependence.

The teens start medication-assisted therapy, most often with buprenorphine, to address their cravings; get additional meds to manage any side effects of withdrawal; and receive cognitive behavioral therapy to help them with their recovery. Once they can be safely discharged, they are connected to addiction treatment programs in their communities. Thurstone believes providing that continuum of care will help reduce teen overdoses in the Denver region.

“We can do better than, you know, an ER visit and a list of resources to call,” he said.

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Markian Hawryluk, Author at KFF Health News

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