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  • Pregnancy care was always lacking in jails. It could get worse.

    Pregnancy care was always lacking in jails. It could get worse.

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    Standing in front of the concrete steps of her home in Midway, Texas, Collier, initially barefoot and wearing a baggy gray T-shirt, told officers she planned to see a doctor in the morning because she had been bleeding.

    Police body camera footage obtained by KFF Health News through an open records request shows that the officers then told Collier — who was 29 at the time and enrolled in online classes to study psychology — to turn around.

    Instead of taking her to get medical care, they handcuffed and arrested her because she had outstanding warrants in a neighboring county for failing to appear in court to face misdemeanor drug charges three weeks earlier. She had missed that court date, medical records show, because she was at a hospital receiving treatment for pregnancy complications.

    Despite her symptoms and being about 13 weeks pregnant, Collier spent the next day and a half in the Walker County Jail, about 80 miles north of Houston. She said her bleeding worsened there and she begged repeatedly for medical attention that she didn’t receive, according to a formal complaint she filed with the Texas Commission on Jail Standards.

    “There wasn’t anything I could do,” she said, but “just lay there and be scared and not know what was going to happen.”

    Welfare Check Turns Into Arrest for Pregnant Texan

    Collier’s experience highlights the limited oversight and absence of federal standards for reproductive care for pregnant women in the criminal justice system. Incarcerated people have a constitutional right to health care, yet only a half-dozen states have passed laws guaranteeing access to prenatal or postpartum medical care for people in custody, according to a review of reproductive health care legislation for incarcerated people by a research group at Johns Hopkins School of Medicine. And now abortion restrictions might be putting care further out of reach.

    Collier’s arrest was “shocking and disturbing” because officers “blithely” took her to jail despite her miscarriage concerns, said Wanda Bertram, a spokesperson for the Prison Policy Initiative, a nonprofit organization that studies incarceration. Bertram reviewed the body cam footage and Collier’s complaint.

    “Police arrest people who are in medical emergencies all the time,” she said. “And they do that regardless of the fact that the jail is often not equipped to care for those people in the way an emergency room might be.”

    After a decline during the first year of the pandemic, the number of women in U.S. jails is once again rising, hitting nearly 93,000 in June 2022, a 33% increase over 2020, according to the Department of Justice. Tens of thousands of pregnant women enter U.S. jails each year, according to estimates by Carolyn Sufrin, an associate professor of gynecology and obstetrics at Johns Hopkins School of Medicine, who researches pregnancy care in jails and prisons.

    The health care needs of incarcerated women have “always been an afterthought,” said Dana Sussman, deputy executive director at Pregnancy Justice, an organization that defends women who have been charged with crimes related to their pregnancy, such as substance use. For example, about half of states don’t provide free menstrual products in jails and prisons. “And then the needs of pregnant women are an afterthought beyond that,” Sussman said.

    Researchers and advocates worry that confusion over recent abortion restrictions may further complicate the situation. A nurse cited Texas’ abortion laws as one reason Collier didn’t need care, according to her statement to the standards commission.

    Texas law allows treatment of miscarriage and ectopic pregnancies, a life-threatening condition in which a fertilized egg implants outside the uterus. However, different interpretations of the law can create confusion.

    A nurse told Collier that “hospitals no longer did dilation and curettage,” Collier told the commission. “Since I wasn’t hemorrhaging to the point of completely soaking my pants, there wasn’t anything that could be done for me,” she said.

    Collier testified that she saw a nurse only once during her stay in jail, even after she repeatedly asked jail staffers for help. The nurse checked her temperature and blood pressure and told her to put in a formal request for Tylenol. Collier said she completed her miscarriage shortly after being released.

    Collier’s case is a “canary in a coal mine” for what is happening in jails; abortion restrictions are “going to have a huge ripple effect on a system already unequipped to handle obstetric emergencies,” Sufrin said.

    ‘There are no consequences’

    Jail and prison health policies vary widely around the country and often fall far short of the American College of Obstetricians and Gynecologists’ guidelines for reproductive health care for incarcerated people. ACOG and other groups recommend that incarcerated women have access to unscheduled or emergency obstetric visits on a 24-hour basis and that on-site health care providers should be better trained to recognize pregnancy problems.

    In Alabama, where women have been jailed for substance use during pregnancy, the state offers pregnancy tests in jail. But it doesn’t guarantee a minimum standard of prenatal care, such as access to extra food and medical visits, according to Johns Hopkins’ review.

    Policies for pregnant women at federal facilities also don’t align with national standards for nutrition, safe housing, and access to medical care, according to a 2021 report from the Government Accountability Office.

    Even when laws exist to ensure that incarcerated pregnant women have access to care, the language is often vague, leaving discretion to jail personnel.

    Since 2020, Tennessee law has required that jails and prisons provide pregnant women “regular prenatal and postpartum care, as necessary.” But last August a woman gave birth in a jail cell after seeking medical attention for more than an hour, according to the Montgomery County Sheriff’s Office.

    Pregnancy complications can quickly escalate into life-threatening situations, requiring more timely and specialized care than jails can often provide, said Sufrin. And when jails fail to comply with laws on the books, little oversight or enforcement may exist.

    In Louisiana, many jails didn’t consistently follow laws that aimed to improve access to reproductive health care, such as providing free menstrual items, according to a May 2023 report commissioned by state lawmakers. The report also said jails weren’t transparent about whether they followed other laws, such as prohibiting the use of solitary confinement for pregnant women.

    Krishnaveni Gundu, as co-founder of the Texas Jail Project, which advocates for people held in county jails, has lobbied for more than a decade to strengthen state protections for pregnant incarcerated people.

    In 2019, Texas became one of the few states to require that jails’ health policies include obstetrical and gynecological care. The law requires jails to promptly transport a pregnant person in labor to a hospital, and additional regulations mandate access to medical and mental health care for miscarriages and other pregnancy complications.

    But Gundu said lack of oversight and meaningful enforcement mechanisms, along with “apathy” among jail employees, have undermined regulatory protections.

    “All those reforms feel futile,” said Gundu, who helped Collier prepare for her testimony. “There are no consequences.”

    Before her arrest, Collier had been to the hospital twice that month experiencing pregnancy complications, including a bladder infection, her medical records show. Yet the commission found that Walker County Jail didn’t violate minimum standards. The commission did not consider the police body cam footage or Collier’s personal medical records, which support her assertions of pregnancy complications, according to investigation documents obtained by KFF Health News via an open records request.

    In making its determination, the commission relied mainly on the jail’s medical records, which note that Collier asked for medical attention for a miscarriage once, in the morning on the day she was released, and refused Tylenol.

    “Your complaint of no medical care is unfounded,” the commission concluded, “and no further action will be taken.”

    Collier’s miscarriage had ended before she entered the jail, argued Lt. Keith DeHart, jail lieutenant for the Walker County Sheriff’s Office. “I believe there was some misunderstanding,” he said.

    Brandon Wood, executive director of the commission, wouldn’t comment on Collier’s case but defends the group’s investigation as thorough. Jails “have a duty to ensure that those records are accurate and truthful,” he said. And most Texas jails are complying with heightened standards, he said.

    Bertram disagrees, saying the fact that care was denied to someone who was begging for it speaks volumes. “That should tell you something about what these standards are worth,” she said.

    Last year, Chiree Harley spent six weeks in a Comal County, Texas, jail shortly after discovering she was pregnant and before she could get prenatal care, she said.

    I was “thinking that I was going to be well taken care of,” said Harley, 37, who also struggled with substance use.

    Jail officials put her in the infirmary, Harley said, but she saw only a jail doctor and never visited an OB-GYN, even though she had previous pregnancy complications including losing multiple pregnancies at around 21 weeks. This time she had no idea how far along she was.

    She said that she started leaking amniotic fluid and having contractions on Nov. 1, but that jail officials waited nearly two days to take her to a hospital. Harley said officers forced her to sign papers releasing her from jail custody while she was having contractions in the hospital. Harley delivered at 23 weeks; the baby boy died less than a day later in her arms.

    The whole experience was “very scary,” Harley said. “Afterwards we were all very, very devastated.”

    Comal County declined to send Harley’s medical and other records in response to an open records request. Michael Shaunessy, a partner at McGinnis Lochridge who represents Comal County, said in a statement that, “at all times, the Comal County Jail provided Chiree Harley with all appropriate and necessary medical treatment for her and her unborn child.” He did not respond to questions about whether Harley was provided specialized obstetric care.

    ‘I trusted those people’

    In states like Idaho, Mississippi, and Louisiana that installed near-total abortion bans after the Supreme Court eliminated the constitutional right to abortion in 2022, some patients might have to wait until no fetal cardiac activity is detected before they can get care, said Kari White, the executive and scientific director of Resound Research for Reproductive Health.

    White co-authored a recent study that documented 50 cases in which pregnancy care deviated from the standard because of abortion restrictions even outside of jails and prisons. Health care providers who worry about running afoul of strict laws might tell patients to go home and wait until their situations worsen.

    “Obviously, it’s much trickier for people who are in jail or in prison, because they are not going to necessarily be able to leave again,” she said.

    Advocates argue that boosting oversight and standards is a start, but that states need to find other ways to manage pregnant women who get caught in the justice system.

    For many pregnant people, even a short stay in jail can cause lasting trauma and interrupt crucial prenatal care.

    Collier remembers being in “disbelief” when she was first arrested but said she was not “distraught.”

    “I figured I would be taken care of, that nothing bad was gonna happen to me,” she said. As it became clear that she wouldn’t get care, she grew distressed.

    After her miscarriage, Collier saw a mental health specialist and started medication to treat depression. She hasn’t returned to her studies, she said.

    “I trusted those people,” Collier said about the jail staff. “The whole experience really messed my head up.”




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • What factors are associated with recent prostate-specific antigen screening in transgender women?

    What factors are associated with recent prostate-specific antigen screening in transgender women?

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    A new report in JAMA Network Open reports on factors associated with prostate cancer screening among transgender women.

    Study: Prostate Cancer Screening Uptake in Transgender Women. Image Credit: Jarun Ontakrai/Shutterstock.com
    Study: Prostate Cancer Screening Uptake in Transgender Women. Image Credit: Jarun Ontakrai/Shutterstock.com

    Background

    Not much is known about the incidence of prostate cancer in this population, but some research indicates that it may be as high as 14 per 10,000 cases. Moreover, transgender women on hormone therapy are more likely to develop aggressive disease, potentially due to diagnostic delay from misinterpreting the prostate-specific antigen (PSA) test values in the context of the suppressive effects of estrogen.

    As of now, there is no guideline on when prostate cancer screening via (PSA) test should be done in transgender women. However, it is known that they are at increased risk for this cancer since prostatectomies are not part of the surgical procedure to change gender in such individuals.

    The current study sought to identify factors common to transgender women who underwent a PSA screening test during the previous two years compared to cisgender men.

    What did the study show?

    The data came from the Behavioral Risk Factor Surveillance System (BRFSS) surveys of 2018 and 2020, which were carried out by the Centers for Disease Control and Prevention (CDC). This survey covers more than 400,000 American adults each year.

    In the current study, there were nearly 1,300 participants, all 40 years or above, without a history of prostate cancer. Approximately 260 transgender women were matched to over 1,000 men. About 45% were between 55 and 69 years old. Almost 80% were White.

    Transgender women were less likely to have a college degree or have current work and found it more difficult to pay healthcare costs compared to cisgender men. The odds of their earning $75,000 or more yearly were much lower compared to cisgender men.

    In the age group of 55-69 years, PSA screening was performed within the previous two years in over one in five transgender women vs well over one in three cisgender men. The percentages in the over-70 group were similar between the groups, at ~40%.

    When matched for confounding factors, such as whether a doctor had recommended or discussed a PSA test or time since the last clinical visit, there was no significant difference in screening proportions between the two groups. The strongest factor associated with PSA screening among transgender women was a doctor recommending the test, with such individuals being over 12 times more likely to be tested. Similarly, if a doctor had discussed the advantages of PSA testing, the odds were almost 8-fold.

    However, those with higher educational status and higher incomes were also more likely to have been recently screened. Having a college degree increased the odds of recent screening by 2.55 times.

    Older individuals (70 years or more) were almost twice as likely to have been screened recently vs those aged 55-69 years. This corroborates earlier reports. The difference in screening rates in the younger age group remained unexplained and did not vary with primary care follow-up frequency.

    What are the implications?

    This was among the largest cohort studies of PSA screening among transgender women so far. While it appeared on the surface that transgender women were less likely to undergo screening than cisgender men, the difference became smaller and statistically insignificant when accounting for the influence of a doctor’s recommendation to have the test done.

    The large effect of clinician recommendations on the rate of PSA screening among transgender women makes it important that doctors educate themselves on how best to treat transgender patients. Further study is essential to arrive at a quantitative estimate of the cost-effectiveness of PSA screening among transgender women.

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  • Early detection may help Kentucky tamp down its lung cancer crisis

    Early detection may help Kentucky tamp down its lung cancer crisis

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    Anthony Stumbo’s heart sank after the doctor shared his mother’s chest X-ray.

    “I remember that drive home, bringing her back home, and we basically cried,” said the internal medicine physician, who had started practicing in eastern Kentucky near his childhood home shortly before his mother began feeling ill. “Nobody wants to get told they’ve got inoperable lung cancer. I cried because I knew what this meant for her.”

    Now Stumbo, whose mother died the following year, in 1997, is among a group of Kentucky clinicians and researchers determined to rewrite the script for other families by promoting training and boosting awareness about early detection in the state with the highest lung cancer death rate. For the past decade, Kentucky researchers have promoted lung cancer screening, first recommended by the U.S. Preventive Services Task Force in 2013. These days the Bluegrass State screens more residents who are at high risk of developing lung cancer than any state except Massachusetts — 10.6% of eligible residents in 2022, more than double the national rate of 4.5% — according to the most recent American Lung Association analysis.

    The effort has been driven by a research initiative called the Kentucky LEADS (Lung Cancer Education, Awareness, Detection, and Survivorship) Collaborative, which in 2014 launched to improve screening and prevention, to identify more tumors earlier, when survival odds are far better. The group has worked with clinicians and hospital administrators statewide to boost screening rates both in urban areas and regions far removed from academic medical centers, such as rural Appalachia. But, a decade into the program, the researchers face an ongoing challenge as they encourage more people to get tested, namely the fear and stigma that swirl around smoking and lung cancer.

    Lung cancer kills more Americans than any other malignancy, and the death rates are worst in a swath of states including Kentucky and its neighbors Tennessee and West Virginia, and stretching south to Mississippi and Louisiana, according to data from the Centers for Disease Control and Prevention.

    It’s a bit early to see the impact on lung cancer deaths because people may still live for years with a malignancy, LEADS researchers said. Plus, treatment improvements and other factors may also help reduce death rates along with increased screening. Still, data already shows that more cancers in Kentucky are being detected before they become advanced, and thus more difficult to treat, they said. Of total lung cancer cases statewide, the percentage of advanced cases — defined as cancers that had spread to the lymph nodes or beyond — hovered near 81% between 2000 and 2014, according to Kentucky Cancer Registry data. By 2020, that number had declined to 72%, according to the most recent data available.

    “We are changing the story of families. And there is hope where there has not been hope before,” said Jennifer Knight, a LEADS principal investigator.

    Older adults in their 60s and 70s can hold a particularly bleak view of their mortality odds, given what their loved ones experienced before screening became available, said Ashley Shemwell, a nurse navigator for the lung cancer screening program at Owensboro Health, a nonprofit health system that serves Kentucky and Indiana.

    “A lot of them will say, ‘It doesn’t matter if I get lung cancer or not because it’s going to kill me. So I don’t want to know,’” said Shemwell. “With that generation, they saw a lot of lung cancers and a lot of deaths. And it was terrible deaths because they were stage 4 lung cancers.” But she reminds them that lung cancer is much more treatable if caught before it spreads.

    The collaborative works with several partners, including the University of Kentucky, the University of Louisville, and GO2 for Lung Cancer, and has received grant funding from the Bristol Myers Squibb Foundation. Leaders have provided training and other support to 10 hospital-based screening programs, including a stipend to pay for resources such as educational materials or a nurse navigator, Knight said. In 2022, state lawmakers established a statewide lung cancer screening program based in part on the group’s work.

    Jacob Sands, a lung cancer physician at Boston’s Dana-Farber Cancer Institute, credits the LEADS collaborative with encouraging patients to return for annual screening and follow-up testing for any suspicious nodules. “What the Kentucky LEADS program is doing is fantastic, and that is how you really move the needle in implementing lung screening on a larger scale,” said Sands, who isn’t affiliated with the Kentucky program and serves as a volunteer spokesperson for the American Lung Association.

    In 2014, Kentucky expanded Medicaid, increasing the number of lower-income people who qualified for lung cancer screening and any related treatment. Adults 50 to 80 years old are advised to get a CT scan every year if they have accumulated at least 20 pack years and still smoke or have quit within the past 15 years, according to the latest task force recommendation, which widened the pool of eligible adults. (To calculate pack years, multiply the packs of cigarettes smoked daily by years of smoking.) The lung association offers an online quiz, called “Saved By The Scan,” to figure out likely eligibility for insurance coverage.

    Half of U.S. patients aren’t diagnosed until their cancer has spread beyond the lungs and lymph nodes to elsewhere in the body. By then, the five-year survival rate is 8.2%.

    But regular screening boosts those odds. When a CT scan detects lung cancer early, patients have an 81% chance of living at least 20 years, according to data published in November in the journal Radiology.

    Some adults, like Lisa Ayers, didn’t realize lung cancer screening was an option. Her family doctor recommended a CT scan last year after she reported breathing difficulties. Ayers, who lives in Ohio near the Kentucky border, got screened at UK King’s Daughters, a hospital in far eastern Kentucky. The scan didn’t take much time, and she didn’t have to undress, the 57-year-old said. “It took me longer to park,” she quipped.

    She was diagnosed with a lung carcinoid tumor, a type of neuroendocrine cancer that can grow in various parts of the body. Her cancer was considered too risky for surgery, Ayers said. A biopsy showed the cancer was slow-growing, and her doctors said they would monitor it closely.

    Ayers, a lifelong smoker, recalled her doctor said that her type of cancer isn’t typically linked to smoking. But she quit anyway, feeling like she’d been given a second chance to avoid developing a smoking-related cancer. “It was a big wake-up call for me.”

    Adults with a smoking history often report being treated poorly by medical professionals, said Jamie Studts, a health psychologist and a LEADS principal investigator, who has been involved with the research from the start. The goal is to avoid stigmatizing people and instead to build rapport, meeting them where they are that day, he said.

    “If someone tells us that they’re not ready to quit smoking but they want to have lung cancer screening, awesome; we’d love to help,” Studts said. “You know what? You actually develop a relationship with an individual by accepting, ‘No.’”

    Nationally, screening rates vary widely. Massachusetts reaches 11.9% of eligible residents, while California ranks last, screening just 0.7%, according to the lung association analysis.

    That data likely doesn’t capture all California screenings, as it may not include CT scans done through large managed care organizations, said Raquel Arias, a Los Angeles-based associate director of state partnerships at the American Cancer Society. She cited other 2022 data for California, looking at lung cancer screening for eligible Medicare fee-for-service patients, which found a screening rate of 1%-2% in that population.

    But, Arias said, the state’s effort is “nowhere near what it needs to be.”

    The low smoking rate in California, along with its image as a healthy state, “seems to have come with the unintended consequence of further stigmatizing people who smoke,” said Arias, citing one of the findings from a 2022 report looking at lung cancer screening barriers. For instance, eligible patients may be reluctant to share prior smoking habits with their health provider, she said.

    Meanwhile, Kentucky screening efforts progress, scan by scan.

    At Appalachian Regional Healthcare, 3,071 patients were screened in 2023, compared with 372 in 2017. “We’re just scratching the surface of the potential lives that we can have an effect on,” said Stumbo, a lung cancer screening champion at the health system, which includes 14 hospitals, most located in eastern Kentucky.

    The doctor hasn’t shed his own grief about what his family missed after his mother died at age 51, long before annual screening was recommended. “Knowing that my children were born, and never knowing their grandmother,” he said, “just how sad is that?”




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • States target health insurers’ ‘prior authorization’ red tape

    States target health insurers’ ‘prior authorization’ red tape

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    Christopher Marks noticed an immediate improvement when his doctor prescribed him the Type 2 diabetes medication Mounjaro last year. The 40-year-old truck driver from Kansas City, Missouri, said his average blood sugar reading decreased significantly and that keeping it within target range took less insulin than before.

    But when his doctor followed the typical prescribing pattern and increased his dose of Mounjaro — a drug with a wholesale list price of more than $1,000 a month — Marks’ health insurer declined to pay for it.

    Marks had Cigna insurance that he purchased on the federal health insurance marketplace, healthcare.gov. After two appeals over a month and a half, Cigna agreed to cover the higher dose. A few months later, he said, when it was time to up his dose once more, he was denied again. By November, he decided it wasn’t worth sparring with Cigna anymore since the insurer was leaving the marketplace in Missouri at the start of this year. He decided to stay on the lower dose until his new insurance kicked in.

    “That is beyond frustrating. People shouldn’t have to be like, ‘It’s not worth the fight to get my medical treatment,’” Marks said.

    The process Marks encountered is called “prior authorization,” or sometimes “pre-certification,” a tool insurers say they use to rein in costs and protect patients from unnecessary or ineffective medical treatment. But the practice has prompted backlash from patients like Marks, as well as groups representing medical professionals and hospitals that say prior authorization can interfere with treatment, cause medical provider burnout, and increase administrative costs.

    In January, the Biden administration announced new rules to streamline the process for patients with certain health plans, after attempts stalled out in Congress, including a bill that passed the House in 2022. But states are considering prior authorization bills that go even further. Last year, lawmakers in 29 states and Washington, D.C., considered some 90 bills to limit prior authorization requirements, according to the American Medical Association, with notable victories in New Jersey and Washington, D.C. The physicians association expects more bills this year, many with provisions spelled out in model legislation the group drafted.

    In 2018, health insurers signed a consensus statement with various medical facility and provider groups that broadly laid out areas for improving the prior authorization process. But the lack of progress since then has shown the need for legislative action, said Jack Resneck Jr., past president of the AMA and a current trustee.

    “They have not lived up to their promises,” Resneck said.

    Resneck, a California dermatologist, emphasized pending bills in Indiana, Massachusetts, North Carolina, Oklahoma, and Wyoming that include several policies backed by the AMA, including quicker response times, requirements for public reporting of insurers’ prior authorization determinations, and programs to reduce the volume of requests, sometimes called “gold carding.” Legislation has come from both Democratic and Republican lawmakers, and some is bipartisan, as in Colorado.

    In Missouri, legislation introduced by Republican state Rep. Melanie Stinnett aims to establish one of those gold carding programs for treatment and prescriptions. Stinnett said she regularly was frustrated by prior authorization hurdles in her work as a speech pathologist before joining the legislature in 2023.

    “The stories all kind of look similar: It’s a big fight to get something done on the insurance side for approval,” Stinnett said. “Then sometimes, even after all of that fight, it feels like it may have not been worthwhile because some people then have a change at the beginning of the year with their insurance.”

    Under her bill, a medical provider’s prior authorization requests during a six-month evaluation period would be reviewed. After that period, providers whose requests were approved at least 90% of the time would be exempt from having to submit requests for the next six months. The exemptions would also apply to facilities that meet that threshold. Then, she said, they would need to continue meeting the threshold to keep the “luxury” of the exemption.

    Five states have passed some form of gold carding program: Louisiana, Michigan, Texas, Vermont, and West Virginia. The AMA is tracking active gold carding bills in 13 states, including Missouri.

    A 2022 survey of 26 health insurance plans conducted by the industry trade group AHIP found that just over half of those plans had used a gold carding program for medical services while about a fifth had done so for prescriptions. They gave mixed reviews: 23% said patient safety improved or stayed the same, while 20% said the practice increased costs without improving quality.

    The new federal prior authorization rules finalized by the Centers for Medicare & Medicaid Services stop short of gold carding and don’t address prior authorizations for prescription drugs, like Marks’ Mounjaro prescription. Beginning in 2026, the new rules establish response time frames and public reporting requirements — and ultimately will mandate an electronic process — for some insurers participating in federal programs, such as Medicare Advantage or the health insurance marketplace. Manual submissions accounted for 39% of prior authorization requests for prescriptions and 60% of those for medical services, according to the 2022 insurance survey.

    In Missouri, state and national organizations representing doctors, nurses, social workers, and hospitals, among others, back Stinnett’s bill. Opposition to the plan comes largely from pharmacy benefit managers and the insurance industry, including the company whose prior authorization process Marks navigated last year. A Cigna Healthcare executive submitted testimony saying the company’s experience showed gold card policies “increase inappropriate care and costs.”

    The St. Louis Area Business Health Coalition, which represents dozens of employers that purchase health insurance for employees, also opposes the bill. Members of the coalition include financial services firm Edward Jones, coal company Peabody Energy, and aviation giant Boeing, as well as several public school districts and the St. Louis city and county governments.

    Louise Probst, the coalition’s executive director, said the prior authorization process has issues but that the coalition would prefer that a solution come from insurers and providers rather than a new state law.

    “The reason I hate to see things just set in stone is that you lose the flexibility and the nuance that could be helpful to patients,” Probst said.

    On the other side of the state, Marks purchased insurance for this year on the federal marketplace from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed the higher dose of Mounjaro that Cigna had declined to cover. A little over a week later, Marks said, his new insurance approved the higher dose “without any fuss.”

    Cigna spokesperson Justine Sessions said the company uses prior authorizations for popular drugs such as Mounjaro to help ensure patients get the right medications and dosages.

    “We strive to make authorizations quickly and correctly, but in Mr. Marks’ case, we fell short and we greatly regret the stress and frustration this caused,” she said. “We are reviewing this case and identifying opportunities for improvement to ensure this does not happen in the future.”

    Marks’ aim with this higher dose of Mounjaro is to get off his other diabetes medications. He particularly hopes to stop taking insulin, which for him requires multiple injections a day and carries a risk of dangerous complications from low blood sugar.

    “I don’t really use the word ‘life-changing,’ but it kind of is,” Marks said. “Getting off insulin would be great.”

    Do you have an experience with prior authorization you’d like to share? Click here to tell your story.




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • Reducing unnecessary testing or treatments in older patients

    Reducing unnecessary testing or treatments in older patients

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    When a doctor ordered a routine prostate screening for an 80-year-old man -; as doctors often do -; a dramatic yellow alert popped up on the electronic health record with dire warnings. 

    It flashed: “You are ordering a test that no guideline recommends. Screening with PSA can lead to harms from diagnostic and treatment procedures. If you proceed without a justification, the unnecessary test will be noted on the health record.” 

    This was the strategy Northwestern Medicine investigators tested to see if they could move the needle on the stubbornly persistent practice of ordering unnecessary screenings for older adults. Doctors got the message.

    The results, published Feb. 6 in Annals of Internal Medicine, found a significant decrease in screenings for prostate cancer and urinary tract infections. 

    After 18 months of delivering the alerts to 370 clinicians in 60 Northwestern Medicine clinics, unnecessary testing was reduced 9% in the PSA intervention group and 5.5% in the urine testing intervention group. There was, however, only a small change, in the overtreatment of blood sugar, which also can result in potential harm. Half of the physicians received the alerts, the other half did not. 

    To our knowledge, this is the first study to significantly reduce all of the unnecessary testing or treatments studied using point-of-care alerts. We believe that incorporating elements like a focus on potential harms, sharing social norms and promoting a sense of social accountability and reputational concerns led to the effectiveness of these messages.”


    Dr. Stephen Persell, lead investigator, professor of medicine at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician

    Several recent trials that attempted to reduce overuse of testing, using interventions delivered to clinicians through the electronic health record, have not been particularly successful at changing clinicians’ behavior, Persell noted. 

    “But if messages clinicians find compelling can be delivered by electronic health records at the time clinicians place their orders, this could be a straightforward way to improve care and could be applied across large health systems easily,” Persell said. 

    Harm from unnecessary screening and overtreatment

    Screening a man 76 years or older for prostate cancer may result in overtreatment that could cause him serious health problems than simply living with an indolent cancer.

    Even so, a man’s primary care physician will often obtain a PSA test to screen for prostate cancer. Ditto for women 65 and older being tested for urinary tract infections without any symptoms. Doctors also overtreat diabetes with hypoglycemic agents in patients aged 75 years and older.

    The overuse of low-value screenings and unnecessary care remains a problem in American health care, particularly for older adults. 

    “These are screening practices people have adopted without good evidence,” Persell said. 

    “If a man is not going to live another 10 or 15 years due to his age, you won’t save his life from prostate cancer by screening him, but you will subject him to the potential harms of treatment,” said Persell, also director of the Center for Primary Care Innovation at Feinberg. The treatment may lead to surgery or radiation treatment that can cause urinary incontinence or urinary symptoms, impair sexual function or cause rectal bleeding. 

    “What’s right for a 68-year-old man might not be right for one who is 75 or 85 years old,” Persell said. 

    Harm can also result from testing women 65 and older for urinary tract infections, if they are not experiencing any symptoms.

    “These asymptomatic urinary tract infections are common in older women, but there is no evidence that you can improve a woman’s health with antibiotics,” Persell said. Antibiotics, however, can cause allergic reactions, diarrhea and antibiotic resistance, which could make bacterial infections harder to treat in the future.

    In addition, treating blood sugar to very low levels in older adults with drugs like insulin or sulfonylureas puts older patients at risk for dangerous low blood sugar events. 

    But doctors and patients resist change in blood sugar interventions. “We have taught patients to strive to control their blood sugar, even when it gets to a point when it’s safer to have slightly less controlled blood sugar,” Persell said. “It’s hard to convince patients and doctors to change their goals.”

    The next step in the research and other ongoing studies are testing whether similar approaches can be used to improve the quality of care in other areas where treatments may be overused such as opioids, sleeping pills and drug combinations that may cause harm. 

    Other authors include Lucia C. Petito, Ji Young Lee, Daniella Meeker, Jason N. Doctor, Noah J. Goldstein, Craig R. Fox, Theresa A. Rowe, Dr. Jeffrey A. Linder, Ryan Chmiel, Yaw Amofa Peprah and Tiffany Brown.

    The title of the article is “Reducing Care Overuse in Older Patients Using Professional Norms and Accountability.”

    The research was supported by National Institute on Aging of the National Institutes of Health award R33AG057383.

    Source:

    Journal reference:

    Persell, S. D., et al. (2024). Reducing Care Overuse in Older Patients Using Professional Norms and Accountability. Annals of Internal Medicine. doi.org/10.7326/m23-2183.

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  • Trust in doctors key to boosting vaccination rates

    Trust in doctors key to boosting vaccination rates

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    “Trust me, I’m a doctor.”

    While this expression has become an advertising slogan and meme, physicians and nurses continually rank among the most trusted professions in the U.S.

    Now, a new study by researchers at the NYU School of Global Public Health shows that how Americans view the medical profession shapes whether they are likely to get vaccinated against COVID-19.

    Among people who were hesitant or initially didn’t want a COVID-19 vaccine, those who trust the medical profession were more likely to ultimately get vaccinated. In addition,

    people who were vaccinated and reported trusting their own doctor were more likely to get a booster.

    In contrast, trust in public officials-;including national, state, and local leaders-;did not shift behaviors around vaccination.

    “Our research suggests mobilizing the medical community is critical for addressing reluctance, uncertainty, and distrust of vaccines,” said Diana Silver, professor of public health policy and management at the NYU School of Global Public Health and the lead author of the study, published in the February issue of Preventive Medicine Reports.

    Trust in government institutions, experts, and the medical community emerged as flashpoints in the polarized context of the COVID-19 pandemic. Medical professionals, including doctors and nurses, have long played a critical role in educating their patients about vaccination and administering vaccines, but the COVID-19 pandemic brought about new questions on the relationship among experts, trust, and attitudes toward vaccines.

    The NYU researchers analyzed data collected by Social Science Research Solutions from 1,967 U.S. adults who were surveyed twice, once in April 2021 and again in June 2022. Participants were asked about their levels of trust in the medical profession, their own doctor, and national, state, and local officials. They also answered questions about their views on the COVID-19 vaccine and whether they were vaccinated (in 2021 and/or 2022) and boosted (in 2022).

    A divide in public trust

    Levels of trust varied considerably between those who were vaccinated or eager to be vaccinated and those who were hesitant or refused to be vaccinated. Among individuals who were vaccinated or eager to do so, 88% reported high levels of trust in their own doctors and 70% had high levels of trust in state and local officials. In contrast, vaccine-hesitant individuals were far less trusting of officials: 46% reported high levels of trust in their own doctors and about 25% had high levels of trust in state and local officials. This pattern was the same for trust in federal officials and the medical profession.

    Among those hesitant to get vaccinated in 2021, trust in the medical profession was associated with ultimately deciding to get vaccinated by 2022. And for those who were vaccinated or eager to be in 2021, trust in one’s own doctor was linked to seeking a booster by 2022.

    The research also revealed how COVID-19 vaccines have been politicized: holding trust in officials and other factors constant, Republicans and Independents were far less likely to ultimately choose to be vaccinated or seek booster shots than Democrats.

    The researchers conclude that engaging the medical profession in communicating the benefits of vaccines will be needed in future pandemics.

    The primary care workforce may, in particular, play an important role, given that many have long-standing relationships with their patients and have built trust.”


    Diana Silver, professor of public health policy and management, NYU School of Global Public Health

    Additional study authors include David Abramson of NYU School of Global Public Health and NYU alumnae Rachael Piltch-Loeb and Yeerae Kim. The authors were supported by a grant from the National Science Foundation (#2049886).

    Source:

    Journal reference:

    Silver, D., et al. (2024). One year later: What role did trust in public officials and the medical profession play in decisions to get a booster and to overcome vaccine hesitancy? Preventive Medicine Reports. doi.org/10.1016/j.pmedr.2024.102626.

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