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Category: Health Care

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Whistleblower: Medicaid managed-care firm improperly denied care to thousands

In early October, an executive at one of the nation’s largest physician-practice management firms handed her bosses the equivalent of a live grenade — a 20-page report that blew up the company and shook the world of managed care for poor patients across California.

For years, she wrote, SynerMed, a behind-the-scenes administrator of medical groups and managed-care contracts, had improperly denied care to thousands of patients — most of them on Medicaid — and falsified documents to hide it.

The violations were “widespread, systemic in nature,” according to the confidential Oct. 5 report by the company’s senior director of compliance, Christine Babu. And they posed a “serious threat to members’ health and safety,” according to the report, which was obtained by Kaiser Health News.

Days later, someone sent the report — labeled as a “draft” — anonymously to California health officials. Within weeks, state regulators had launched an investigation, major health insurers swept in for surprise audits, the company’s chief executive announced the firm would close and doctors’ practices up and down the state braced for a tumultuous transition to new management.

Jennifer Kent, California’s health services and Medicaid director, said her agency received the whistleblower’s report Oct. 8 and, working with health plans, confirmed “widespread deficiencies” at SynerMed, which manages the care of at least 650,000 Medicaid recipients in the state.

“I think it’s pretty egregious actions on the part of that company,” Kent said in an interview this week.

In a Nov. 17 order issued to insurers, state Medicaid officials said “members are currently in imminent danger of not receiving medically necessary health care services” due to SynerMed’s conduct. The state ordered insurers to determine how many enrollees experienced delayed or unfulfilled services.

Consumer advocates expressed alarm at the whistleblower’s findings and questioned why these problems went undetected for so long. Some said it underscores a lack of accountability among companies involved in Medicaid managed care — which receive billions in taxpayer dollars and have expanded significantly under the Affordable Care Act.

Linda Nguy, a policy advocate at the Western Center on Law and Poverty in Sacramento, called the situation “outrageous.”

“It raises questions about oversight by the state and the health plans,” she said.

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In Trump Era, the Long Fight Against Hunger is Even Tougher

As the Trump administration sets its sights on cutting federal nutrition programs, millions of Americans could stop receiving aid and millions of undocumented immigrants are afraid to sign up for the help they desperately need. Leaders in the anti-hunger movement in California gathered in San Francisco on November 9 for a discussion, co-hosted by the Food & Environment Reporting Network and the Center for Urban Education about Sustainable Agriculture, of what it takes to fight hunger in the age of Trump.

More than half of adult Americans will receive food assistance through the federal Supplemental Nutrition Assistance Program (SNAP) at some point in their lifetime. In California, more than 10 percent of the state was on SNAP as of 2015. Each year, the program costs taxpayers $53 billion, but every $1 of SNAP benefits generates $1.79 in economic activity, according to the USDA.

By purchasing food, people on federal food assistance create jobs — for grocery store employees, meatpackers, farmworkers, and truckers, said Jessica Bartholow, a policy advocate at the Western Center on Law & Poverty, and one of the evening’s panelists. “Every billion (dollars) we receive in California in SNAP benefits, creates 14,000 jobs,” she said.

But the White House has proposed cutting support for SNAP by 25 percent, while tightening eligibility requirements, especially for so-called able-bodied adults. The administration also hopes to lower funding to the federal food assistance program known as WIC, which serves 7.8 million women, infants and children each year.

“When we talk about more people living below the poverty line as a result of some of the proposals coming out of D.C., we’re talking about our failure to recognize their humanity,” said Bartholow. “When we cut SNAP, it doesn’t mean [people will] find money to go find food in some other way. It means they go hungry.”

But even if they’re eligible for support, many people are hesitant to sign up for it due to heightened fear about Trump’s immigration policies. “Immediately following the election, we had people calling us not to ask for help signing up with CalFresh (California’s food assistance program) or SNAP,” but for help cancelling their benefits, said Elizabeth Gomez, associate director of client services at the Alameda County Community Food Bank, which serves over 300,000 people annually, or one of five residents in Alameda County. The bank fielded at least 40 such calls in the first few weeks after Trump was elected, something Gomez said had never happened before.

Some people are afraid that, by signing up, they will be added to a national database and tracked down by immigration services if they or someone in their family is undocumented. Many also fear that by receiving food assistance they would count as a “public charge,” and thus be disqualified for ever earning citizenship, which Gomez said is one of the many mistruths that shadows food assistance. She made clear that applicants do not have to offer up proof of citizenship or even their names to receive emergency food assistance, and doing so doesn’t bar them from becoming a citizen later on.

At least not yet, noted Bartholow, but the Trump administration is considering adding food benefits and healthcare to the list of government services that designate someone a “public charge.”

 

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The fight over health coverage for children, pregnant women

Health insurance coverage for 1.3 million California children and pregnant women is at risk because of Congress’ delay in extending the Children’s Health Insurance Program.

While the House recently approved a bill to extend the program for five years, the bill still needs approval by the Senate and a fight is expected about how to pay for the extension.

The remaining 2 percent – about 26,000 people – would be in danger of being dropped because their incomes are too high for that program. CHIP serves low-income families. The 20-year-old program expired Sept. 30 and California may run out of funding by the end of the year or early January. The state receives $2.7 billion in funding a year for CHIP.

“The impact is major,” said Anthony Wright, executive director of Health Access California, an advocacy organization. “You can’t lose that much money without their being an impact.”

According to the state Department of Health Care Services, 98 percent of those covered under CHIP would keep their health insurance through 2019 under Medicaid even if the extension isn’t granted. But the remaining 2 percent – about 26,000 people – would be in danger of being dropped because their incomes are too high for that program.

“If CHIP is not reauthorized, the governor and the Legislature would need to deliberate on how to address the population no longer eligible for federal funding,” said Anthony Cava, a department spokesman in an email.

CHIP benefits working families who aren’t able to get health insurance through their jobs.
California’s senators Dianne Feinstein and Kamala Harris have been outspoken in their support for CHIP and have called for the program to be reauthorized quickly.  They pointed out that the program has helped reduce the uninsured rate among American children to 4.5 percent from 13.9 percent in 1997 when the program was enacted.

Feinstein and Harris criticized the delay in a letter last month to the Senate leadership. “Our working families deserve better than this,” the letter said.

In California, CHIP funds used to be administered through a program called Healthy Families. But in 2013, the program was eliminated and those enrolled in it were transferred to Medi-Cal, California’s name for the federal Medicaid program.

Sixty-one percent of CHIP enrollees in California are Hispanic, with 15 percent identified as Caucasian, 11 percent as Asian, 3 percent as African-American and 10 percent as other. Overall, about 13 percent of California’s children are covered by CHIP.

Republicans have faced opposition from Democrats for wanting to pay for CHIP by cutting funds for public health prevention programs created by the Affordable Care Act
Cary Sanders, director of policy analysis for the California Pan-Ethnic Health Network, said CHIP benefits working families who aren’t able to get health insurance through their jobs. It helps families get their kids in for needed doctor visits and ensures that they get vaccinations. “It’s a really important investment in future generations,” she said.

Families enrolled in CHIP don’t have to pay any co-pays or deductibles, said Jen Flory, a policy advocate at the Western Center on Law and Poverty. “It ensures kids get to the doctor at the first sign of something,” she said.

CHIP has long had widespread support from both Democrats and Republicans and advocates, but it was tabled this year during unsuccessful fights by the Republicans to overturn the Affordable Care Act.

The main issue of contention is how to pay for the continuation of the program. Republicans have faced opposition from Democrats for wanting to pay for CHIP by cutting funds for public health prevention programs created by the Affordable Care Act. “They have agreement on the policy but on on the pay fors,” said Michael Odeh, health policy director for Children Now, an advocacy organization.

Wright said he is hopeful that Congress will eventually extend CHIP but is concerned that it is taking this long.

“We don’t want to unnecessarily scare children and families about health coverage so vital to themselves and their economic vitality but the longer this goes on, the more it will force the choice of somebody losing care or coverage,” Wright said.

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California lawmaker passes bill to get public schools to provide free tampons to low-income girls

While it’s clear that the Trump administration hates girls and women and will do everything it can to violate our rights, local lawmakers are doing what they can to make life more normal and equitable for girls—particularly those from marginalized communities. In California, Assembly Member Cristina Garcia has a passion for making sure that women in the state have access to feminine hygiene and menstrual products. Known as the “Tampon Queen,” she was instrumental in recently getting AB 10 passed, a bill that provides menstrual products to low-income, school-aged girls.

A proposal to make such products tax-free in the Golden State was vetoed last year. This year a similar bill didn’t even make it out of committee. But the lawmaker from Bell Gardens [Garcia] finally found victory in AB 10, which requires lower-income schools to provide menstrual products to girls at no charge in half the bathrooms on a given campus.

This is an issue many people don’t think about, but it’s one that deeply impacts girls who are poor. When menstrual products are not easily accessible, girls may miss school. In addition to the mental and emotional stress of trying to cope without pads or tampons, missing school can have a negative effect on girls’ academic performance and future life chances.

Sadly, this is a global phenomenon and not limited to countries in the developing world. This same issue has been reported in the UK, New Zealand, and Canada. While assumptions may lead us to believe that this is an urban and/or rural phenomenon, it also impacts Native American girls living on reservations. In short, there are nearly no poor girls across the country and world who are not touched by this.

Jessica Bartholow, a policy advocate for the Western Center on Law & Poverty, called it “landmark legislation for California.” She said New York City schools have a pilot program that mirrors AB 10. She said providing the products free to lower-income girls encourages them to come to school, feel normal and participate in extracurricular activities. That, in turn, increases their chances of graduating, going to college and landing good jobs.

“It’s a great measure of equity,” she said. “The humiliation of poverty runs deep. This isn’t going to solve the fact that a girl growing up in poverty is treated differently in so many ways. But it’s one little thing we can do to make sure girls feel welcome at school.”

While she’s helped to secure this victory in California, Garcia’s work is far from finished. Her next steps are to once again try to eliminate the tax on menstrual products in the state. After all, why should girls and women pay a tax on something that is completely natural and necessary? While there are only about seven states that allow menstrual products to be sold tax-free, Viagra isn’t taxed in any state except Illinois. Sure, it’s true that Viagra is a drug which requires a prescription. which is why it isn’t taxed. But let’s remember that Viagra isn’t at all necessary to live. These products are essential to women and girls’ health and well-being.

It’s a good thing lawmakers like Garcia know that and are working to make sure that girls have access to what they need be happy, healthy, and thriving.

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Free Tampons Are Coming to a Public School Near You

For Southeast L.A. County state Assemblywoman Cristina Garcia, making menstrual products easier to obtain for California women has become a major cause in the last few years. She’s embraced a nickname given to her, the Tampon Queen. But, until recently, her reign in the realm of menstrual health has been unsuccessful.

A proposal to make such products tax-free in the Golden State was vetoed last year. This year a similar bill didn’t even make it out of committee. But the lawmaker from Bell Gardens finally found victory in AB 10, which requires lower-income schools to provide menstrual products to girls at no charge in half the bathroom on a given campus.

Gov. Jerry Brown signed it. Garcia, who rose to prominence as a community activist during the city of Bell corruption scandal and is now the chair of the California Legislative Women’s Caucus, is elated. “I’m really proud and excited,” she says. “Practice makes perfect.”

Jessica Bartholow, a policy advocate for the Western Center on Law & Poverty, called it “landmark legislation for California.” She said New York City schools have a pilot program that mirrors AB 10. She said providing the products free to lower-income girls encourages them to come to school, feel normal and participate in extracurricular activities. That, in turn, increases their chances of graduating, going to college and landing good jobs.

“It’s a great measure of equity,” she said. “The humiliation of poverty runs deep. This isn’t going to solve the fact that a girl growing up in poverty is treated differently in so many ways. But it’s one little thing we can do to make sure girls feel welcome at school.”

The bill requires Golden State public schools that include grades 6 through 12 and that meet “the 40 percent pupil poverty threshold” to make tampons and pads available to girls for free in at least half the bathrooms. It would appear that a good portion of the Los Angeles Unified School District, where as much as 80 percent of students have come from households at or below the poverty line, would have to adhere to the new law, which goes into effect next year.

Read more here

Transparency Coming to Prescription Drug Prices in California

California Gov. Jerry Brown on Monday approved a health care bill that requires pharmaceutical companies to give advance notice of price increases, and mandates new cost reporting from health insurance providers.

The measure, Senate Bill 17, was crafted to shed light on rising prescription drug costs and force the pharmaceutical industry to justify its prices going forward.

Supporters called SB 17 a much-needed victory for consumers and a rare loss for the powerful pharmaceutical industry, which lobbied heavily against the measure.

“Drug companies abuse their market power by jacking up prices, and the public is looking to their government for help,” said state Sen. Ed Hernandez, D-Azusa, the bill’s author. “Requiring drug companies to provide advance notice and some explanation for large price hikes is a step toward a more stable and predictable prescription drug marketplace.”

The bill requires drug companies to give the state and insurers at least 60 days’ notice before planned price increases of more than 16 percent over a two-year period. It also forces insurance companies to file yearly reports with state regulators outlining the impact of medicine costs on health care premiums.

The powerful pharmaceutical lobby, which helped derail a similar proposal and a veteran drug cost initiative supported by Vermont Sen. Bernie Sanders in 2016, called the transparency requirements “misguided government intrusion.” Opponents warn the new reporting regulations could drive businesses out of California.

“The legislation the governor signed into law seriously jeopardizes the future of California’s leadership in this innovative industry,” Gary Andres, Biotechnology Innovation Organization spokesman, said in a statement. “Despite its intent, this law will neither provide meaningful information to patients nor lower prescription drug costs.”

The legislation was supported by a wide array of California unions and health care groups. Proponents included the California Labor Federation, Health Access California, Anthem Blue Cross, Kaiser Permanente and the Western Center on Law and Poverty. It cleared the state Senate by a wide margin and with bipartisan support.

In a signing ceremony, Brown said “Californians have a right to know why their medication costs are out of control, especially when pharmaceutical profits are soaring.”