KHN Investigation On Opioid Prescribers Pains Some Readers And Tweeters

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

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In Defense Of Opioid Prescribers

Articles such as this one are leaving elderly patients with debilitating pain and also hospice patients struggling to get adequate pain control (“Surgeons’ Opioid-Prescribing Habits Are Hard To Kick,” June 21). After seeing my father in agony in hospice care this year, I am upset by this opioid-induced fear of prescribing. Also, leaving post-surgical patients in pain by not prescribing enough pain medication is a shame in this day and age. The anti-opioid movement pendulum has swung way too far to the opposite side. I watched my dad suffer needlessly in hospice care because the nurse practitioner (who, by the way, never once visited my father) would balk anytime we begged for them to relieve my father’s uncontrolled pain. I am angry. I am sorry. But things need to change in the health care field. Medical practitioners are more scared of getting in trouble than they are helping patients in pain.

— David Colegrove, Powell, Ohio

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Data shows that for most common surgical procedures, such as laparoscopic appendectomy or cholecystectomy, the right duration of opioid use is a day or at most two days of IR medicine. Yet many patients get sent home with much more than that https://t.co/04zmZVkqli

— Scott Gottlieb, MD (@ScottGottliebMD) June 21, 2019

— Dr. Scott Gottlieb, Washington, D.C., former commissioner of the Food and Drug Administration

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You are engaging in the worst kind of public shaming with this investigation of opioid prescribers (“Opioid Operators: How Surgeons Ply Patients With Painkillers,” June 20). I remember when my dad had bypass surgery and he was in a lot of pain. I look at these numbers and wonder how many patients didn’t have someone to get the prescription filled. We are attacking the wrong people. The overdoses are caused by illegal heroin and fentanyl. I have been on these medications a long time for intractable pain. I have never taken more than prescribed and nearly all patients like me do the same. If I have been taking the same dose for six years, I would say the odds of an overdose are slim to none. Learn the difference between physical dependence and addiction.

— Dennis Ewing, San Antonio

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The tone of this article and tweet borders on slander. Inaccurate unfair criticism. There is NO DOUBT Surgeons have changed their prescribing habits and patients (as first comment proves) are not homogenous.

— Edward T Chory (@DrEdMDBFD) July 7, 2019

— Dr. Edward Chory, Lancaster, Pa.

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Your project entitled “Opioid Operators” is ridiculously inflammatory. I hope you get sued by the same doctors you are “exposing.” You have no idea what each individual patient needs because you aren’t there.

In addition to being wracked with the pain of complex regional pain syndrome (CRPS) 24/7, I am also the caregiver to my husband, who has end-stage renal disease. Taking away pain medication when 99% of the pain patients who use it never abuse it is a crime. It will have no effect on addiction. It will just kill people who are already frail from having to combat pain from incurable disorders.

— Bijoux Faraj, Concord, Calif.

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I’m legit SHOCKED that 10 pills is the Johns Hopkins recommended # for minimally invasive gallbladder removal. I got ~120 pills~ of generic oxycodone and that was barely enough.

— madi alexander (@MadiLAlexander) June 24, 2019

— Madi Alexander, Arlington, Va.

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Why do groups constantly put “information” out to the public that fits their narrative? This story about opioids is nothing more than a reason to bash doctors who prescribe pain medication to people in pain. Why not investigate why doctors prescribe this medication to patients? I have had chronic pain for 25 years. These stories have caused my medication to be all but taken away. How about running a “rebuttal” to that story and let the “other side” speak?

— Dennis Shivers, Lake Ronkonkoma, N.Y.

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Tough: they need to prescribe fewer #opiates and then, believe it or not, be AVAILABLE for patients who might need a refill, and actually talk to or examine them!! (They don’t like to be bothered…that is the problem!)#opioidcrisis

https://t.co/57LycWQFjC via @khnews

— peter grinspoon (@Peter_Grinspoon) June 22, 2019

— Peter Grinspoon, Boston

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Boggled By Mind Games In ACA Court Battle

I want to congratulate Julie Appleby (“DOJ Lawyers Try New Tricks To Undo Obamacare. Will It Work?” July 12) for distilling what I consider to be one of the worst oral presentations by the Department of Justice I have ever seen or heard (I listened to the entire audio of the oral arguments). I say this as a health care attorney of some 46 years who was also brought to D.C. to counsel members of Congress on the Affordable Care Act as it was being developed.

The positions taken by DOJ counsel floored me — viz a viz, that the outcome of the case should apply to only the plaintiff states and not the rest of the country; or that the entire act is inseverable from the mandate provision, but since the act is “complicated” (really? of course it is), it would have to be worked out which provisions could remain in effect — for only the plaintiffs? for the entire country?

Scholars on both sides of the ACA agree the decision of the lower court was anathema to sound judicial foundation and precedent. The critical fact is that the 2017 Congress — not the one that passed the ACA in 2010 —eliminated the tax/penalty to zero and kept the rest of the act in place. Judges do not eliminate laws unless there are clear expressions from the legislature in its legislation to do so, or the language of the act is so ambiguous as to require judicial interpretation of the words used. With the ACA, there was no expression of inseverability related to zeroing out the individual mandate … despite the DOJ telling the appeals panel there was.

Finally, Judge Kurt Engelhardt, a member of the panel hearing the case and a Donald Trump appointee, questioned why the House could not pass another bill that kept the worthy features of the ACA in the event the current law remains unconstitutional. The role of appeals jurists is to probe the strengths and weaknesses of all sides during oral argument, not ask foolish questions, considering Mitch McConnell controls the Senate, the majority of the House is blue and, of course, Trump presently remains president. As I have written for over a decade before it was in vogue to do so, health care is a right for all Americans, and the ACA is the embodiment of this philosophy ingrained within the fabric of our country. To even posture a new health care bill given the current political environment is glaring fool’s gold.

— Miles J. Zaremski, Highland Park, Ill.

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Caring For Survivors Of Sexual Assault

I just read Michelle Andrew’s story about the staggering, and often re-traumatizing, hospital bills that survivors of sexual assault frequently receive after getting a forensic exam in a hospital setting (“Despite Federal Protections, Rape Victims Still Get Billed For Forensic Exams,” July 12). At The SAFE Alliance in Austin, Texas, we operate a community-based sexual assault clinic called Eloise House, where survivors can receive a private exam and evidence collection as well as free medical care after experiencing an assault.

We’ve found that this free, trauma-informed model eliminates many barriers for people who’ve experienced an extremely traumatizing situation by eliminating emergency room wait times and creating an environment that feels more like a home than a hospital. Our advocates work alongside our forensic nurses to offer emotional support, explain the steps of the exam process, answer questions about what the reporting process may look like if the survivor chooses to report, assist with safety planning and much more. Since we opened the clinic in 2015, we’ve served over 2,000 survivors of sexual assault in Central Texas.

I hope that one day every community has access to a clinic like Eloise House, to make the healing process even a little easier for survivors of sexual assault. Thank you for reporting on this little-known issue.

Emma Rogers, Austin, Texas

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As Rural Areas Lose Hospitals, Misplaced Priorities?

I’m getting more discouraged as people exclaim how well our economy is doing when there are losses in our communities such as the closing of rural hospitals (“Have Cancer, Must Travel: Patients Left In Lurch After Hospital Closes,” July 1). Similar reductions and losses are occurring in education, infrastructure and environmental protection, to name a few. This contrast must be reported so citizens can better understand these upside-down priorities are hurting all of us — except for the ultra-rich. This downward spiral will ultimately catch up with them, too, as they will then end up paying for the resultant problems this “ignore-ance” will create.

— Victoria Mosse, Joseph, Ore.

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This was the closest hospital for my in-laws. Long distances for cancer treatment are all too common in rural America. My dad had 60 miles each way to get to his radiation appointments in another part of Kansas. https://t.co/Gle9TrvtTd

— Mark Fleury (@ME_Fleury) July 1, 2019

— Mark Fleury, Washington, D.C.

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Hospitals in rural areas are closing. Americans are not being treated with human dignity and care. And ignorant people of this country have the audacity to care about immigrants? I have no respect for the immigrants coming here for all the freebies of medical care and housing while Americans are being treated like second-class citizens.

— Debra Schaal, Hobe Sound, Fla.

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Terrible things happen when rural hospitals close. But in many states, these are preventable tragedies. Why hasn’t Kansas expanded Medicaid, which would save many hospitals? Why doesn’t this story ask? Big miss. @SJTribble https://t.co/HAcmG0Waha

— Jim Tananbaum (@JTananbaum) July 1, 2019

— Jim Tananbaum, San Francisco

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Preventing Falls For A New Generation

Your piece “More Seniors Are Dying In Falls. Doctors Could Do More To Reduce The Risk” (June 27) addresses an important yet rarely discussed epidemic that has become increasingly deadly over the past decade. According to the Centers for Disease Control and Prevention, fall deaths among seniors increased by 31% from 2007 to 2016 — a trend slated to worsen over the next few years as more baby boomers enter retirement. Falls are now the No. 1 cause of injury for older Americans, resulting in 800,000 hospitalizations every year and $50 billion in health care spending.

As a physical therapist (PT), I’ve seen the effectiveness of some of the treatment strategies mentioned in this article. But, while fall risk assessments and personalized patient plans are important preventive tactics, one important factor that wasn’t mentioned in the article is the value of telehealth in reducing seniors’ risk of falling.

Telehealth appointments and virtual fall risk assessments can be incredibly beneficial, particularly for patients with age-related disabilities and limited mobility. Telehealth services provide valuable opportunities for seniors to receive professional PT in the comfort and privacy of their own homes. In turn, this reduces access barriers — particularly for patients in rural and underserved areas — and helps seniors who struggle with transportation issues get the care they need. In fact, one of the initiatives mentioned in your article included a strong telehealth component, which improved compliance with and the effectiveness of PT-prescribed fall prevention exercise regimens. Because falling once doubles the chances of falling again, it is critical to empower America’s seniors with care that makes them stronger, steadier and more flexible.

With an increasingly graying U.S. population, this problem demands a novel and comprehensive response. Having helped countless patients reduce their fall risk, I believe that telehealth PT, together with other solutions mentioned in your article, will play an important role in addressing this epidemic. By embracing evidence-based practices such as telehealth PT, we can seize the opportunity to prevent falls, reduce Medicare spending and, ultimately, save lives.

— Nikesh Patel, PT, DPT, physical therapist and executive director of the Alliance for Physical Therapy Quality and Innovation, Washington, D.C.

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Great tips fr @judith_graham on #fall prevention. Doctors Could Do More To Reduce The Risk. https://t.co/gsklcP5QIW via @khnews

Would add using hiking poles when walking on uneven surfaces.

And trifocals are G-d’s gift to orthopedists.

I also rec some sort of medical alert system

— Judy Stone (@DrJudyStone) July 6, 2019

— Dr. Judy Stone, Cumberland, Md.

Is a thorough foot exam part of your Annual Wellness Visit? Mine neither. This alone could potentially prevent so many falls. #doctorswakeup

https://t.co/sPE5PTEprh via @khnews

— Wendl Kornfeld (@WendlKornfeld) July 1, 2019

— Wendl Kornfeld, New York City

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While Fact-Checking Debates, Check The Moderator’s Attitude

KHN reader Ira Dember demonstrates outside U.S. Sen. John Cornyn’s office in Houston in January. (Courtesy of FairNow.org)

While the facts were somewhat interesting, the elephant in the room was the rigged, wildly biased phrasing of host Lester Holt’s “Medicare for All” question: “Who here would abolish their private health insurance in favor of a government-run plan? Just a show of hands …” On this point, I’m surprised and disappointed KHN didn’t deconstruct that framework (“PolitiFact & KHN HealthCheck: ‘Medicare For All’ Emerges As Early Divide In First Democratic Debate,” June 27).

Last week, the latest voter poll from The Washington Post and ABC News included a Medicare for All question so carefully crafted it could serve as the gold standard for questions that strive to eliminate respondent bias on emotionally charged issues. It asked: [Would you support or oppose M4A] “if there was no private insurance option available?” This phrasing removes the actor: No one is abolishing or taking away anything. It’s the passive voice put to exquisitely good use to avoid bias: “… if there was no private insurance option available.”

Also, notice pollsters’ use of the word “option.” It implicitly frames private insurance as something expendable. It’s an option. Not a requirement, not written in stone. I give big kudos to the pollsters for this careful, and truthful, framing.

And while we’re on the subject of wording: The day before the first debate, an NPR commentator prospectively boiled it down to a struggle between “pragmatists” and “progressives.” Obviously, progressives advocate for substantive change such as Medicare for All — which by implicit definition is not “pragmatic.”

Current public policies that leave us with upward of 500,000 medical-related bankruptcies a year and 36,000 annual deaths attributed strictly to lack of health care coverage are somehow blandly acceptable as “pragmatic.” Needless to say (but I’ll say it anyway), this is an affront to both logic and morality.

— Ira Dember, Houston, founder of FairNow.org

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Ensuring The Robust Right To Appeal

On behalf of the California Association of Health Plans, which represents 46 public and private health plans that collectively provide health care coverage to over 26 million Californians, we would contend that the “Asking Never Hurts” column “Did Your Health Plan Deny You Care? Fight Back” (July 15) mistakenly implies that California’s long-standing system for handling grievances, complaints and medical reviews is somehow confrontational, contentious and unknown. The fact is that California has had a robust framework of consumer protections for decades — long before the Affordable Care Act created similar consumer rights at the national level. Our system of resolving disputes balances maintaining a functional and affordable health care system while giving enrollees and providers an opportunity to appeal.

If a patient’s claim is denied by their health plan, the patient has the right to appeal with their health plan, and the right to an independent medical review by the state regulator if they disagree with the health plan’s decision. Independent medical reviews are conducted by a team of providers that have no affiliation with the health plan, and the decision of the independent medical review is binding.

Health plans ensure enrollees are aware of their existing consumer protections under California law, and we provide a comprehensive list of covered services when they are medically necessary. This happens millions and millions of times without dispute. When there is a difference of opinion, health plans want to get it right.

Every Californian deserves to have the peace of mind that they have access to an independent appeals process should they need it. California’s health plans work hard to provide consumers with that peace of mind as we continuously strive to improve outcomes for patients and provide accessible, high-quality, affordable care for all Californians.

— Charles Bacchi, president and CEO of California Association of Health Plans, Sacramento

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A Handy Takeaway From Your Podcast

I heard the “An Arm and a Leg” podcast recently (“Forget The Shakedown. To Get Paid, Hospitals Get Creative,” June 12). Great stuff!

Then I dislocated a bone in my foot and went to see an orthopedist at SportsMED Orthopedic Surgery & Spine Center in Huntsville, Ala. Doc ordered an Aircast AirSelect brace. The brace shop said my insurance covered it 100%. That was good, so I had them fit it. My foot felt better right away, more stable. Then, as I’m ready to leave, I’m told I have to sign a digital pad with only a signature space. “What is it you want me to sign?” I asked.

Turns out it was a form stating I agreed to pay all costs that may be later billed and not covered by insurance (which they could not tell me what that would be). Long story short — forget about my insurance covering it 100%. After checking with Blue Cross Blue Shield, I learned my out-of-pocket cost could have been $378.

If I had come in with no insurance, it would only be $110, and a variety of other permutations of random pricing all “the fault of my insurer, not their pricing,” per their insurance supervisor. Having heard your podcast, I checked Amazon — an identical Aircast was $78 with free shipping. So, I limped out and ordered it on Amazon. At least I knew how much I would pay. The person before me left with a knee brace for his son for a $415 insurance copay.

— Lisa Moore, Huntsville, Ala.

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Out In The Open About Well-Thought-Out Exit Strategies

https://khn.org/news/rational-suicide-seniors-preemptive-death-medical-aid-in-dying/

This is a topic (“In Secret, Seniors Discuss ‘Rational Suicide,’” June 25) that should be public, not sequestered in private. My 87-year-old father and I have had this conversation, and it’s not taboo in our family. Thank you for talking about it.

It’s sad that as a society we can’t face the fact that people want to have choice, especially on the quality of their life and remaining years — whether or not they have a terminal diagnosis. Just because medicine could possibly prolong our lives doesn’t mean we want it to do so.

— Laura Palmer, Denver

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Would love to know if the individuals meeting to discuss this have their advance directives in place. That is a way to address fears of decline, I think. Nevada failed to move forward a death with dignity bill to a vote this Legislative session so it is a fraught topic.

— Homa S. Woodrum (@woodrumlaw) June 25, 2019

— Homa S. Woodrum, Carson City, Nev.

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I think a point missed may be that many seniors are becoming increasingly distraught with the state of the world — not so much from depression, but from the pervasive hostility, anger, loss of traditional values, ignorance, lack of caring, political bickering and general “meanness” that is the world nowadays.

Together with my physical limitations that further limit my ability to find continued meaning in life, I am glad to say that I have an exit strategy in place that I can activate when the time is right. I think if the right to choose were available and supported, there would be (and likely will be, if current trends continue) more interest in having this option more easily available.

— Dr. Bill Saunders, Snohomish County, Wash.

This goes for anyone who has a debilitating disease.

— Rich Meyer (@richmeyer) June 25, 2019

— Rich Meyer, Naples, Fla.

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I’m 65, healthy, happy and enjoying life. 25 years from now I hope to be 90, healthy, happy, and enjoying life. I might also be 90, bed-bound, in daily pain, and emotionally spent. These days it’s not uncommon to outlive our bodies. I’ve seen. I get it. https://t.co/HOLTmWL7mi

— Duane Blackwell (@DuaneBwell) June 25, 2019

— Duane Blackwell, Alexandria, La.

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No More Band-Aid Solutions On Surprise Medical Bills

An approach to solving this problem is to set standard costs for all procedures (“Bill Of The Month: A Year After Spinal Surgery, A $94,031 Bill Feels Like A Back-Breaker,” June 17). Using Medicare reimbursement as a benchmark, set national reimbursement rates adjusted for regional cost of living. Set the rates as Medicare plus a percentage and require all providers to accept those rates. This would do away with the need for networks.

Standardize insurance plans using the Medicare Part B concept. There can be a variety of plans, but each insurer must offer the exact same coverage for a specific plan. Then the purchaser can make an informed comparison among plans. If the goal is to lower medical costs, standardization, along with best practices is probably the best approach.

We need to drive out the unnecessary costs and eliminate the annual 160,000 unnecessary deaths and estimated 100 million medication errors in the U.S. hospital system. The unnecessary annual death total is greater than annual opioid deaths, gun violence deaths and automobile accident deaths combined.

This will be a long struggle because of the entrenched financial interests, but we need to draw a line in the sand.

— Michael Hausig, San Antonio

#MedicareforAll. Fulfilling the Hippocratic oath.

— Kerri Barber, One of the Squad (@ACA_Sherpa) June 17, 2019

— Kerri Barber, Chicago

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Not Anti-Vaccine, Just Against This Legislation

I oppose Senate Bill 276 in California (“A Proposal To Make It Harder For Kids To Skip Vaccines Gives Powerful Voices Pause,” June 14). I have a child who nearly died from seizures after being administered the DTaP vaccine [to guard against diphtheria, tetanus, and whooping cough, or pertussis]. That reaction is a CDC-acknowledged adverse event. Stop calling everyone who opposes this bill “anti-vaccine activists.” While some people might characterize themselves as “anti-vaccine,” most people are simply parents who did vaccinate their child until they were seriously harmed. To call us “anti-vaccine” activists and ignore that fact is extremely deceptive.

We are activists now, that part is true. We had to become activists, because these organizations you mention in your article (such as the American Academy of Pediatrics) have done nothing to help our children. The AAP is a lobbying organization that receives funds from vaccine manufacturers. It lobbied against AB-2832 (Assemblyman Travis Allen), which was a one-sentence bill that would have put a link on the California Department of Health website to two “.gov” websites: the Vaccine Adverse Event Reporting Systems (VAERS), the database for serious adverse events after vaccination, and the National Vaccine Injury Compensation Program. The purpose was to help parents find this information when they need it. That the AAP lobbied against it says everything you need to know about their priorities when it comes to vaccines. They are not doing what is in the best interest of families. Clearly, their pharmaceutical company funding influences their lobbying.

In your story, Dr. Michelle Bholat’s concern about who would qualify for a medical exemption is exactly the same concern that parents opposed to this bill have. There is a good chance my child would not qualify for a medical exemption to the vaccine that nearly killed him, and he definitely would not qualify for an exemption to any others. If I had another child, I would not be able to get a medical exemption to the vaccine that nearly killed my son for that new baby. This bill puts our kids at serious risk for irreparable harm or even death.

— Kara Morales, San Diego

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Issuing fraudulent non-evidence based school #vaccine exemptions is malpractice https://t.co/xnyz1ZxPJp

— Amesh Adalja (@AmeshAA) June 17, 2019

— Dr. Amesh Adalja, Pittsburgh

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Something In The Water? Drink To Your Health!

A recently published article (“A Million Californians Don’t Have Clean Drinking Water. Where Do They Live?” June 28) cast some doubts concerning the safety of drinking water available out of the tap for Alpine County residents and visitors.

First, some background. There were 1,175 persons counted in the 2010 census in Alpine County. There are several hundred private wells in Alpine County, which are initially permitted by the county, but then managed by the owner. The Environmental Health Program staff of the Alpine County Public Health Department regulates about 40 small public water systems, including the Markleeville Water Co., Woodfords Mutual Water Co., Diamond Valley Elementary School and numerous campgrounds. Two large water systems are regulated by the California State Water Resources Control Board: Kirkwood Meadows Public Utilities District and Lake Alpine Water Co., along with the Grover Hot Springs State Park. The definition of a “large” water system is one with more than 200 connections.

The greatest risk to the public’s health from drinking water is bacterial contamination, which is controlled by disinfection. The surface water used by the large water systems is disinfected with chlorine. Byproducts of the disinfection process include trihalomethanes (TTHM) and haloacetic acids (HAA5). Managers work to achieve the ideal balance between enough chlorine to provide water free of bacterial contamination, and at the same time keeping levels of byproducts lower than the maximum contaminant level (MCL) as required by the State Water Resources Control Board.

Conclusions in the article were drawn from a review of state compliance data dating prior to 2018 and refer only to the Lake Alpine Water Co.

The facts:

1. The data source stated that the Lake Alpine Water Co. serves a population of 625. This includes 125 residents and 500 transients (skiers, visitors at the Bear Valley Lodge, and condos); thus, the original statement “more than half of residents” was incorrect. The data source states that Lake Alpine Water Co. serves 487 service connections. This includes 294 single-family residences, 179 multiple-dwelling units (lodge, condos), 12 commercial, and two irrigation systems. So, essentially correct, but includes water provided to visitors.

2. The data shows that the Lake Alpine Water Co. was out of compliance with levels of total haloacetic acid exceeding the MCL, the latest violation on 12/31/17. However, what it does not show is that corrective action was promptly performed, with compliance obtained in January 2018. Quarterly testing during the past 18 months has shown continued compliance, and an official Return to Compliance (RTC) status will be achieved in the near future. There have not been any other violations or enforcement actions taken.

3. The Water Board has never issued an order that “residents can’t drink water flowing from their taps,” as the article stated— anywhere in the county.

4. In the past 25 years of records and memories, water systems in Alpine County have not exceeded MCLs for either nitrates or arsenic — anywhere in the county.

My conclusion: Drink up (water)!

— Dr. Richard O. Johnson, health officer for Alpine County, Calif.

(Editor’s note: Thank you for your salient points. The article has been revised to reflect your concerns.)