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Health insurance co-pay accumulators little known, costly for patients



Julie Turner was just 17 when she needed powerful doses of radiation and chemotherapy to wipe out her stage 3 Hodgkin’s Disease. 

The harsh, 12 rounds of chemo and 60 radiation treatments at Ohio State University hospital in the 1970s came with two major side effects: She was sterile, and her bones became abnormally brittle, eventually requiring a twice-a-year regimen in the hospital for medication to reduce her risk for fractures. 

But now, her post-retirement health insurance no longer covers those $5,000 semi-annual treatments of Prolia she needs to protect her fragile bones.

At first, after finding a pharmacy in her hometown of Springfield that would give her the shots at a much lower cost, then landing a $1,500 grant from Prolia manufacturer Amgen to help offset the cost, Turner thought she had discovered a way around her insurance company.

Unfortunately, she did not.

The former school treasurer learned that Aetna wouldn’t count the $1,500 from Amgen toward her $4,000 maximum annual co-pay – even though Aetna isn’t contributing a dime for the Amgen drug. 

The upshot: She still has to come up with that $1,500 toward her co-pay out of her own pocket each year. It’s as if the grant doesn’t exist.

It turns out that Turner ran head-on into a little-known practice that pharmacy benefit managers and health insurers have come up with in recent years known as a co-pay accumulator. Simply put, the maneuver doesn’t count any co-pay assistance that patients obtain toward either their health-insurance deductible or their maximum annual out-of-pocket spending. That includes increasingly common aid from a drug manufacturer striving not to lose a prescription for an expensive drug – even though the insurance company still winds up with that patient aid.

Consolidation provides fewer choices to consumers

You might wonder: How are pharmacy benefit managers, known as PBMs, and insurance companies able to do this?

The answer: Because America’s health-care system is so consolidated that consumers have few options. Without the full-fledged competition that’s a basic component of capitalism driving prices down, it puts consumers in a position to take it or leave it.

Just three PBMs control nearly 80% of the U.S. market. And owners of all three – such as CVS Health, whose $69 billion union with Aetna in 2018 was the biggest health care merger in U.S. history – also offer health insurance.

The sale of expensive specialty drugs like the one Turner takes are especially monopolized. In 2020, just four specialty pharmacies – led by CVS – accounted for 75% ($132 billion) of total U.S. prescription revenue from specialty drugs dispensed by pharmacies, the nonpartisan newsletter Drug Channels found in early May.

No company outside of the “big four” has a market share of more than 3%. And each of the four is completely or partly owned by one of the country’s largest PBMs – which are part of large, vertically integrated organizations themselves, the newsletter said.

The PBMs and health insurers both say that “co-pay accumulators” are necessary to alleviate the high cost of prescription drugs, especially specialized brand-name products that typically are the most expensive. 

Brand-name drugs account for 10% of Americans’ prescriptions but 80% of the cost –$409 billion a year, the nonprofit West Health notes. Last year, PBMs generated a third of their gross profits from specialty medications, Drug Channels says.

The increasing price of prescription drugs consistently registers as a major concern among Americans. 

Two-thirds said in an April 2020 Gallup Poll that their prescription costs were going up. In November 2019, Gallup found that nearly a quarter had at least one instance in the previous year when they didn’t have enough money to pay for needed prescription drugs. And 13% said that within the previous five years, they’ve had a friend or family member die after not being able to pay for needed medical treatment.

Patients all across America are ‘astonished’ when they see their bill

If your health insurance policy doesn’t already have such a co-pay accumulator, sometimes called an “accumulator adjustment program,” it likely will soon. A regulation approved by the administration of President Donald Trump authorized them for the first time starting this year. 

Drug Channels estimates that within the next year, more than 80% of commercially insured beneficiaries will be in plans with these benefit designs – although not all plan sponsors will have fully implemented them.

“This is all consolidation and it’s all part of a theme,” said Ted Okon, executive director of the ‎Community Oncology Alliance, a nonprofit based in Washington, D.C.

“The PBM-insurer complex has gotten more aggressive over time,” he said.

He said thousands of Julie Turners exist across America – people who are astonished when they receive their pharmacy bill and realize it’s not covered by insurance because of the obscure co-pay accumulator clause.

“What that does is it takes money out of the pocket of the patient and puts in the PBM/insurers’ pocket,” Okon said. “It’s going to get worse. Because of consolidation, the PBMs and insurers have gotten more brash, more aggressive, and they will in the future.”

The bottom line of PBMs, some of the biggest corporations in the U.S., actually was helped by the COVID-19 pandemic. 

“Some of the leading PBMs and health-coverage companies in this market have been reporting staggering sales, with people stocking up medications to deal (with) lockdowns and movement restrictions, said Fortune Business Insights, citing quarterly increases of as much as 20% or more.

Annual revenue at UnitedHealthcare revenue jumped 20% to $357.1 billion; its PBM and care services group, Optum, reported revenue of $35.9 billion, up more than 20%, in the fourth quarter alone. Revenue for CVS Health, which includes its PBM, Caremark, climbed 4.6% to $268.7 billion in 2020. In the first quarter of 2021, CVS recorded 10% profit growth.

The 2020 total for Cigna, which owns the PBM Express Scripts, was $160.4 billion, a 4.5% increase from 2019.

Profits for major health insurers in the first quarter of 2021, compared to net income for the same period last year, were up across the board. Anthem’s bottom line increased over 9%, to $1.7 billion; Centene’s jumped to $699 million from $46 million; Humana’s total of $828 million represents a 75% leap; Molina ‘s $228 million was $50 million higher than during the first three months of 2020; UnitedHealthcare Group’s figure was $4.9 billion, a rise of 43%.

At the same time, co-pay accumulator programs are making life-saving treatments increasingly inaccessible, the Hepatitis Foundation says: “Research shows that the more out-of-pocket costs a person has to pay, the more likely they are to abandon their medication.”

Ted Okon, executive director of the Community Oncology Alliance in Washington, D.C., says three pharmacy benefit managers now control 80% of the market.

Health insurers, PBMs say co-pay accumulators help control costs

On the other side of the argument, the trade group America’s Health Insurance Plans, which represents health insurance companies, sees co-pay accumulators as a method to hold down costs.

“Branded (drug) manufacturers offer coupons to circumvent patients’ cost-sharing for branded drugs and to avoid responsibility for the fundamental reason for higher patient costs – namely, the high price of the drug that is set and controlled solely by manufacturers,” said a statement the trade group based in Washington, D.C., provided from Jeanette Thornton, senior vice president of product, employer, and commercial policy.

The group notes that coupons are banned from government health-care programs such as Medicare and Veterans Affairs. The Department of Health and Human Services deems them a violation of a federal anti-kickback statute because the drug manufacturer offering the coupon is directly benefiting from its use at the expense of taxpayers.

Ashley Czin, deputy vice president of policy and research for the Washington-based Pharmaceutical Research and Manufacturers of America, which represents major U.S. drug makers, said the group believes that co-pay accumulators “are operating at the detriment of patients.”

“We believe the accumulator-adjustment program unfairly targets patient cost-sharing assistance,” she said.

A statement from the Pharmaceutical Care Management Association, the trade association for PBMs, the middlemen in the drug supply chain, blamed drug makers for the situation.

“Co-pay accumulator programs mitigate the harmful impact that drug manufacturer copay coupons have on overall health plan costs,” the association said.

“The accumulator programs are needed because drug manufacturers offer coupons to insured patients, regardless of their incomes, to induce patients to take a more expensive brand drug instead of a less costly generic or equally effective, less expensive, alternative medication,” the group said in a statement.

Doctors groups oppose provision that limits prescriptions

It’s that “equally effective” medication statement that especially upsets Turner. Her insurance company informed her that, although it wouldn’t cover the Prolia injections that had been helping her for years, it would pay for the cheaper Fosamax, a pill taken weekly.

But about a year and a half after switching to the new medication, a bone-density scan known as DEXA (dual energy X-ray absorptiometry) by her doctor showed that her bone-mineral density had deteriorated significantly, which increased the likelihood of a debilitating break. The AARP notes that breaking a major bone increases the mortality rate for older adults.

However, her insurance company still wouldn’t pay for the drug that worked.

Finally, Turner’s doctor suggested contacting Prolia’s manufacturer to seek financial help.

Physicians take a dim view of pharmacy benefit managers and insurance companies in effect second-guessing their medical judgment for the best treatment of their patients.

The American Medical Association approved a resolution last fall to “support federal and state legislation or regulation that would ban co-pay accumulator policies.”

Doctors’ groups have staunchly opposed “non-medical switching” by PBMs and health insurers – altering a patient’s drug therapy for reasons other than a drug’s efficacy, side effects or clinical outcome.

The Ohio State Medical Association is backing a bill that essentially would ban co-pay accumulators in the state. House Bill 135 was approved 16-0 on March 16 by the House Health Committee. However in late May, Taylor Jach, spokeswoman for House Speaker Bob Cupp, said the measure hasn’t gone to the full House because “members are continuing to work on a couple remaining issues.”

Even if it gets through the House, its future in the Senate is unknown.

“Practices like co-pay accumulators can have a devastating impact,” testified the OSMA’s senior director of government relations, Monica Hueckel.

Monica Hueckel, senior director of government relations for the Ohio State Medical Association

“Patients often do not even know about these policies until the (drug maker’s) coupons are no longer usable. As you can imagine, for patients with expensive medications and/or high-deductible health plans, the impact is disastrous.”

The legislation would still allow co-pay accumulators in which a generic version of a brand-name drug exists, unless the patient’s physician prescribes the more expensive brand-name drug as medically necessary.

Former state Rep. Randi Clites, a Democrat from Ravenna who is now policy director for the Ohio Bleeding Disorders Council, said that nine out of 10 insurers on the Affordable Care Act exchange in the Buckeye State now have some form of accumulator program that prevents co-pay assistance from counting toward deductibles and out-of-pocket costs.

Randi Clites of Ravenna, with husband, Mike, and son, Colton, kicks off her successful 2017 campaign for the Ohio House.

Clites – whose son, Colton, now 19, was born with severe hemophilia – noted that the average cost of treating that condition “is easily $400,000 a year. There is no generic for his treatment, and costs between similar products are comparable. We would have never made it without assistance programs over the years.”

Bipartisan bill essentially would ban co-pay accumulators in Ohio

The proposal to virtually end the use of co-pay accumulators has bipartisan sponsorship from Republican Rep. Susan Manchester of Waynesfield in northwestern Ohio and Democratic Rep. Thomas West of Canton.

Ohio state Rep. Thomas West, D Canton, speaking at an Ohio Promise rally in his hometown.

“This bill strives to protect patients who are being blindsided by unfair policies when learning they owe thousands of dollars because of unmet deductibles,” Manchester said.

Susan Manchester, R Waynesfield, talks with Ohio House colleagues when the legislature reconvened at the beginning of 2019.

Similar bans already have passed in Arizona, Illinois, Virginia and West Virginia, with legislation under consideration in Indiana, Kentucky and North Carolina, she said.

West said, “I’ve heard stories of patients rationing drugs or going without a dose to make their prescriptions last longer. No one should be put in this position, caught between a rock and a hard place. A constituent of mine with a rare bleeding disorder has lived this experience, along with countless others across our state.”

A who’s who of health advocates are backing the Ohio proposal, from Akron Children’s Hospital and the National Alliance on Mental Illness to the American Academy of Pediatrics and the Susan G. Komen breast-cancer-fighting organization.

Logos of organizations supporting HB 135, which would ban co-pay accumulators.

Ohioans tell how they were personally affected by co-pay accumulators

Several Ohioans testified in March about how they were personally affected by co-pay accumulators:

• Jenna Hoffman of Canton said she uses the drug Humate-P to treat her von Willebrand’s Disease, a rare, severe bleeding disorder for which treatment costs $4,300 per dose. “There is no generic or cheaper version of this intravenous medication. I rely on manufacturer copay cards to help pay for my life-saving medication, but insurance company co-pay accumulator policies have made my medication difficult to afford.”

Jenna Hoffman of Canton, who suffers from a rare bleeding disorder that requires treatment with an expensive specialty drug, testifies March 9 before the Ohio House Health Committee in favor of a bill to ban co-pay accumulators

• Nikki Snyder of Canfield has multiple sclerosis, as does her mother. “This new rule had been buried in the fine print of my health-insurance policy and I was not aware of the change. It is frustrating that insurers get to keep both the assistance payment and any co-pays paid directly by me while in the deductible phase – it is a double-dip that jeopardizes the health of patients. …

“My annual medication costs are over $100,000, and not being able to use any patient assistance toward my co-pay is a financial hardship to say the least.”

• Robbie Huston of Cincinnati didn’t know for years that she had Acromegaly, a rare hormonal disorder caused by a tumor on the pituitary gland producing excess growth hormone. Her treatment works, but it costs about $7,500 per shot.

“I was so relieved when I found out about the co-pay assistance program. It would cover my out-of-pocket expenses up to $20,000 a year,” she testified. Now that the $20,000 in effect has been taken away by her health insurer, she has stopped taking her medicine regularly because of the cost.

“If I can’t get my medication, I will eventually become disabled in a very slow and painful way. Then I will have to go on public assistance. I’ll lose everything.”

Sharon Lamberton, a deputy vice president with PhRMA, said the organization of more than 33 biopharmaceutical companies strongly opposes the accumulators because they so often result in an unexpected bill of possibly thousands of dollars for patients – who, like Huston, may then give up taking the medication they need.

“The reason for that? It is simply because they were later informed that, while the insurer accepted the assistance when presented by patients at the pharmacy counter, it did not apply the value of the assistance toward the patient’s mandated co-payment, co-insurance, or deductible requirements. I do not believe anyone would believe that policy is in the best interest of patients.”

New drugs worked; insurer says they aren’t a ‘medical necessity’

At the Madison Avenue Pharmacy in Springfield, which provided the Prolia shots for Julie Turner for $3,500 each, instead of the $5,000 each the local hospital was charging, patient care specialist Erin Phillips says people with all sorts of maladies are going through the same battle as Turner.

Some have rheumatoid arthritis, others psoriasis or high cholesterol that can’t be corrected by statins. All are complicated ailments that can be treated only with expensive, brand-name specialty drugs – as opposed to radically cheaper generics.

“I know what hoops people have to jump through,” she said.

Erin Phillips assists customers such as Julie Turner with navigating the process of dealing with health insurance and drug companies in her Patient Care Specialist role at Madison Avenue Pharmacy in Springfield, west of Columbus.

In fact, Phillips has done it so often that she has the routine down by now: Call for approval if the drug the patient needs is not on the formulary set by pharmacy benefit managers for the health insurer. (A formulary is the list of drugs the insurance will cover.)

When that’s denied – and it virtually always is – file an appeal. After that’s turned down, appeal again.

Once rejected for a third time, the patient has a fighting chance: The next appeal usually receives consideration from people outside the insurance company.

Still, Phillips said, the chances of winning approval from the health insurer even at this stage is 50-50 at best.

“It can be months of work,” she said. “They can just do whatever they want, and there’s no repercussions.”

Madison Avenue Pharmacy in Springfield, Ohio.

A Health Affairs blog by University of California associate professor Alice J. Chen and others noted, “For patients with rapidly progressive diseases, these delays can be life-threatening.”

One of the most frustrating cases for Phillips involved a patient who battled agonizing migraines for 13 years.

“She was on every medication you can imagine,” Phillips said.

At last, she found one that worked after getting a grant from a drug maker that made it affordable. The severe headaches dropped from daily occurrences to happening just five times a month.

But the insurance company wouldn’t cover it, Phillips said, saying it did not meet the required threshold of “medical necessity.”

‘A choice whether they have the best care or what they can afford’

Turner, now 63, said she, too, received no sympathy.

“I was told during one of my calls to the insurance company, insurance is changing, and we have to become better consumers,” she remembered. “I said, ‘What do you think I’m doing?'”

She is bewildered that she gets no credit for using the drug company grant to help cover her cost, because “the insurance company is still getting the money.”

Indeed, a study by the AIDS Foundation last year found that “insurers profit by keeping the co-pay assistance funds. This double-dipping comes at the patient’s expense. … only adding more financial strain for patients who may be facing hardships due to the coronavirus pandemic’s impact on jobs and family budgets.”

When Turner began treatments back in the 1970s, they were almost entirely covered by the robust insurance policy of her father, a Springfield firefighter.

But the aggressive treatment was traumatic for the high schooler who started out merely wondering why she got so tired that she couldn’t practice with the marching band.

“I swung from this mighty 17-year-old that could handle anything that was thrown at her to this scared little girl who wanted to crawl into my mother’s arms for safety,” she said.

About 25 years later, cancer would claim her mother’s life a few short weeks after the illness was diagnosed.

Turner’s treatment also was covered by the health plan she had as treasurer for decades at her alma mater, Clark Shawnee High School near Springfield.

She needed the help. Her spleen was removed during the initial rounds of her battle against cancer. With little ability to filter viruses or infections, she easily contracted many illnesses floating around her in ensuing years.

The intense cancer treatment – primitive by today’s standards – left other lasting effects. The chemo damaged her heart. The radiation, along with making her unable to bear children and causing fragile bones, left scar tissue on her lungs.

But she says she’s had a good life. She got married and she and husband, Chuck Wickline, adopted a daughter, Jodie.

“I’m so blessed to be here,” Turner said.

Julie Turner says her insurance company told her she had to become a better consumer.

She retired in 2016, and the couple moved to a condo in Vandalia, near Dayton. That’s when she went on a “bridge” health insurance policy with Aetna through the School Employees Retirement System of Ohio to get her to Medicare in a couple of years.

Turner has become an advocate for the American Cancer Society, where she hears stories of others enduring the same struggle she has in a country overtaken by health-care consolidation.

“Unfortunately, for the patients that are going through active treatment now, they have to make a choice whether they have the best care or what they can afford,” she said.

Her reward comes from moments like the one at a Relay for Life in Fayette County. After hearing Turner’s story, a mother with a teen-age daughter fighting cancer came up to her with a simple message:

“You’ve given us hope.”

A grant from the nonpartisan, nonprofit National Institute for Health Care Management helped pay for research for this story; the organization had no input on its content.


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Serious gaps in mental health care in Washington prisons, report warns



Inadequate psychiatric care in Washington prisons puts some prisoners at increased risk of self-harm and suicide and contributes to long stays in solitary confinement, according to a new report from the Ombudsman.

The report, which has been in the works for months, raises the alarm over numerous shortcomings, including high-case psychiatric staff and desperate prisoners waiting to see a psychologist.

Other issues identified by the Office of the Corrections Ombuds (OCO) include problems with prescribing psychiatric drugs and a disciplinary process that often fails to take into account the mental health of the detainee.

“The big realization is that we need more mental health services for incarcerated people,” said Joanna Carns, director of the OCO.

In response to the report, the Department of Corrections (DOC) recognized the continuing challenges in the delivery of mental health care to prisoners and pointed out the way it addresses many of the issues, including by working with outside prison reform groups.

The Ombuds Report is the latest in a series of OCO investigations that focus on the state of mental health care in Washington prisons – a strategic priority for the independent bureau, established in 2018.

Previous reports have focused on prisoners who have died from suicide, the effects of solitary confinement, and concerns related to the quarantine and isolation of prisoners due to COVID-19. Future OCO reports will examine the use of violence and restraints among prisoners with mental illness and the well-being of transgender prisoners.

The latest research paints a picture of a prison system that is ill-equipped to meet the mental health needs of a complex population of approximately 15,000 prisoners, spread across 12 prisons and 12 layoffs. Of particular concern to investigators is anecdotal evidence that inmates of color with mental disorders are treated differently. The report also highlights the particular challenges LQBTQ prisoners face.

A new report from the Office of Corrections Ombudsman finds evidence of numerous shortcomings in the availability of mental health care in Washington prisons. According to the report, prisoners in distress often have to wait to see a psychologist, and a lack of robust treatment options means that some prisoners end up in solitary confinement.

Washington State Department of Corrections /

The report is based on an analysis of more than 300 mental health complaints at the OCO between November 2018 and November 2020. In addition, investigators interviewed detainees, checked mental health data and spoke to DOC employees and administrations.

Countless problems

A key finding is that mental health professionals who are responsible for initial examinations of new prisoners are overwhelmed. According to the report, employees have to do an “extremely high” number of screenings each day and sometimes the location where the screenings are held is not private. This is an issue that the OCO previously reported.

Another persistent problem the report identifies is the lack of access to mental health professionals. This can manifest itself in a variety of ways, from delays after a prisoner sends a letter asking for a counselor to a lack of group therapy options.

Prisoners have also complained that DOC doctors reduced or stopped their existing psychiatric medication, or prescribed medication that was ineffective.

In terms of discipline, the report notes that when prisoners break the rules and get into trouble, “the process does not provide an adequate opportunity to take full account of a person’s mental health,” the report said.

In particular, the report describes a cycle in which an incarcerated person acts based on their mental health and then receives a sanction that does not address the root of the behavior. In some cases, individual prisoners suffer numerous violations due to untreated mental illness.

An example of this was included in the OCO’s 2020 annual report. It was a prisoner who injured himself. When the prison staff tried to hold the person, he hit one of the staff and attacked him. As a punishment, the prisoner was placed in solitary confinement and lost part of his “good time” credit for an earlier release.

Another major concern of the OCO is suicide in prison. Since last year, the OCO has published a number of reports of suicide in prisons, along with several recommendations on how to address the problem. This latest report urges the DOC to adopt these earlier recommendations and warns that in some cases the agency has not properly tracked and tracked prisoners who have harmed themselves or on suicide watch.

Another ongoing concern of the OCO is the use of solitary confinement, also known as intensive management or segregation. The report notes that people with serious mental illnesses are often kept in solitary cells for long periods of time.

“This practice contradicts years of research that have shown that time in solitary confinement exacerbates mental symptoms,” the report said.

DOC has worked with the Vera Institute of Justice, a national prison reform group, for the past few years to reduce the use of solitary confinement.

To address mental health deficiencies, the OCO report makes a number of recommendations, including that the DOC reduce the number of cases for staff examining incoming prisoners for mental health issues.

The report also calls on the DOC to increase its mental health staff to ensure timely treatment and expand opportunities for group therapy. As part of this effort, the report says, it is important that clinical staff reflect the racial and ethnic diversity of prison inmates.

Regarding the disciplining of inmates with severe mental illness, the report suggests that the DOC suggest alternatives to the standard sanctions and, if necessary, seek input from mental health workers.

The report also urges the DOC to reduce the time detainees with severe mental illnesses spend in solitary confinement and to investigate best practices for accommodation and treatment options that do not include segregation.

In addition to hiring more mental health staff, the OCO would also like the DOC to train its frontline detainees to better support the mental health needs of detainees. This includes training on mental health awareness and de-escalation tactics. In response, DOC said it is already prioritizing de-escalation, but there are recognized opportunities for more specific training for people in specialized occupational classes.

One final recommendation urges the DOC to work with the Department of Social and Health Services (DHSH) to facilitate the “temporary transfer” of prisoners in need of inpatient psychiatric care to western or eastern state hospitals.

DOC answers

In a lengthy, formal response to the report, DOC said it plans to ask lawmakers to fund two additional psychology positions as well as funds to improve the prisoner reception process next year.

In the meantime, the agency hopes to have a new assessment of the physical space available in prisons for group therapy sessions by September 30. However, DOC warned that finding suitable rooms and then staffing groups with a correctional officer to ensure security is an ongoing challenge. COVID-19 was another barrier to convening groups.

Next year, DOC plans to broadly roll out a new disciplinary program for people with severe mental illness that it has tested in two prisons. The program is modeled after a similar program by the Oregon Department of Corrections and requires the involvement of the inmate’s primary therapist in the disciplinary process.

The ministry also noted that since 2012 it has reduced the use of administrative segregation by a third and reduced the median stay in isolation by 33 percent. DOC said it has also stopped the use of segregation as a form of sanction and is trying alternatives to solitary confinement such as “transitional pods.”

In a statement on Wednesday, DOC said it was working with the OCO, acknowledging “known challenges related to the delivery of mental health services.”

“The department continues to work to equip and train its staff with the knowledge and skills necessary to support people with mental illness, and continues to review and revise its workforce to achieve adequate caseloads to maintain mental health services and to provide where the greatest patient needs are, ”the press release said.

The agency also said it is working with the University of California San Francisco’s AMEND program to bring a public health culture into the prison system. The DOC is also developing intensive outpatient treatment options that allow people with severe mental illness to receive treatment in the general prison population while in residence.

The current DOC secretary is Cheryl Strange, who previously ran DSHS and was previously CEO of Western State Hospital. Strange was appointed to the position in April. Carns, the ombudswoman, said she hoped Strange would prioritize the recommendations in the report given her mental health background.

“The goal is that people who are incarcerated are better off than when they entered Germany and receive psychiatric care [are] a critical component of that, ”said Carns.

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Oregon health care workers will be required to get vaccinated or face frequent testing



Oregon Governor Kate Brown speaks during the June 30, 2021 press conference announcing the end of the state mask mandate.

Kristyna Wentz-Graff

Oregon health workers will need to get vaccinated against COVID-19 or undergo weekly tests, which Governor Kate Brown usually plans to introduce in late September.

As an alarming surge in case numbers and hospital admissions threatens to overwhelm public health authorities and local hospitals, Brown announced Wednesday that it has directed the Oregon Health Authority to enact new rules designed to put pressure on health workers. You can either get vaccinated by September 30th or have frequent tests for the virus.

“The more contagious Delta variant changed everything,” Brown said in a press release. “This new security measure is necessary to prevent Delta from causing serious illness on our first line of defense: our doctors, nurses, medical students and health workers on the front lines.”

The new rule falls short of what the state’s largest hospital association had called for: a new rule or regulation that gives individual health systems the power to require Covid-19 vaccination if they so choose. That would have brought Oregon in line with most other states.

Brown feared that vaccination with no alternative could lead to staff shortages, her spokesman said.

The upcoming rules are similar to the testing requirements President Joe Biden and California Governor Gavin Newsom put in place for federal and state employees during the COVID-19 resurgence. But rather than addressing all state or federal employees, Brown limits her focus to health care workers “who have direct or indirect contact with patients or infectious materials.”

Brown’s office is still considering vaccination and testing requirements for government employees, the statement said. The governor, who in recent weeks has emphasized more localized decision-making over state mandates, urged private and public employers across the state to introduce masking requirements and “facilitate employee access to vaccines” with guidelines such as paid time off for vaccinations and others Incentives.

While vaccination assignments are acceptable as a condition of employment in most sectors, Oregon law prohibits health care providers from making them mandatory unless vaccinations are required by state or federal regulations. The governor’s office said Brown plans to “address” this ban when lawmakers meet early next year.

In the meantime, not all providers are waiting. Kaiser Permanente announced Monday that it will make vaccines mandatory for all employees. PeaceHealth’s medical system announced Tuesday that all of its caregivers must be vaccinated against COVID-19 or submit a qualified medical exemption. Those who do not can be removed from patient care.

Health systems across the state have said they support a change in the law, while the Oregon Nurses Association has warned that if nurses are not part of the contract negotiations, they could result in resignation when morale is low and hospitals and long-term care facilities last are already scarce.

The increased demands come as COVID-19 patients are being hospitalized at a worrying rate. As of Wednesday, 393 people with the virus had been hospitalized in the state, 95 more than last Friday and 14 more than the day before.

State health officials released modeling results last week that suggested that nearly 100 people a day could be hospitalized by mid-August if steps are not taken to contain the spread of the Delta variant. The same modeling suggested that the daily case numbers could rise to nearly 1,200 over the same period. The state reported 1,575 new cases on Tuesday.

The state had 393 available beds in a non-intensive care unit and 110 free beds in the intensive care unit as of Wednesday morning.

Despite worrying trends and calls from their own health advisors to get vaccinated as soon as possible, the new requirements for health workers won’t go into effect until September 30th. Brown’s office said an eight week delay will “give employers time” to prepare for implementation and will give currently unvaccinated health care workers time to fully vaccinate.

Vaccination rates for health care workers are higher than rates for the general population, but they vary widely by region, ranging from a low of 43% in Harney County to a high of 81% in Washington County.

Vaccinations for long-term care facilities are particularly critical, the residents of which were responsible for around half of the deaths in the first year of the pandemic.

Approximately 68% of Oregon long-term care workers have been vaccinated – about 10% more than the national average, according to the Oregon Health Care Association, which represents the industry.

In Oregon, by July 3, 70% of all health workers were vaccinated. The rates vary depending on the profession: 87% of vaccinated doctors, 74% of registered nurses and 57% of certified nursing assistants.

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It’s time to expand the definition of ‘women’s health’



Common diseases such as cardiovascular disease are under-researched in women, making diagnosis, prognosis and treatment difficult in women.Photo credit: BSIP / UIG / Getty

More than one eighth of the world’s population has a condition that can cause pain, profuse bleeding, and decreased fertility, all possible consequences of benign tumors known as uterine leiomyomas or fibroids. Fibroids can be debilitating and are a common reason for surgical removal of the uterus.

Still, fibroids have received relatively little attention from scientists, either in academia or in pharmaceutical companies. The cause of the disease – and how to reduce its impact on fertility – has been debated for decades, leaving doctors unsure how best to treat people.

Unfortunately, fibroids are just one of many underrated aspects of health in people who were female at birth. (This includes cis women, transgender men, and some non-binary and intersex people; the term “women” in the remainder of this editorial refers to cis women.) Clinical and preclinical studies tend to focus equally on men: a third of the Individuals participating in cardiovascular disease clinical trials are women, and an analysis of neuroscientific studies published in six journals in 2014 found that 40% of them used male animals only. Two studies and an article published in Nature on Aug. 5 shed light on the advances in women’s health research – and the need for more.

A study examines the molecular origins of fibroids and reveals a possible mechanism by which tumors form. Drugs targeting key molecular actors in this process could open up new treatment options with further studies.

The other study takes a multidisciplinary approach, examining both the genetic mechanisms and epidemiological factors involved in ovarian aging, which leads to menopause and fertility loss. The age at which women experience menopause varies widely – with a range of around 20 years for healthy women – and fertility can drop dramatically for up to a decade before it begins.

This work expanded the list of genes that contribute to early ovarian aging and highlights the importance of DNA repair mechanisms in determining the age at which women experience menopause.

Both studies illustrate the advances that can be made if the health challenges of women are brought to the fore. However, advocates of women’s health warn that the field is often too narrowly considered. The study of health and disease in women should not be limited to conditions that affect women only. Conditions like type 2 diabetes, Alzheimer’s disease, and heart disease affect men and women differently. Such diseases need to be investigated in both men and women, and the diagnosis, prognosis, and treatment may need to differ between the sexes.

Heart attacks, for example, are one of the leading causes of death in both women and men, but women do not always have the “typical” symptoms that men normally experience. Women are also more prone to blood clots after a heart attack, but are less likely to be prescribed anticoagulant drugs by their doctors. Women are 50% more likely to get an initial misdiagnosis after a heart attack than men and are less likely to be prescribed medication to reduce the risk of a second attack, according to the British Heart Foundation.

When it comes to exercise, women are at risk of serious long-term injury if we continue to model head injury training and management on data from men. As our News Feature reports, it is becoming increasingly clear that women experience head injuries and recover from them very differently than men. Understanding why women are nearly twice as likely to experience concussions as men in sports like soccer and rugby requires multi-disciplinary research – and to understand why women take longer to recover from such injuries.

So far, the evidence is sparse, but preliminary data suggest structural differences in the brain. Axons in the brain of women are wired to thinner microtubules that tear more easily; Hormonal fluctuations should also contribute to this. Biomechanics could also play a role – in rugby, for example, it seems that women fall differently when attacked, which could increase the risk of a concussion. Exercise programs designed specifically for women can help alleviate these injuries.

But the clear message from sports researchers is that it is no longer acceptable to exclusively use data from men in these studies. And when women are included, the data needs to be broken down by gender and include a sufficient number of women. A recent study examining MRI images of elite rugby players included women (KA Zimmerman Brain Commun. 3, fcab133; 2021) but of the 44 elite players, only 3 were women.

But the relative lack of women on committees and scientific advisory boards has meant that few of these decision-makers have direct personal experiences with women’s health needs or research gaps. It is all the more important that funders consult the public when determining research priorities.

Since 2016, the US National Institutes of Health has required researchers to conduct preclinical studies in both male and female animals, tissues and cells, or to provide an explanation as to why it is not appropriate to study both sexes. Now it is up to other funders, researchers, and journals to amplify the impact of this change by making sure to include gender-specific data in publications. Funders should also strengthen the resources allocated to support studies of health and disease in women and keep track of how much money is being used to support such research in all areas, not just gynecological diseases. What is measured is done.

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