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Open enrollment: Weekly volume down again
Plan selections at HealthCare.gov fell for the second week in a row as overall volume for open enrollment 2019 continues to lag behind last year, according to the Centers for Medicare & Medicaid Services.
Just over 500,000 plans – 369,000 renewals and 131,000 new applications – were selected during week 4 (Nov. 18-24) for the 2019 coverage year in the 39 states that use the HealthCare.gov platform, which is down from 748,000 for week 3 and 805,000 for week 2. A similar pattern of decreases in weeks 3 and 4 was seen during last year’s open-enrollment period.
For the entire open enrollment so far this year, a little over 2.42 million plans have been selected, which is down by 12.8% from last year’s 4-week total of 2.78 million selections, the CMS data show.
Plan selections at HealthCare.gov fell for the second week in a row as overall volume for open enrollment 2019 continues to lag behind last year, according to the Centers for Medicare & Medicaid Services.
Just over 500,000 plans – 369,000 renewals and 131,000 new applications – were selected during week 4 (Nov. 18-24) for the 2019 coverage year in the 39 states that use the HealthCare.gov platform, which is down from 748,000 for week 3 and 805,000 for week 2. A similar pattern of decreases in weeks 3 and 4 was seen during last year’s open-enrollment period.
For the entire open enrollment so far this year, a little over 2.42 million plans have been selected, which is down by 12.8% from last year’s 4-week total of 2.78 million selections, the CMS data show.
Plan selections at HealthCare.gov fell for the second week in a row as overall volume for open enrollment 2019 continues to lag behind last year, according to the Centers for Medicare & Medicaid Services.
Just over 500,000 plans – 369,000 renewals and 131,000 new applications – were selected during week 4 (Nov. 18-24) for the 2019 coverage year in the 39 states that use the HealthCare.gov platform, which is down from 748,000 for week 3 and 805,000 for week 2. A similar pattern of decreases in weeks 3 and 4 was seen during last year’s open-enrollment period.
For the entire open enrollment so far this year, a little over 2.42 million plans have been selected, which is down by 12.8% from last year’s 4-week total of 2.78 million selections, the CMS data show.
Medical liability at sea
Question: Regarding medical care aboard cruise ships, which of the following is incorrect?
A. It is difficult to prove negligence because of jurisdictional issues.
B. The American College of Emergency Physicians has published practice guidelines.
C. Cruise line owners are immune from liability under the Barbetta rule.
D. The Franza decision may be a game changer.
E. Lawsuits are on the increase.
Answer: A. More and more people are cruising, with the number of passengers on North American lines reaching nearly 18 million in 2017, about one-third out of Florida. Medical illnesses and accidents predictably occur at sea, and unfortunately, substandard and negligent care occasionally follows some of these mishaps.
However, up until recently, courts have immunized cruise line owners from legal liability by relying on the so-called Barbetta rule, which is based on historical notions of limited resources at sea and the impossibility of exerting control over the conduct of a ship’s health care providers.
A 2007 Florida case is illustrative. The doctor aboard a Carnival cruise ship failed to diagnose acute appendicitis in a 14-year-old girl who had complained of several days of abdominal symptoms. As a result, the patient ruptured her appendix, and this eventually resulted in sterility. The parents sued the cruise line, which denied liability because the doctor was not an employee, a fact specifically disclosed in the cruise ticket.
Although the doctor’s contract stated that he was an independent contractor, the District Court of Appeal of Florida reasoned that, in a claim based on agency, it is the right of control rather than actual control itself that matters.
It therefore held that: “for purposes of fulfilling cruise line’s duty to exercise reasonable care, the ship’s doctor is an agent of cruise line whose negligence should be imputed to cruise line ... regardless of the contractual status ascribed to the doctor” and to the extent cruise ticket sought to limit cruise line’s liability for negligence of doctor, it was invalid.
However, the Florida Supreme Court quashed this decision, because federal maritime law has historically protected shipowners from liability flowing from the medical negligence of shipboard physicians.1
The Barbetta rule was named after a 1988 case in which Florence L. Barbetta suffered serious medical complications during a Mexican cruise out of Florida. The ship’s doctor was alleged to have been negligent for his failure to diagnose diabetes.2 The lower court dismissed the case, and the appellate court affirmed.
The appellate court noted that an impressive number of courts from many jurisdictions have, for almost 100 years, followed the same basic rule: If the doctor is negligent in treating a passenger, that negligence will not be imputed to the carrier unless the carrier itself was negligent in hiring the doctor.
Citing approvingly from another case, the appellate court noted: “[A] shipping company is not in the business of providing medical services to passengers; it does not possess the expertise requisite to supervise a physician or surgeon carried on board a ship as a convenience to passengers. A ship is not a floating hospital; a ship’s physician is an independent medical expert engaged on the basis of his professional qualifications and carried on board a ship for the convenience of passengers, who are free to contract with him for any medical services they may require.”
However, courts now appear ready to jettison this rule.
In the 2014 case of Franza v. Royal Caribbean Cruises, Ltd., a passenger fell and hit his head while his ship was at port in Bermuda.3 He died several days later, allegedly because of negligence and delay by the ship’s medical staff. The lower courts barred the lawsuit, based on Barbetta, but on appeal, the 11th Circuit Court reversed. It rejected the historical justifications for immunizing shipowners from liability, concluding that past reasons were no longer applicable to modern-day cruise ships.
The court wrote: “Here, the roots of the Barbetta rule snake back to a wholly different world. Instead of 19th-century steamships, we now confront state-of-the-art cruise ships that house thousands of people and operate as floating cities complete with well-stocked modern infirmaries and urgent-care centers. In place of independent doctors and nurses, we must now acknowledge that medical professionals routinely work for corporate masters. And whereas ships historically went ‘off the grid’ when they set sail, modern technology enables distant ships to communicate instantaneously with the mainland in meaningful ways.”
However, the injured person must still prove that the doctor or nurse was acting as a ship employee rather than an independent contractor. Some of the factors to be considered include whether the cruise line advertised its medical center or medical staff to passengers, whether it retained the right to hire and fire medical staff, and methods of payment.
This 2014 11th Circuit Court ruling has particular impact on Florida, because the state’s federal court system falls within its jurisdiction, and many cruise lines – such as Carnival, Celebrity, Disney, Norwegian, Royal Caribbean, and Silversea Cruises – are headquartered in Florida. Because most ocean liners hire medical professionals who are foreign nationals, seeking legal remedy against the individuals can be difficult.
As a result, suing the cruise line directly can serve as the simplest way to obtain compensation. Some major cruise lines have already seen an increase in personal injury lawsuits. According to Bloomberg Law, there were 164 such federal injury suits in 2016, 188 in 2017, and 83 cases in just the first 3 months of 2018.
The popular press recently highlighted the latest example of medical malpractice at sea. A cruise worker was awarded $3.34 million after a young, inexperienced doctor prescribed a large dose of intravenous promethazine for nausea. Instead of using 6.25 mg, the usual dose, he prescribed 25 mg, which was inadvertently injected into the ulnar artery. The caustic drug, known to injure vascular walls, caused severe damage with extravasation, and tissue swelling, ending in compartment syndrome.
Furthermore, he had to wait 24 hours before arriving in port for treatment. By then, his arm was gangrenous and had to be amputated. The defense had argued unsuccessfully that the plaintiff had a venous anomaly to account for the injury.4
These changes in the law augur well for the cruising public. The Franza decision puts cruise line owners on notice that they no longer enjoy blanket immunity, and will be held responsible for the negligence of their health care providers. Hopefully, this will ensure a more uniform and adequate standard of care.
The American College of Emergency Physicians has published specific guidelines regarding medical standards aboard cruise ships. In addition to having established medical policies and procedures, and a dedicated medical emergency telephone number, they must have at least one doctor available 24/7 to provide emergency medical care and maintain certain equipment on board, such as pulse oximeters, cardiac monitors, defibrillators, an EKG device, as well as a laboratory.
Norwegian Cruise Line has taken a step further: It recently installed the capability to consult in real time with the Cleveland Clinic for diagnostic and treatment advice.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Carlisle v. Carnival Corporation, et al., 953 So.2d 461, 2007.
2. Barbetta v. S/S Bermuda Star, 848 F.2d 1364 (5th Cir. 1988).
3. Franza v. Royal Caribbean Cruises Ltd., 772 F.3d 1225 (11th Cir. 2014).
4. Loncar v. NCL Bahamas, International Center for Dispute Resolution, Case # 01-16-0004-3640, June 13, 2018.
Question: Regarding medical care aboard cruise ships, which of the following is incorrect?
A. It is difficult to prove negligence because of jurisdictional issues.
B. The American College of Emergency Physicians has published practice guidelines.
C. Cruise line owners are immune from liability under the Barbetta rule.
D. The Franza decision may be a game changer.
E. Lawsuits are on the increase.
Answer: A. More and more people are cruising, with the number of passengers on North American lines reaching nearly 18 million in 2017, about one-third out of Florida. Medical illnesses and accidents predictably occur at sea, and unfortunately, substandard and negligent care occasionally follows some of these mishaps.
However, up until recently, courts have immunized cruise line owners from legal liability by relying on the so-called Barbetta rule, which is based on historical notions of limited resources at sea and the impossibility of exerting control over the conduct of a ship’s health care providers.
A 2007 Florida case is illustrative. The doctor aboard a Carnival cruise ship failed to diagnose acute appendicitis in a 14-year-old girl who had complained of several days of abdominal symptoms. As a result, the patient ruptured her appendix, and this eventually resulted in sterility. The parents sued the cruise line, which denied liability because the doctor was not an employee, a fact specifically disclosed in the cruise ticket.
Although the doctor’s contract stated that he was an independent contractor, the District Court of Appeal of Florida reasoned that, in a claim based on agency, it is the right of control rather than actual control itself that matters.
It therefore held that: “for purposes of fulfilling cruise line’s duty to exercise reasonable care, the ship’s doctor is an agent of cruise line whose negligence should be imputed to cruise line ... regardless of the contractual status ascribed to the doctor” and to the extent cruise ticket sought to limit cruise line’s liability for negligence of doctor, it was invalid.
However, the Florida Supreme Court quashed this decision, because federal maritime law has historically protected shipowners from liability flowing from the medical negligence of shipboard physicians.1
The Barbetta rule was named after a 1988 case in which Florence L. Barbetta suffered serious medical complications during a Mexican cruise out of Florida. The ship’s doctor was alleged to have been negligent for his failure to diagnose diabetes.2 The lower court dismissed the case, and the appellate court affirmed.
The appellate court noted that an impressive number of courts from many jurisdictions have, for almost 100 years, followed the same basic rule: If the doctor is negligent in treating a passenger, that negligence will not be imputed to the carrier unless the carrier itself was negligent in hiring the doctor.
Citing approvingly from another case, the appellate court noted: “[A] shipping company is not in the business of providing medical services to passengers; it does not possess the expertise requisite to supervise a physician or surgeon carried on board a ship as a convenience to passengers. A ship is not a floating hospital; a ship’s physician is an independent medical expert engaged on the basis of his professional qualifications and carried on board a ship for the convenience of passengers, who are free to contract with him for any medical services they may require.”
However, courts now appear ready to jettison this rule.
In the 2014 case of Franza v. Royal Caribbean Cruises, Ltd., a passenger fell and hit his head while his ship was at port in Bermuda.3 He died several days later, allegedly because of negligence and delay by the ship’s medical staff. The lower courts barred the lawsuit, based on Barbetta, but on appeal, the 11th Circuit Court reversed. It rejected the historical justifications for immunizing shipowners from liability, concluding that past reasons were no longer applicable to modern-day cruise ships.
The court wrote: “Here, the roots of the Barbetta rule snake back to a wholly different world. Instead of 19th-century steamships, we now confront state-of-the-art cruise ships that house thousands of people and operate as floating cities complete with well-stocked modern infirmaries and urgent-care centers. In place of independent doctors and nurses, we must now acknowledge that medical professionals routinely work for corporate masters. And whereas ships historically went ‘off the grid’ when they set sail, modern technology enables distant ships to communicate instantaneously with the mainland in meaningful ways.”
However, the injured person must still prove that the doctor or nurse was acting as a ship employee rather than an independent contractor. Some of the factors to be considered include whether the cruise line advertised its medical center or medical staff to passengers, whether it retained the right to hire and fire medical staff, and methods of payment.
This 2014 11th Circuit Court ruling has particular impact on Florida, because the state’s federal court system falls within its jurisdiction, and many cruise lines – such as Carnival, Celebrity, Disney, Norwegian, Royal Caribbean, and Silversea Cruises – are headquartered in Florida. Because most ocean liners hire medical professionals who are foreign nationals, seeking legal remedy against the individuals can be difficult.
As a result, suing the cruise line directly can serve as the simplest way to obtain compensation. Some major cruise lines have already seen an increase in personal injury lawsuits. According to Bloomberg Law, there were 164 such federal injury suits in 2016, 188 in 2017, and 83 cases in just the first 3 months of 2018.
The popular press recently highlighted the latest example of medical malpractice at sea. A cruise worker was awarded $3.34 million after a young, inexperienced doctor prescribed a large dose of intravenous promethazine for nausea. Instead of using 6.25 mg, the usual dose, he prescribed 25 mg, which was inadvertently injected into the ulnar artery. The caustic drug, known to injure vascular walls, caused severe damage with extravasation, and tissue swelling, ending in compartment syndrome.
Furthermore, he had to wait 24 hours before arriving in port for treatment. By then, his arm was gangrenous and had to be amputated. The defense had argued unsuccessfully that the plaintiff had a venous anomaly to account for the injury.4
These changes in the law augur well for the cruising public. The Franza decision puts cruise line owners on notice that they no longer enjoy blanket immunity, and will be held responsible for the negligence of their health care providers. Hopefully, this will ensure a more uniform and adequate standard of care.
The American College of Emergency Physicians has published specific guidelines regarding medical standards aboard cruise ships. In addition to having established medical policies and procedures, and a dedicated medical emergency telephone number, they must have at least one doctor available 24/7 to provide emergency medical care and maintain certain equipment on board, such as pulse oximeters, cardiac monitors, defibrillators, an EKG device, as well as a laboratory.
Norwegian Cruise Line has taken a step further: It recently installed the capability to consult in real time with the Cleveland Clinic for diagnostic and treatment advice.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Carlisle v. Carnival Corporation, et al., 953 So.2d 461, 2007.
2. Barbetta v. S/S Bermuda Star, 848 F.2d 1364 (5th Cir. 1988).
3. Franza v. Royal Caribbean Cruises Ltd., 772 F.3d 1225 (11th Cir. 2014).
4. Loncar v. NCL Bahamas, International Center for Dispute Resolution, Case # 01-16-0004-3640, June 13, 2018.
Question: Regarding medical care aboard cruise ships, which of the following is incorrect?
A. It is difficult to prove negligence because of jurisdictional issues.
B. The American College of Emergency Physicians has published practice guidelines.
C. Cruise line owners are immune from liability under the Barbetta rule.
D. The Franza decision may be a game changer.
E. Lawsuits are on the increase.
Answer: A. More and more people are cruising, with the number of passengers on North American lines reaching nearly 18 million in 2017, about one-third out of Florida. Medical illnesses and accidents predictably occur at sea, and unfortunately, substandard and negligent care occasionally follows some of these mishaps.
However, up until recently, courts have immunized cruise line owners from legal liability by relying on the so-called Barbetta rule, which is based on historical notions of limited resources at sea and the impossibility of exerting control over the conduct of a ship’s health care providers.
A 2007 Florida case is illustrative. The doctor aboard a Carnival cruise ship failed to diagnose acute appendicitis in a 14-year-old girl who had complained of several days of abdominal symptoms. As a result, the patient ruptured her appendix, and this eventually resulted in sterility. The parents sued the cruise line, which denied liability because the doctor was not an employee, a fact specifically disclosed in the cruise ticket.
Although the doctor’s contract stated that he was an independent contractor, the District Court of Appeal of Florida reasoned that, in a claim based on agency, it is the right of control rather than actual control itself that matters.
It therefore held that: “for purposes of fulfilling cruise line’s duty to exercise reasonable care, the ship’s doctor is an agent of cruise line whose negligence should be imputed to cruise line ... regardless of the contractual status ascribed to the doctor” and to the extent cruise ticket sought to limit cruise line’s liability for negligence of doctor, it was invalid.
However, the Florida Supreme Court quashed this decision, because federal maritime law has historically protected shipowners from liability flowing from the medical negligence of shipboard physicians.1
The Barbetta rule was named after a 1988 case in which Florence L. Barbetta suffered serious medical complications during a Mexican cruise out of Florida. The ship’s doctor was alleged to have been negligent for his failure to diagnose diabetes.2 The lower court dismissed the case, and the appellate court affirmed.
The appellate court noted that an impressive number of courts from many jurisdictions have, for almost 100 years, followed the same basic rule: If the doctor is negligent in treating a passenger, that negligence will not be imputed to the carrier unless the carrier itself was negligent in hiring the doctor.
Citing approvingly from another case, the appellate court noted: “[A] shipping company is not in the business of providing medical services to passengers; it does not possess the expertise requisite to supervise a physician or surgeon carried on board a ship as a convenience to passengers. A ship is not a floating hospital; a ship’s physician is an independent medical expert engaged on the basis of his professional qualifications and carried on board a ship for the convenience of passengers, who are free to contract with him for any medical services they may require.”
However, courts now appear ready to jettison this rule.
In the 2014 case of Franza v. Royal Caribbean Cruises, Ltd., a passenger fell and hit his head while his ship was at port in Bermuda.3 He died several days later, allegedly because of negligence and delay by the ship’s medical staff. The lower courts barred the lawsuit, based on Barbetta, but on appeal, the 11th Circuit Court reversed. It rejected the historical justifications for immunizing shipowners from liability, concluding that past reasons were no longer applicable to modern-day cruise ships.
The court wrote: “Here, the roots of the Barbetta rule snake back to a wholly different world. Instead of 19th-century steamships, we now confront state-of-the-art cruise ships that house thousands of people and operate as floating cities complete with well-stocked modern infirmaries and urgent-care centers. In place of independent doctors and nurses, we must now acknowledge that medical professionals routinely work for corporate masters. And whereas ships historically went ‘off the grid’ when they set sail, modern technology enables distant ships to communicate instantaneously with the mainland in meaningful ways.”
However, the injured person must still prove that the doctor or nurse was acting as a ship employee rather than an independent contractor. Some of the factors to be considered include whether the cruise line advertised its medical center or medical staff to passengers, whether it retained the right to hire and fire medical staff, and methods of payment.
This 2014 11th Circuit Court ruling has particular impact on Florida, because the state’s federal court system falls within its jurisdiction, and many cruise lines – such as Carnival, Celebrity, Disney, Norwegian, Royal Caribbean, and Silversea Cruises – are headquartered in Florida. Because most ocean liners hire medical professionals who are foreign nationals, seeking legal remedy against the individuals can be difficult.
As a result, suing the cruise line directly can serve as the simplest way to obtain compensation. Some major cruise lines have already seen an increase in personal injury lawsuits. According to Bloomberg Law, there were 164 such federal injury suits in 2016, 188 in 2017, and 83 cases in just the first 3 months of 2018.
The popular press recently highlighted the latest example of medical malpractice at sea. A cruise worker was awarded $3.34 million after a young, inexperienced doctor prescribed a large dose of intravenous promethazine for nausea. Instead of using 6.25 mg, the usual dose, he prescribed 25 mg, which was inadvertently injected into the ulnar artery. The caustic drug, known to injure vascular walls, caused severe damage with extravasation, and tissue swelling, ending in compartment syndrome.
Furthermore, he had to wait 24 hours before arriving in port for treatment. By then, his arm was gangrenous and had to be amputated. The defense had argued unsuccessfully that the plaintiff had a venous anomaly to account for the injury.4
These changes in the law augur well for the cruising public. The Franza decision puts cruise line owners on notice that they no longer enjoy blanket immunity, and will be held responsible for the negligence of their health care providers. Hopefully, this will ensure a more uniform and adequate standard of care.
The American College of Emergency Physicians has published specific guidelines regarding medical standards aboard cruise ships. In addition to having established medical policies and procedures, and a dedicated medical emergency telephone number, they must have at least one doctor available 24/7 to provide emergency medical care and maintain certain equipment on board, such as pulse oximeters, cardiac monitors, defibrillators, an EKG device, as well as a laboratory.
Norwegian Cruise Line has taken a step further: It recently installed the capability to consult in real time with the Cleveland Clinic for diagnostic and treatment advice.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Carlisle v. Carnival Corporation, et al., 953 So.2d 461, 2007.
2. Barbetta v. S/S Bermuda Star, 848 F.2d 1364 (5th Cir. 1988).
3. Franza v. Royal Caribbean Cruises Ltd., 772 F.3d 1225 (11th Cir. 2014).
4. Loncar v. NCL Bahamas, International Center for Dispute Resolution, Case # 01-16-0004-3640, June 13, 2018.
Open enrollment: HealthCare.gov busier in week 2
but the gap has closed since week 1, according to the Centers for Medicare & Medicaid Services.
With almost 805,000 plans selected this year during the second week (Nov. 4-10) of open enrollment, the total for the 2019 coverage year stands at nearly 1.18 million for the 39 states that use the HealthCare.gov platform, which is down 20.4% from the 1.48 million plans selected through the first 2 weeks of last year’s enrollment period. After week 1, this year’s total enrollment was down by 38%, compared with last year, CMS data show.
Consumers renewing their insurance plans account for the majority selected for 2019 coverage – 619,000 in week 2 and 901,000 for weeks 1 and 2 (close to 77% in each case) – with the rest coming from new consumers – 186,000 in week 2 and 275,000 overall. The figures reported in the weekly enrollment snapshot could change later since they represent selections only and not “consumers who have paid premiums to effectuate their enrollment,” CMS said.
but the gap has closed since week 1, according to the Centers for Medicare & Medicaid Services.
With almost 805,000 plans selected this year during the second week (Nov. 4-10) of open enrollment, the total for the 2019 coverage year stands at nearly 1.18 million for the 39 states that use the HealthCare.gov platform, which is down 20.4% from the 1.48 million plans selected through the first 2 weeks of last year’s enrollment period. After week 1, this year’s total enrollment was down by 38%, compared with last year, CMS data show.
Consumers renewing their insurance plans account for the majority selected for 2019 coverage – 619,000 in week 2 and 901,000 for weeks 1 and 2 (close to 77% in each case) – with the rest coming from new consumers – 186,000 in week 2 and 275,000 overall. The figures reported in the weekly enrollment snapshot could change later since they represent selections only and not “consumers who have paid premiums to effectuate their enrollment,” CMS said.
but the gap has closed since week 1, according to the Centers for Medicare & Medicaid Services.
With almost 805,000 plans selected this year during the second week (Nov. 4-10) of open enrollment, the total for the 2019 coverage year stands at nearly 1.18 million for the 39 states that use the HealthCare.gov platform, which is down 20.4% from the 1.48 million plans selected through the first 2 weeks of last year’s enrollment period. After week 1, this year’s total enrollment was down by 38%, compared with last year, CMS data show.
Consumers renewing their insurance plans account for the majority selected for 2019 coverage – 619,000 in week 2 and 901,000 for weeks 1 and 2 (close to 77% in each case) – with the rest coming from new consumers – 186,000 in week 2 and 275,000 overall. The figures reported in the weekly enrollment snapshot could change later since they represent selections only and not “consumers who have paid premiums to effectuate their enrollment,” CMS said.
Trump administration rule erodes ACA contraceptive mandate
More employers can opt out of providing contraception coverage to their employees under final regulations from the Trump administration that narrow the Affordable Care Act’s contraceptive mandate.
The two regulations, released Nov. 7, allow an expanded group of employers and insurers to get out of covering contraception methods by objecting on either religious or moral grounds.
The first rule broadens exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. The second rule protects nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions apply to institutions of education, issuers, and individuals, but not to governmental entities.
When first proposed in 2017, Trump administration officials said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” The U.S. Department of Health & Human Services estimates that the rules, which take effect in January 2019, will affect no more than 200 employers.
The American College of Obstetricians and Gynecologists expressed concern that the final rules will restrict patient access to meaningful contraceptive methods and will erode decades of progress in increasing women’s reproductive autonomy and restrict patient access to contraception.
“Women, families and our nation all benefit from seamless, affordable access to contraception,” ACOG President Lisa M. Hollier, MD, said in a statement. “Contraception improves women’s health and well-being, reduces unintended pregnancy, enables pregnancy spacing for safer pregnancies and deliveries, and empowers women’s engagement in the workforce and economic self-sufficiency. A woman’s employer should not determine whether or not she has this access.”
Marjorie Dannenfelser, president of Susan B. Anthony List, an anti-abortion group, praised the final rules, calling them needed protections from the burdensome Obama-era ACA abortifacient drug mandate.
“President Trump and HHS Secretary Azar delivered a huge victory for conscience rights and religious liberty in America,” Ms. Dannenfelser said in a statement. “No longer will Catholic nuns who care for the elderly poor be forced by the government to provide abortion-inducing drugs in their health care plans. Not only that, moral objectors such as Susan B. Anthony List, will also no longer have to pay for life-ending drugs that are antithetical to their mission and for which we have argued there is certainly no compelling state interest.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
Under the approved regulations, employers or insurers can stop their coverage of contraceptive services if they have religious beliefs or moral convictions against covering birth control. Exempted entities and individuals also can choose to cover some, but not all, contraceptive services, depending on their specific religious or moral objection, according to an HHS fact sheet.
The agency emphasized that the regulations leave in place government programs that provide free or subsidized contraceptive coverage to low-income women, such as through community health centers, and that the rules do not ban any employer from covering contraceptives.
The regulations become effective 60 days after they are published in the Federal Register.
More employers can opt out of providing contraception coverage to their employees under final regulations from the Trump administration that narrow the Affordable Care Act’s contraceptive mandate.
The two regulations, released Nov. 7, allow an expanded group of employers and insurers to get out of covering contraception methods by objecting on either religious or moral grounds.
The first rule broadens exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. The second rule protects nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions apply to institutions of education, issuers, and individuals, but not to governmental entities.
When first proposed in 2017, Trump administration officials said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” The U.S. Department of Health & Human Services estimates that the rules, which take effect in January 2019, will affect no more than 200 employers.
The American College of Obstetricians and Gynecologists expressed concern that the final rules will restrict patient access to meaningful contraceptive methods and will erode decades of progress in increasing women’s reproductive autonomy and restrict patient access to contraception.
“Women, families and our nation all benefit from seamless, affordable access to contraception,” ACOG President Lisa M. Hollier, MD, said in a statement. “Contraception improves women’s health and well-being, reduces unintended pregnancy, enables pregnancy spacing for safer pregnancies and deliveries, and empowers women’s engagement in the workforce and economic self-sufficiency. A woman’s employer should not determine whether or not she has this access.”
Marjorie Dannenfelser, president of Susan B. Anthony List, an anti-abortion group, praised the final rules, calling them needed protections from the burdensome Obama-era ACA abortifacient drug mandate.
“President Trump and HHS Secretary Azar delivered a huge victory for conscience rights and religious liberty in America,” Ms. Dannenfelser said in a statement. “No longer will Catholic nuns who care for the elderly poor be forced by the government to provide abortion-inducing drugs in their health care plans. Not only that, moral objectors such as Susan B. Anthony List, will also no longer have to pay for life-ending drugs that are antithetical to their mission and for which we have argued there is certainly no compelling state interest.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
Under the approved regulations, employers or insurers can stop their coverage of contraceptive services if they have religious beliefs or moral convictions against covering birth control. Exempted entities and individuals also can choose to cover some, but not all, contraceptive services, depending on their specific religious or moral objection, according to an HHS fact sheet.
The agency emphasized that the regulations leave in place government programs that provide free or subsidized contraceptive coverage to low-income women, such as through community health centers, and that the rules do not ban any employer from covering contraceptives.
The regulations become effective 60 days after they are published in the Federal Register.
More employers can opt out of providing contraception coverage to their employees under final regulations from the Trump administration that narrow the Affordable Care Act’s contraceptive mandate.
The two regulations, released Nov. 7, allow an expanded group of employers and insurers to get out of covering contraception methods by objecting on either religious or moral grounds.
The first rule broadens exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. The second rule protects nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions apply to institutions of education, issuers, and individuals, but not to governmental entities.
When first proposed in 2017, Trump administration officials said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” The U.S. Department of Health & Human Services estimates that the rules, which take effect in January 2019, will affect no more than 200 employers.
The American College of Obstetricians and Gynecologists expressed concern that the final rules will restrict patient access to meaningful contraceptive methods and will erode decades of progress in increasing women’s reproductive autonomy and restrict patient access to contraception.
“Women, families and our nation all benefit from seamless, affordable access to contraception,” ACOG President Lisa M. Hollier, MD, said in a statement. “Contraception improves women’s health and well-being, reduces unintended pregnancy, enables pregnancy spacing for safer pregnancies and deliveries, and empowers women’s engagement in the workforce and economic self-sufficiency. A woman’s employer should not determine whether or not she has this access.”
Marjorie Dannenfelser, president of Susan B. Anthony List, an anti-abortion group, praised the final rules, calling them needed protections from the burdensome Obama-era ACA abortifacient drug mandate.
“President Trump and HHS Secretary Azar delivered a huge victory for conscience rights and religious liberty in America,” Ms. Dannenfelser said in a statement. “No longer will Catholic nuns who care for the elderly poor be forced by the government to provide abortion-inducing drugs in their health care plans. Not only that, moral objectors such as Susan B. Anthony List, will also no longer have to pay for life-ending drugs that are antithetical to their mission and for which we have argued there is certainly no compelling state interest.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
Under the approved regulations, employers or insurers can stop their coverage of contraceptive services if they have religious beliefs or moral convictions against covering birth control. Exempted entities and individuals also can choose to cover some, but not all, contraceptive services, depending on their specific religious or moral objection, according to an HHS fact sheet.
The agency emphasized that the regulations leave in place government programs that provide free or subsidized contraceptive coverage to low-income women, such as through community health centers, and that the rules do not ban any employer from covering contraceptives.
The regulations become effective 60 days after they are published in the Federal Register.
Cigarette smoking at lowest level ever
“This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment, and it demonstrates the importance of continued proven strategies to reduce smoking,” CDC Director Robert Redfield said in a written statement.
In 2017, 19.3% of adults aged 18 years and older – approximately 47.4 million Americans – reported current use of some type of tobacco product, and current use of combustible tobacco was 16.7%, Teresa W. Wang, PhD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and her associates reported in the Morbidity and Mortality Weekly Report. Current use was defined as use every day or some days, with an added requirement of at least 100 cigarettes in a lifetime added for cigarette smokers.
Data from the National Health Interview Survey showed that from 2016 to 2017, current use declined for any tobacco product, any combustible tobacco product, cigarettes, smokeless tobacco, and the combination of two or more tobacco products. The most common combination in 2017 was cigarettes and e-cigarettes, which was reported by 30.1% of the 9 million adults who used more than one product, Dr. Wang and her associates said.
Prevalence of current tobacco use was higher among men than women (24.8% vs. 14.2%), and adults aged 25-44 years (22.5%) had the highest level by age, followed by those aged 45-64 years (21.3%), 18-24 years (18.3%), and 65 years or older (11%). Use by race/ethnicity was highest among American Indian/Alaska Natives (29.8%), with the Midwest putting up the highest prevalence by region at 23.5%, they said.
“Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products,” Dr. Wang and her associates wrote. “Implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States.”
SOURCE: Wang TW et al. MMWR. 2018 Nov 9;67[44]:1225-32.
“This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment, and it demonstrates the importance of continued proven strategies to reduce smoking,” CDC Director Robert Redfield said in a written statement.
In 2017, 19.3% of adults aged 18 years and older – approximately 47.4 million Americans – reported current use of some type of tobacco product, and current use of combustible tobacco was 16.7%, Teresa W. Wang, PhD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and her associates reported in the Morbidity and Mortality Weekly Report. Current use was defined as use every day or some days, with an added requirement of at least 100 cigarettes in a lifetime added for cigarette smokers.
Data from the National Health Interview Survey showed that from 2016 to 2017, current use declined for any tobacco product, any combustible tobacco product, cigarettes, smokeless tobacco, and the combination of two or more tobacco products. The most common combination in 2017 was cigarettes and e-cigarettes, which was reported by 30.1% of the 9 million adults who used more than one product, Dr. Wang and her associates said.
Prevalence of current tobacco use was higher among men than women (24.8% vs. 14.2%), and adults aged 25-44 years (22.5%) had the highest level by age, followed by those aged 45-64 years (21.3%), 18-24 years (18.3%), and 65 years or older (11%). Use by race/ethnicity was highest among American Indian/Alaska Natives (29.8%), with the Midwest putting up the highest prevalence by region at 23.5%, they said.
“Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products,” Dr. Wang and her associates wrote. “Implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States.”
SOURCE: Wang TW et al. MMWR. 2018 Nov 9;67[44]:1225-32.
“This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment, and it demonstrates the importance of continued proven strategies to reduce smoking,” CDC Director Robert Redfield said in a written statement.
In 2017, 19.3% of adults aged 18 years and older – approximately 47.4 million Americans – reported current use of some type of tobacco product, and current use of combustible tobacco was 16.7%, Teresa W. Wang, PhD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and her associates reported in the Morbidity and Mortality Weekly Report. Current use was defined as use every day or some days, with an added requirement of at least 100 cigarettes in a lifetime added for cigarette smokers.
Data from the National Health Interview Survey showed that from 2016 to 2017, current use declined for any tobacco product, any combustible tobacco product, cigarettes, smokeless tobacco, and the combination of two or more tobacco products. The most common combination in 2017 was cigarettes and e-cigarettes, which was reported by 30.1% of the 9 million adults who used more than one product, Dr. Wang and her associates said.
Prevalence of current tobacco use was higher among men than women (24.8% vs. 14.2%), and adults aged 25-44 years (22.5%) had the highest level by age, followed by those aged 45-64 years (21.3%), 18-24 years (18.3%), and 65 years or older (11%). Use by race/ethnicity was highest among American Indian/Alaska Natives (29.8%), with the Midwest putting up the highest prevalence by region at 23.5%, they said.
“Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products,” Dr. Wang and her associates wrote. “Implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States.”
SOURCE: Wang TW et al. MMWR. 2018 Nov 9;67[44]:1225-32.
FROM MMWR
Open enrollment: Slow first week at HealthCare.gov
About 372,000 people selected a health insurance plan during the first week of Affordable Care Act open enrollment for 2019, according to the Centers for Medicare & Medicaid Services. The first week was short, with only 3 days to select coverage.
For Nov. 1-3, the exact number of plans selected was 371,676, which is about 38% less than last year’s first week, which was 4 days long, so the average number of plans selected per day was down by a little less than 18%, CMS data show.
“The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations,” CMS officials said, adding that the weekly data release “only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.”
Open enrollment will continue for another 6 weeks, with Dec. 15 being the final day to enroll for 2019 coverage on the 39 state exchanges that use the HealthCare.gov platform.
About 372,000 people selected a health insurance plan during the first week of Affordable Care Act open enrollment for 2019, according to the Centers for Medicare & Medicaid Services. The first week was short, with only 3 days to select coverage.
For Nov. 1-3, the exact number of plans selected was 371,676, which is about 38% less than last year’s first week, which was 4 days long, so the average number of plans selected per day was down by a little less than 18%, CMS data show.
“The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations,” CMS officials said, adding that the weekly data release “only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.”
Open enrollment will continue for another 6 weeks, with Dec. 15 being the final day to enroll for 2019 coverage on the 39 state exchanges that use the HealthCare.gov platform.
About 372,000 people selected a health insurance plan during the first week of Affordable Care Act open enrollment for 2019, according to the Centers for Medicare & Medicaid Services. The first week was short, with only 3 days to select coverage.
For Nov. 1-3, the exact number of plans selected was 371,676, which is about 38% less than last year’s first week, which was 4 days long, so the average number of plans selected per day was down by a little less than 18%, CMS data show.
“The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations,” CMS officials said, adding that the weekly data release “only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.”
Open enrollment will continue for another 6 weeks, with Dec. 15 being the final day to enroll for 2019 coverage on the 39 state exchanges that use the HealthCare.gov platform.
ED clinicians’ confidence in dealing with ICE mixed, survey finds
.
“More robust training and education may improve provider comfort and ability to appropriately balance patients’ rights with law enforcement,” one of the study authors, Charlotte Roy, MD, said at the annual meeting of the American College of Emergency Physicians.
Immigration and Customs Enforcement (ICE) is a federal government agency responsible for the detainment and deportation of immigrants whom they deem to be in violation of federal immigration law. Typically, hospitals have fallen into the category of “sensitive locations,” meaning they are avoided by ICE for enforcement actions, said Dr. Roy, a third-year resident in the department of emergency medicine at University of Chicago Hospital. However, “we’ve seen an increase in the apprehension and removal of illegal immigrants by 30% in 2017 across all locations,” she said.
In an effort to assess provider comfort, knowledge, and previous training on the subject, Dr. Roy and her colleagues administered a 15-question multiple-choice survey to 128 emergency residents, fellows, and attendings at John H. Stroger Jr. Hospital of Cook County and University of Chicago Hospital. Most of the 128 survey participants were residents (70), followed by 54 fellows and 4 attendings. One of the two hospital ED programs offered formal training on the topic, yet only 44% of respondents from that program reported that they participated in the training.
Examples of questions included “Do you know in what circumstances you are required to give protected health information of patients to immigration officers?” “Do you feel confident in your knowledge of which areas of the emergency department ICE agents could enter?” and “Are you confident you can get real-time help to answer questions regarding interactions with immigration officers?”
Among all respondents, 52% said that they would not feel comfortable interacting with immigration officers in the ED, 12% felt confident knowing which areas of the ED immigration officers could freely enter, and 11% were familiar with the designation of “sensitive locations” within their hospital. In addition, 23% of respondents knew that immigration status is protected under the Health Insurance Portability and Accountability Act of 1996 as protected health information, 16% knew in which circumstances they were required to convey immigrant status, and 51% knew a warrant or a court order is required for an immigration office to enter a patient’s room.
“Our conclusion based on these survey results is that there is very limited comfort and knowledge amongst ED providers regarding interactions with ICE officers in the ED,” Dr. Roy said. One resource she recommended is the National Immigration Law Center, which publishes a guide, “What to Do If Immigration Comes to Your Workplace.” The study’s primary author was Joseph Palter, MD. The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
.
“More robust training and education may improve provider comfort and ability to appropriately balance patients’ rights with law enforcement,” one of the study authors, Charlotte Roy, MD, said at the annual meeting of the American College of Emergency Physicians.
Immigration and Customs Enforcement (ICE) is a federal government agency responsible for the detainment and deportation of immigrants whom they deem to be in violation of federal immigration law. Typically, hospitals have fallen into the category of “sensitive locations,” meaning they are avoided by ICE for enforcement actions, said Dr. Roy, a third-year resident in the department of emergency medicine at University of Chicago Hospital. However, “we’ve seen an increase in the apprehension and removal of illegal immigrants by 30% in 2017 across all locations,” she said.
In an effort to assess provider comfort, knowledge, and previous training on the subject, Dr. Roy and her colleagues administered a 15-question multiple-choice survey to 128 emergency residents, fellows, and attendings at John H. Stroger Jr. Hospital of Cook County and University of Chicago Hospital. Most of the 128 survey participants were residents (70), followed by 54 fellows and 4 attendings. One of the two hospital ED programs offered formal training on the topic, yet only 44% of respondents from that program reported that they participated in the training.
Examples of questions included “Do you know in what circumstances you are required to give protected health information of patients to immigration officers?” “Do you feel confident in your knowledge of which areas of the emergency department ICE agents could enter?” and “Are you confident you can get real-time help to answer questions regarding interactions with immigration officers?”
Among all respondents, 52% said that they would not feel comfortable interacting with immigration officers in the ED, 12% felt confident knowing which areas of the ED immigration officers could freely enter, and 11% were familiar with the designation of “sensitive locations” within their hospital. In addition, 23% of respondents knew that immigration status is protected under the Health Insurance Portability and Accountability Act of 1996 as protected health information, 16% knew in which circumstances they were required to convey immigrant status, and 51% knew a warrant or a court order is required for an immigration office to enter a patient’s room.
“Our conclusion based on these survey results is that there is very limited comfort and knowledge amongst ED providers regarding interactions with ICE officers in the ED,” Dr. Roy said. One resource she recommended is the National Immigration Law Center, which publishes a guide, “What to Do If Immigration Comes to Your Workplace.” The study’s primary author was Joseph Palter, MD. The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
.
“More robust training and education may improve provider comfort and ability to appropriately balance patients’ rights with law enforcement,” one of the study authors, Charlotte Roy, MD, said at the annual meeting of the American College of Emergency Physicians.
Immigration and Customs Enforcement (ICE) is a federal government agency responsible for the detainment and deportation of immigrants whom they deem to be in violation of federal immigration law. Typically, hospitals have fallen into the category of “sensitive locations,” meaning they are avoided by ICE for enforcement actions, said Dr. Roy, a third-year resident in the department of emergency medicine at University of Chicago Hospital. However, “we’ve seen an increase in the apprehension and removal of illegal immigrants by 30% in 2017 across all locations,” she said.
In an effort to assess provider comfort, knowledge, and previous training on the subject, Dr. Roy and her colleagues administered a 15-question multiple-choice survey to 128 emergency residents, fellows, and attendings at John H. Stroger Jr. Hospital of Cook County and University of Chicago Hospital. Most of the 128 survey participants were residents (70), followed by 54 fellows and 4 attendings. One of the two hospital ED programs offered formal training on the topic, yet only 44% of respondents from that program reported that they participated in the training.
Examples of questions included “Do you know in what circumstances you are required to give protected health information of patients to immigration officers?” “Do you feel confident in your knowledge of which areas of the emergency department ICE agents could enter?” and “Are you confident you can get real-time help to answer questions regarding interactions with immigration officers?”
Among all respondents, 52% said that they would not feel comfortable interacting with immigration officers in the ED, 12% felt confident knowing which areas of the ED immigration officers could freely enter, and 11% were familiar with the designation of “sensitive locations” within their hospital. In addition, 23% of respondents knew that immigration status is protected under the Health Insurance Portability and Accountability Act of 1996 as protected health information, 16% knew in which circumstances they were required to convey immigrant status, and 51% knew a warrant or a court order is required for an immigration office to enter a patient’s room.
“Our conclusion based on these survey results is that there is very limited comfort and knowledge amongst ED providers regarding interactions with ICE officers in the ED,” Dr. Roy said. One resource she recommended is the National Immigration Law Center, which publishes a guide, “What to Do If Immigration Comes to Your Workplace.” The study’s primary author was Joseph Palter, MD. The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
AT ACEP18
Key clinical point: Emergency physicians’ knowledge of how to interact with immigration agencies is highly variable.
Major finding: More than half of respondents (52%) said that they would not feel comfortable interacting with immigration officers in the ED.
Study details: A survey of 128 emergency medicine physicians.
Disclosures: The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
Most nonemergent diagnoses can’t be predicted at ED presentation
based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
REPORTING FROM ACEP18
Key clinical point: A program to deny coverage for nonemergent visits to the ED is likely to have an adverse impact on patient care.
Major finding: Of patients with serious diseases eligible for reimbursement, 87.9% also have symptoms associated with nonurgent diseases.
Study details: An analysis of 29.6 million adult ED visits by commercially insured patients in the National Hospital Ambulatory Medical Care Survey.
Disclosures: Dr. Chou reported no financial relationships relevant to this study.
Source: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
Marijuana: Know the Rules in Your State
In 1992, then-governor of Massachusetts William F. Weld signed a bill into law legalizing the use of marijuana for glaucoma, cancer therapy, and certain asthmatic disorders under a limited Department of Public Health (DPH) research program. In 1996, the legislature gave DPH the power to approve any Massachusetts patient to “possess and use pot” legally for relief of symptoms.1 In my position as Health Policy Coordinator with DPH, those two acts were my introduction to the controversy of medical marijuana.
Since then, the popularity of—or rather, the shift in public sentiment regarding—marijuana (cannabis/cannabinoid) use has changed. There has been significant interest in the use of marijuana as an adjunct to treating chronic and/or debilitating medical conditions. There is also increasing interest in the potential therapeutic uses of marijuana and other cannabinoid compounds.
In recent years, we’ve seen significant momentum on this front. Point in fact, in fiscal year 2017, the National Institutes of Health supported projects on cannabinoid research totaling almost $140 million.2 More than 30 US jurisdictions have passed legislation to legalize marijuana for medical use (while a few have legalized its use, period).3 All of which has prompted quite the debate not only among the public but also among health care providers.
A review of the history of cannabis use is very interesting—specifically, that the use of cannabis as a therapeutic modality predates recorded history. Cannabis was very popular in ancient China, India, and Greece as a medicine to alleviate pain or cure a variety of ailments.4,5 In the early 1900s, cannabis was available OTC and commonly used for a variety of illnesses in the US. The first law regarding marijuana was enacted in 1619 at Jamestown Colony, Virginia; it “ordered” all farmers to grow Indian hempseed.6
But by 1906, cannabis was labeled as a poison in many states, and by the 1920s absolute prohibitions began. The Controlled Substances Act of 1970 outlawed cannabis for any use. Despite that ban, marijuana is the most common illegal drug used in the US today.7
Marijuana, not a completely benign substance, occupies a unique position in our society. On the one hand, it is a recreational compound, used to attain pleasant euphoria and a sense of relaxation. On the other, it has been used as a therapeutic compound, relieving nausea and anorexia from chemotherapy. In the former, it is viewed by many as a dangerous drug that can lead to madness (as depicted in the film Reefer Madness).8 In the latter, its use as an effective analgesic and appetite stimulant has been supported by people who have realized a therapeutic benefit.
The potential medicinal benefits of marijuana and its components have been the subject of research and ongoing heated debates. Decades of anecdotal evidence regarding the effectiveness of marijuana on the aforementioned symptoms have been documented. There are also numerous studies on marijuana as a therapeutic agent for multiple conditions, using the plant itself or extracts derived from it.9-11
Continue to: Perhaps most interesting...
Perhaps most interesting, emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal.12 Two recent studies examining cannabis laws and prescription of opioids found that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population,” concluding that the potential for marijuana to decrease opioid use in the Medicaid population deserves consideration during policy discussions about marijuana reform and the opioid epidemic.13, 14
The support for policy changes in states that have legalized marijuana for medical use suggests it is gaining greater acceptance in our society. The increase in jurisdictions that have approved marijuana for medical use requires that we, as health care providers, understand the implications for our practice and educate ourselves on the laws and regulations in our respective states.
Recent guidelines from the National Council of State Boards of Nursing (NCSBN) identify six principles of essential knowledge for NPs (that could apply to PAs, as well) who care for patients who qualify to participate in a Medical Marijuana Program (MMP). These include principles of safe and knowledgeable practice for clinicians when qualifying a patient for an MMP.3 Note that I said qualifying a patient and not prescribing marijuana. Federal law still classifies cannabis as a Schedule I controlled substance, thus prohibiting the actual prescription of marijuana, and prohibits pharmacies from dispensing cannabis. Quite a contradiction!
All of that said, it is incumbent upon each of us to understand the complexities of the MMP in our state. Each has its own specifications as to the qualifying conditions or symptoms, as well as the requirements to become an approved provider. And each is as diverse as the opinions on marijuana use.
Without doubt, the debate and dichotomy about medical marijuana will ensue for years. What we as health care providers must do is keep current on the laws and regulations not only in our state, but also at the federal level. As a primer on the status of MMPs and provider approval, I encourage all to review the NCSBN document.3
As always, you can share your thoughts with me via [email protected].
1. State House News Service. Marijuana in Massachusetts: where are we, what’s next? Beacon Hill Patch. November 12, 2017. https://patch.com/massachusetts/beaconhill/marijuana-massachusetts-where-are-we-whats-next. Accessed October 12, 2018.
2. National Institute on Drug Abuse. NIDA’s role in providing marijuana for research. April 2018. www.drugabuse.gov/drugs-abuse/marijuana/nidas-role-in-providing-marijuana-research. Accessed October 12, 2018.
3. The National Council of State Boards of Nursing. The NCSBN national nursing guidelines for medical marijuana. 2018;9(suppl 2). www.ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf. Accessed October 12, 2018.
4. ProCon.org. Historical timeline: history of marijuana as medicine—2900 BC to present. http://medicalmarijuana.procon.org/view.timeline.php?timelineID=000026. Accessed October 12, 2018.
5. National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding—First Report. Washington, DC: US Government Printing Office; 1972.
6. Guither P. Why is marijuana illegal? DrugWarRant.com. http://www.drugwarrant.com/articles/why-is-marijuana-illegal. Accessed October 12, 2018.
7. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf. Accessed October 12, 2018.
8. Reefer Madness (1938). https://publicdomainreview.org/collections/reefer-madness-1938. Accessed October 12, 2018.
9. ProCon.org. 60 peer-reviewed studies on medical marijuana: medical studies involving cannabis and cannabis extracts (1990-2014). http://medicalmarijuana.procon.org/view.resource.php?resourceID=000884. Accessed October 12, 2018.
10. Cochrane Library. Cochrane evidence: cannabis. www.cochrane.org/search/site/cannabis. Accessed October 12, 2018.
11. The National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017. https://doi.org/10.17226/24625. Accessed October 12, 2018.
12. Carroon JM, Mischley LK, Sexton M. Cannabis as a substitute for prescription drugs: a cross-sectional study. J Pain Res. 2017;10:989-998.
13. Bradford AC, Bradford WD, Abraham A, Adams GB. Association between US state medical cannabis laws and opioid prescribing in the Medicare Part D population. JAMA Intern Med. 2018;178(5):667-672.
14. Wen H, Hockenberr M. Association of medical and adult-use marijuana laws with opioid prescribing for Medicaid enrollees. JAMA Intern Med. 2018;178(5):673-679.
In 1992, then-governor of Massachusetts William F. Weld signed a bill into law legalizing the use of marijuana for glaucoma, cancer therapy, and certain asthmatic disorders under a limited Department of Public Health (DPH) research program. In 1996, the legislature gave DPH the power to approve any Massachusetts patient to “possess and use pot” legally for relief of symptoms.1 In my position as Health Policy Coordinator with DPH, those two acts were my introduction to the controversy of medical marijuana.
Since then, the popularity of—or rather, the shift in public sentiment regarding—marijuana (cannabis/cannabinoid) use has changed. There has been significant interest in the use of marijuana as an adjunct to treating chronic and/or debilitating medical conditions. There is also increasing interest in the potential therapeutic uses of marijuana and other cannabinoid compounds.
In recent years, we’ve seen significant momentum on this front. Point in fact, in fiscal year 2017, the National Institutes of Health supported projects on cannabinoid research totaling almost $140 million.2 More than 30 US jurisdictions have passed legislation to legalize marijuana for medical use (while a few have legalized its use, period).3 All of which has prompted quite the debate not only among the public but also among health care providers.
A review of the history of cannabis use is very interesting—specifically, that the use of cannabis as a therapeutic modality predates recorded history. Cannabis was very popular in ancient China, India, and Greece as a medicine to alleviate pain or cure a variety of ailments.4,5 In the early 1900s, cannabis was available OTC and commonly used for a variety of illnesses in the US. The first law regarding marijuana was enacted in 1619 at Jamestown Colony, Virginia; it “ordered” all farmers to grow Indian hempseed.6
But by 1906, cannabis was labeled as a poison in many states, and by the 1920s absolute prohibitions began. The Controlled Substances Act of 1970 outlawed cannabis for any use. Despite that ban, marijuana is the most common illegal drug used in the US today.7
Marijuana, not a completely benign substance, occupies a unique position in our society. On the one hand, it is a recreational compound, used to attain pleasant euphoria and a sense of relaxation. On the other, it has been used as a therapeutic compound, relieving nausea and anorexia from chemotherapy. In the former, it is viewed by many as a dangerous drug that can lead to madness (as depicted in the film Reefer Madness).8 In the latter, its use as an effective analgesic and appetite stimulant has been supported by people who have realized a therapeutic benefit.
The potential medicinal benefits of marijuana and its components have been the subject of research and ongoing heated debates. Decades of anecdotal evidence regarding the effectiveness of marijuana on the aforementioned symptoms have been documented. There are also numerous studies on marijuana as a therapeutic agent for multiple conditions, using the plant itself or extracts derived from it.9-11
Continue to: Perhaps most interesting...
Perhaps most interesting, emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal.12 Two recent studies examining cannabis laws and prescription of opioids found that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population,” concluding that the potential for marijuana to decrease opioid use in the Medicaid population deserves consideration during policy discussions about marijuana reform and the opioid epidemic.13, 14
The support for policy changes in states that have legalized marijuana for medical use suggests it is gaining greater acceptance in our society. The increase in jurisdictions that have approved marijuana for medical use requires that we, as health care providers, understand the implications for our practice and educate ourselves on the laws and regulations in our respective states.
Recent guidelines from the National Council of State Boards of Nursing (NCSBN) identify six principles of essential knowledge for NPs (that could apply to PAs, as well) who care for patients who qualify to participate in a Medical Marijuana Program (MMP). These include principles of safe and knowledgeable practice for clinicians when qualifying a patient for an MMP.3 Note that I said qualifying a patient and not prescribing marijuana. Federal law still classifies cannabis as a Schedule I controlled substance, thus prohibiting the actual prescription of marijuana, and prohibits pharmacies from dispensing cannabis. Quite a contradiction!
All of that said, it is incumbent upon each of us to understand the complexities of the MMP in our state. Each has its own specifications as to the qualifying conditions or symptoms, as well as the requirements to become an approved provider. And each is as diverse as the opinions on marijuana use.
Without doubt, the debate and dichotomy about medical marijuana will ensue for years. What we as health care providers must do is keep current on the laws and regulations not only in our state, but also at the federal level. As a primer on the status of MMPs and provider approval, I encourage all to review the NCSBN document.3
As always, you can share your thoughts with me via [email protected].
In 1992, then-governor of Massachusetts William F. Weld signed a bill into law legalizing the use of marijuana for glaucoma, cancer therapy, and certain asthmatic disorders under a limited Department of Public Health (DPH) research program. In 1996, the legislature gave DPH the power to approve any Massachusetts patient to “possess and use pot” legally for relief of symptoms.1 In my position as Health Policy Coordinator with DPH, those two acts were my introduction to the controversy of medical marijuana.
Since then, the popularity of—or rather, the shift in public sentiment regarding—marijuana (cannabis/cannabinoid) use has changed. There has been significant interest in the use of marijuana as an adjunct to treating chronic and/or debilitating medical conditions. There is also increasing interest in the potential therapeutic uses of marijuana and other cannabinoid compounds.
In recent years, we’ve seen significant momentum on this front. Point in fact, in fiscal year 2017, the National Institutes of Health supported projects on cannabinoid research totaling almost $140 million.2 More than 30 US jurisdictions have passed legislation to legalize marijuana for medical use (while a few have legalized its use, period).3 All of which has prompted quite the debate not only among the public but also among health care providers.
A review of the history of cannabis use is very interesting—specifically, that the use of cannabis as a therapeutic modality predates recorded history. Cannabis was very popular in ancient China, India, and Greece as a medicine to alleviate pain or cure a variety of ailments.4,5 In the early 1900s, cannabis was available OTC and commonly used for a variety of illnesses in the US. The first law regarding marijuana was enacted in 1619 at Jamestown Colony, Virginia; it “ordered” all farmers to grow Indian hempseed.6
But by 1906, cannabis was labeled as a poison in many states, and by the 1920s absolute prohibitions began. The Controlled Substances Act of 1970 outlawed cannabis for any use. Despite that ban, marijuana is the most common illegal drug used in the US today.7
Marijuana, not a completely benign substance, occupies a unique position in our society. On the one hand, it is a recreational compound, used to attain pleasant euphoria and a sense of relaxation. On the other, it has been used as a therapeutic compound, relieving nausea and anorexia from chemotherapy. In the former, it is viewed by many as a dangerous drug that can lead to madness (as depicted in the film Reefer Madness).8 In the latter, its use as an effective analgesic and appetite stimulant has been supported by people who have realized a therapeutic benefit.
The potential medicinal benefits of marijuana and its components have been the subject of research and ongoing heated debates. Decades of anecdotal evidence regarding the effectiveness of marijuana on the aforementioned symptoms have been documented. There are also numerous studies on marijuana as a therapeutic agent for multiple conditions, using the plant itself or extracts derived from it.9-11
Continue to: Perhaps most interesting...
Perhaps most interesting, emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal.12 Two recent studies examining cannabis laws and prescription of opioids found that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population,” concluding that the potential for marijuana to decrease opioid use in the Medicaid population deserves consideration during policy discussions about marijuana reform and the opioid epidemic.13, 14
The support for policy changes in states that have legalized marijuana for medical use suggests it is gaining greater acceptance in our society. The increase in jurisdictions that have approved marijuana for medical use requires that we, as health care providers, understand the implications for our practice and educate ourselves on the laws and regulations in our respective states.
Recent guidelines from the National Council of State Boards of Nursing (NCSBN) identify six principles of essential knowledge for NPs (that could apply to PAs, as well) who care for patients who qualify to participate in a Medical Marijuana Program (MMP). These include principles of safe and knowledgeable practice for clinicians when qualifying a patient for an MMP.3 Note that I said qualifying a patient and not prescribing marijuana. Federal law still classifies cannabis as a Schedule I controlled substance, thus prohibiting the actual prescription of marijuana, and prohibits pharmacies from dispensing cannabis. Quite a contradiction!
All of that said, it is incumbent upon each of us to understand the complexities of the MMP in our state. Each has its own specifications as to the qualifying conditions or symptoms, as well as the requirements to become an approved provider. And each is as diverse as the opinions on marijuana use.
Without doubt, the debate and dichotomy about medical marijuana will ensue for years. What we as health care providers must do is keep current on the laws and regulations not only in our state, but also at the federal level. As a primer on the status of MMPs and provider approval, I encourage all to review the NCSBN document.3
As always, you can share your thoughts with me via [email protected].
1. State House News Service. Marijuana in Massachusetts: where are we, what’s next? Beacon Hill Patch. November 12, 2017. https://patch.com/massachusetts/beaconhill/marijuana-massachusetts-where-are-we-whats-next. Accessed October 12, 2018.
2. National Institute on Drug Abuse. NIDA’s role in providing marijuana for research. April 2018. www.drugabuse.gov/drugs-abuse/marijuana/nidas-role-in-providing-marijuana-research. Accessed October 12, 2018.
3. The National Council of State Boards of Nursing. The NCSBN national nursing guidelines for medical marijuana. 2018;9(suppl 2). www.ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf. Accessed October 12, 2018.
4. ProCon.org. Historical timeline: history of marijuana as medicine—2900 BC to present. http://medicalmarijuana.procon.org/view.timeline.php?timelineID=000026. Accessed October 12, 2018.
5. National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding—First Report. Washington, DC: US Government Printing Office; 1972.
6. Guither P. Why is marijuana illegal? DrugWarRant.com. http://www.drugwarrant.com/articles/why-is-marijuana-illegal. Accessed October 12, 2018.
7. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf. Accessed October 12, 2018.
8. Reefer Madness (1938). https://publicdomainreview.org/collections/reefer-madness-1938. Accessed October 12, 2018.
9. ProCon.org. 60 peer-reviewed studies on medical marijuana: medical studies involving cannabis and cannabis extracts (1990-2014). http://medicalmarijuana.procon.org/view.resource.php?resourceID=000884. Accessed October 12, 2018.
10. Cochrane Library. Cochrane evidence: cannabis. www.cochrane.org/search/site/cannabis. Accessed October 12, 2018.
11. The National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017. https://doi.org/10.17226/24625. Accessed October 12, 2018.
12. Carroon JM, Mischley LK, Sexton M. Cannabis as a substitute for prescription drugs: a cross-sectional study. J Pain Res. 2017;10:989-998.
13. Bradford AC, Bradford WD, Abraham A, Adams GB. Association between US state medical cannabis laws and opioid prescribing in the Medicare Part D population. JAMA Intern Med. 2018;178(5):667-672.
14. Wen H, Hockenberr M. Association of medical and adult-use marijuana laws with opioid prescribing for Medicaid enrollees. JAMA Intern Med. 2018;178(5):673-679.
1. State House News Service. Marijuana in Massachusetts: where are we, what’s next? Beacon Hill Patch. November 12, 2017. https://patch.com/massachusetts/beaconhill/marijuana-massachusetts-where-are-we-whats-next. Accessed October 12, 2018.
2. National Institute on Drug Abuse. NIDA’s role in providing marijuana for research. April 2018. www.drugabuse.gov/drugs-abuse/marijuana/nidas-role-in-providing-marijuana-research. Accessed October 12, 2018.
3. The National Council of State Boards of Nursing. The NCSBN national nursing guidelines for medical marijuana. 2018;9(suppl 2). www.ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf. Accessed October 12, 2018.
4. ProCon.org. Historical timeline: history of marijuana as medicine—2900 BC to present. http://medicalmarijuana.procon.org/view.timeline.php?timelineID=000026. Accessed October 12, 2018.
5. National Commission on Marihuana and Drug Abuse. Marihuana: A Signal of Misunderstanding—First Report. Washington, DC: US Government Printing Office; 1972.
6. Guither P. Why is marijuana illegal? DrugWarRant.com. http://www.drugwarrant.com/articles/why-is-marijuana-illegal. Accessed October 12, 2018.
7. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf. Accessed October 12, 2018.
8. Reefer Madness (1938). https://publicdomainreview.org/collections/reefer-madness-1938. Accessed October 12, 2018.
9. ProCon.org. 60 peer-reviewed studies on medical marijuana: medical studies involving cannabis and cannabis extracts (1990-2014). http://medicalmarijuana.procon.org/view.resource.php?resourceID=000884. Accessed October 12, 2018.
10. Cochrane Library. Cochrane evidence: cannabis. www.cochrane.org/search/site/cannabis. Accessed October 12, 2018.
11. The National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017. https://doi.org/10.17226/24625. Accessed October 12, 2018.
12. Carroon JM, Mischley LK, Sexton M. Cannabis as a substitute for prescription drugs: a cross-sectional study. J Pain Res. 2017;10:989-998.
13. Bradford AC, Bradford WD, Abraham A, Adams GB. Association between US state medical cannabis laws and opioid prescribing in the Medicare Part D population. JAMA Intern Med. 2018;178(5):667-672.
14. Wen H, Hockenberr M. Association of medical and adult-use marijuana laws with opioid prescribing for Medicaid enrollees. JAMA Intern Med. 2018;178(5):673-679.
With midterm elections near, PhRMA continues to spend
PhRMA’s $21.8 million worth of lobbying through September put it ahead of Blue Cross Blue Shield’s $17.2 million. PhRMA remains on pace to exceed its previous spending high of $27.2 million in 2009, and the health sector as a whole, with a lobbying bill of $421.5 million for three-quarters of 2018, is just slightly ahead of last year’s record of $561.3 million, the center reported on OpenSecrets.org.
PhRMA is third overall in lobbying spending so far this year, behind the U.S. Chamber of Commerce ($69.1 million) and the National Association of Realtors ($53.8 million). Blue Cross Blue Shield is sixth overall, with the American Hospital Association ($17.2 million, seventh) and the American Medical Association ($15.5 million, ninth) also in the top 10, according to the center’s analysis of data from the Senate Office of Public Records.
The pharmaceutical/health product industry leads health-sector lobbying with $216.1 million in spending so far in 2018, followed by hospitals/nursing homes at $73.6 million, health professionals at $68.6 million, and health services/HMOs at $57.5 million.
PhRMA’s $21.8 million worth of lobbying through September put it ahead of Blue Cross Blue Shield’s $17.2 million. PhRMA remains on pace to exceed its previous spending high of $27.2 million in 2009, and the health sector as a whole, with a lobbying bill of $421.5 million for three-quarters of 2018, is just slightly ahead of last year’s record of $561.3 million, the center reported on OpenSecrets.org.
PhRMA is third overall in lobbying spending so far this year, behind the U.S. Chamber of Commerce ($69.1 million) and the National Association of Realtors ($53.8 million). Blue Cross Blue Shield is sixth overall, with the American Hospital Association ($17.2 million, seventh) and the American Medical Association ($15.5 million, ninth) also in the top 10, according to the center’s analysis of data from the Senate Office of Public Records.
The pharmaceutical/health product industry leads health-sector lobbying with $216.1 million in spending so far in 2018, followed by hospitals/nursing homes at $73.6 million, health professionals at $68.6 million, and health services/HMOs at $57.5 million.
PhRMA’s $21.8 million worth of lobbying through September put it ahead of Blue Cross Blue Shield’s $17.2 million. PhRMA remains on pace to exceed its previous spending high of $27.2 million in 2009, and the health sector as a whole, with a lobbying bill of $421.5 million for three-quarters of 2018, is just slightly ahead of last year’s record of $561.3 million, the center reported on OpenSecrets.org.
PhRMA is third overall in lobbying spending so far this year, behind the U.S. Chamber of Commerce ($69.1 million) and the National Association of Realtors ($53.8 million). Blue Cross Blue Shield is sixth overall, with the American Hospital Association ($17.2 million, seventh) and the American Medical Association ($15.5 million, ninth) also in the top 10, according to the center’s analysis of data from the Senate Office of Public Records.
The pharmaceutical/health product industry leads health-sector lobbying with $216.1 million in spending so far in 2018, followed by hospitals/nursing homes at $73.6 million, health professionals at $68.6 million, and health services/HMOs at $57.5 million.