Sam Whitehead
Mon, 17 Jun 2024 09:00:00 +0000

DECATUR, Ga. — Malcolm Reid recently marked the anniversary of his HIV diagnosis on Facebook. “Diagnosed with HIV 28 years ago, AND TODAY I THRIVE,” he wrote in a post in April, which garnered dozens of responses.

Reid, an advocate for people with HIV, said he's happy he made it to age 66. But growing older has come with a host of health issues. He survived kidney cancer and currently juggles medications to treat HIV, high blood pressure, and Type 2 diabetes. “It's a lot to manage,” he said.

But Reid's not complaining. When he was diagnosed, HIV was sometimes a death sentence. “I'm just happy to be here,” Reid said. “You weren't supposed to be here, and you're here.”

More than half of the people living with HIV in the United States are, like Reid, older than 50. Researchers estimate that 70% of people living with the virus will fall in that age range by 2030. Aging with HIV means an increased risk of other health problems, such as diabetes, depression, and heart disease, and a greater chance of developing these conditions at a younger age.

Yet the U.S. health care system isn't prepared to handle the needs of the more than half a million people — those already infected and those newly infected with HIV — who are 50 or older, say HIV advocates, doctors, government officials, people living with HIV, and researchers.

They worry that funding constraints, an increasingly dysfunctional Congress, holes in the social safety net, untrained providers, and workforce shortages leave people aging with HIV vulnerable to poorer health, which could undermine the larger fight against the virus.

“I think we're at a tipping point,” said Melanie Thompson, an Atlanta internal medicine doctor who specializes in HIV care and prevention. “It would be very easy to lose the substantial amount of the progress we have made.”

People are living longer with the virus due in part to the development of antiretroviral therapies — drugs that reduce the amount of virus in the body.

But aging with HIV comes with a greater risk of health problems related to inflammation from the virus and the long-term use of harsh medications. Older people often must coordinate care across specialists and are frequently on multiple prescriptions, increasing their risk for adverse drug reactions.

Some people face what researchers call the “dual stigma” of ageism and anti-HIV bias. They also have high rates of anxiety, depression, and substance use disorders.

Many have lost friends and family to the HIV/AIDS epidemic. Loneliness can increase the risks of cognitive decline and other medical conditions in older adults and can lead patients to stop treatment. It isn't an easy problem to solve, said Heidi Crane, an HIV researcher and clinician at the University of Washington.

“If I had the ability to write a prescription for a friend — someone who's supportive and engaged and willing to go walking with you twice a week — the care I provide would be so much better,” she said.

The complexity of care is a heavy lift for the Ryan White HIV/AIDS Program, the federal initiative for low-income people with HIV. The program serves more than half of the Americans living with the virus, and nearly half of its clients are 50 or older.

“Many of the people aging with HIV were pioneers in HIV treatment,” said Laura Cheever, who oversees the Ryan White program for the Health Resources and Services Administration, or HRSA. Researchers have a lot to learn about the best ways to meet the needs of the population, she said.

“We are learning as we go, we all are. But it certainly is challenging,” she said.

The Ryan White program's core budget has remained mostly flat since 2013 despite adding 50,000 patients, Cheever said. The Biden administration's latest budget request asks for less than half a percent bump in program funding.

Local and state public health officials make the bulk of the decisions about how to spend Ryan White money, Cheever said, and constrained resources can make it hard to balance priorities.

“When a lot of people aren't getting care, how do you decide where that next dollar is spent?” Cheever said.

The latest infusion of funding for Ryan White, which has totaled $466 million since 2019, came as part of a federal initiative to end the HIV epidemic by 2030. But that program has come under fire from Republicans in Congress, who last year tried to defund it even though it was launched by the Trump administration.

It's a sign of eroding bipartisan support for HIV services that puts people “in extreme jeopardy,” said Thompson, the Atlanta physician.

She worries that the increasing politicization of HIV could keep Congress from appropriating money for a pilot loan repayment program that aims to lure infectious disease doctors to areas that have a shortage of providers.

Many people aging with HIV are covered by Medicare, the public insurance program for people 65 and older. Research has shown that Ryan White patients on private insurance had better health than those on Medicare, which researchers linked to better access to non-HIV preventive care.

Some 40% of people living with HIV rely on Medicaid, the state-federal health insurance program for low-income people. The decision by 10 states not to expand Medicaid can leave older people with HIV few places to seek care outside of Ryan White clinics, Thompson said.

“The stakes are high,” she said. “We are in a very dangerous place if we don't pay more attention to our care systems.”

About 1 in 6 new diagnoses are in people 50 or older but public health policies haven't caught up to that reality, said Reid, the HIV advocate from Atlanta. The Centers for Disease Control and Prevention, for instance, recommends HIV testing only for people ages 13 to 64.

“Our systems are antiquated. They, for some reason, believe that once you hit a certain number, you stop having sex,” Reid said. Such blind spots mean older people often are diagnosed once the virus has destroyed the cells that help the body fight infection.

In acknowledgment of these challenges, HRSA recently launched a $13 million, three-year program to look at ways to improve health outcomes for older people living with HIV.

Ten Ryan White clinics across the United States participate in the effort, which is testing ways to better track the risk of adverse drug interactions for people taking multiple prescriptions. The program is also testing ways to better screen for conditions like dementia and frailty, and ways to streamline the referral process for people who might need specialty care.

New strategies can't come quickly enough, said Jules Levin, executive director of the National AIDS Treatment Advocacy Project, who, at age 74, has been living with HIV since the 1980s.

His group was one signatory to “The Glasgow Manifesto,” in which an international coalition of older people with HIV called on policymakers to ensure better access to affordable care, to ensure patients get more time with doctors, and to fight ageism.

“It's tragic and shameful that elderly people with HIV have to go through what they're going through without getting the proper attention that they deserve,” Levin said. “This will be a disaster soon without a solution.”

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By: Sam Whitehead
Title: Americans With HIV Are Living Longer. Federal Spending Isn't Keeping Up.
Sourced From: kffhealthnews.org/news/article/aging-with-hiv-medication-health-issues-federal-funding-legislation/
Published Date: Mon, 17 Jun 2024 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/montana-creates-emergency-drive-thru-blood-pickup-service-for-rural-ambulances/

Arielle Zionts
Mon, 17 Jun 2024 09:00:00 +0000

Crystal Hiwalker wonders if her heart and lungs would have kept working if the ambulance crew had been able to give her a transfusion as the blood drained from her body during a stormy, 100-mile ride.

Because of the 2019 snowstorm, it took 2.5 hours to drive from her small town of Lame Deer, Montana, to the advanced trauma center in Billings.

Doctors at the Billings Clinic hospital revived Hiwalker and stopped the bleeding from her ruptured ectopic pregnancy. They were shocked that she not only survived after her heart stopped beating and she lost nearly all her blood, but that she recovered without brain damage.

The Montana State Trauma Care Committee, which works to reduce trauma incidents and to improve care, later realized the ambulance that carried Hiwalker had passed near two hospitals that stocked blood. What if Hiwalker had access to that blood on her way to Billings, committee members asked.

That realization, and question, inspired committee members to create the Montana Interfacility Blood Network, which they say is the first program of its kind in the U.S. The network allows ambulance crews to pick up blood from hospitals and transfuse it to patients on the way to the advanced care they need.

“We kind of came up with the idea of having a blood handoff — like driving through a fast-food restaurant drive-thru — and picking up blood on the way,” said Gordon Riha, a trauma surgeon at the Billings Clinic trauma center, where Hiwalker was treated. Riha said timely blood transfusions can prevent death or permanent brain injury.

The network is aimed at rural patients, who face elevated rates of traumatic injuries and death, said Alyssa Johnson, trauma system manager for the state of Montana.

“We have to get more creative. We don't have a blood bank on every corner, and we don't have a Level 1 trauma center on every corner,” Johnson said.

Network leaders say the program has helped at least three patients since it launched in 2022. They hope it will be used more in the future.

Hiwalker is excited about the program.

“I'm so glad that something like this got started, because it would save a lot of lives from where I live,” she said.

Hiwalker said she has heard about people bleeding to death after car crashes, gunshot wounds, and stabbings in her rural community. Johnson said work injuries, cancer, gastrointestinal problems, and childbirth can also cause serious bleeding.

The Montana trauma committee began discussing the blood network a few months after Hiwalker's brush with death. First, it created a map of 48 facilities with blood banks. Then, it created guidelines for how hospitals, blood banks, ambulances, and labs must communicate about, package, transport, document, and bill for the blood.

The network is used only during emergencies, which means there's no time to test patients' blood types. So it uses only type O red blood cells, which can be transfused safely into most patients.

The receiving hospital — not the one that provided the blood — is responsible for billing patients' insurance for the blood. The cost depends on how much blood patients need but typically ranges from several hundred dollars to more than a thousand, said Sadie Arnold, who manages the blood bank at Billings Clinic.

Arnold said blood must be stored in a lab and managed by professionals with specific degrees, clinical experience, and board certifications.

Some rural hospitals lack space for a lab or money to recruit these specialists, Arnold said. Or they may not need blood often enough to justify storing a product that can expire and — especially during the current national blood shortage — is needed elsewhere. The network uses blood that has a maximum shelf life of 42 days.

Rural hospitals that do store blood may have only small amounts on hand. A rural Montanan with severe bleeding experienced that firsthand when he went to the nearest hospital, which had only one unit of type O blood, according to a report on the blood network. But thanks to the new program, ambulance medics picked up more blood from a hospital halfway through an 80-mile drive to the trauma hospital.

Ideally, rural patients with serious bleeding would be transported by medical helicopters or airplanes outfitted for transfusions. But, as in Hiwalker's case, flying can be impossible during bad weather. That can mean hours-long ambulance rides. Some towns in northeastern Montana, for example, are more than 250 miles away from the nearest advanced trauma center.

“This was truly designed for kind of that last-ditch effort,” Johnson said. When “we're out of options, we've got to get the patient moving towards a larger center, and we can't fly.”

The blood handoff may involve the ambulance stopping at the second hospital, Johnson said. But during one incident, a police officer picked up the blood and delivered it to the ambulance at a highway exit, she said.

Ambulances may also pick up a paramedic or nurse to provide the transfusion along the way, since many rural ambulance crews are staffed by emergency medical technicians, who in Montana aren't authorized to do so.

Medics in other cities and states, including ones with rural areas, have started performing blood transfusions in ambulances and helicopters, said Claudia Cohn, chief medical officer of the national Association for the Advancement of Blood & Biotherapies.

She said researchers are also interested in the potential of using frozen and freeze-dried blood products, which could be helpful in rural areas since they're easier to store and have longer shelf lives.

Johnson said the Montana Interfacility Blood Network is the only program she knows of specifically aimed at rural patients and involving ambulances picking up blood from hospitals along their routes. She said the network is gaining interest from other states with large rural regions, including Oregon.

Hiwalker said receiving a blood transfusion in the ambulance could have prevented her near-death experience and the trauma her husband faced from seeing her suffer as he rode in the ambulance with her. She's glad her ordeal led to an innovation that is helping others.

——————————
By: Arielle Zionts
Title: Montana Creates Emergency ‘Drive-Thru' Blood Pickup Service for Rural Ambulances
Sourced From: kffhealthnews.org/news/article/montana-emergency-drive-thru-blood-pickup-rural-ambulances/
Published Date: Mon, 17 Jun 2024 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/indiana-weighs-hospital-monopoly-as-officials-elsewhere-scrutinize-similar-deals/

Samantha Liss
Fri, 14 Jun 2024 09:00:00 +0000

TERRE HAUTE, Ind. — Locals in this city of 58,000 are used to having to wait at railroad crossings for one of the dozens of daily cargo trains to pass through.

But a proposed merger between the two hospitals on either side of the city could exacerbate the problem in emergencies if the hospitals shut down some services, such as trauma care, at one site, which the proposal cites as a possibility. Tom High, fire chief of a nearby township, said some first responders would be forced to transport critical patients farther, risking longer delays, if they become what locals call “railroaded” by a passing train.

That's just one of the fears in this community as Indiana officials review whether to allow Union Hospital, licensed as a 341-bed facility, to purchase the county's only other acute care hospital, the 278-bed Terre Haute Regional Hospital. The proposed deal also raises concerns about reduced tax revenue, worsening care, and higher prices.

Within the next few months, the Indiana Department of Health must find “clear evidence” that the proposed merger would improve health outcomes, access, and the quality of care. Those benefits must “outweigh any potential disadvantages.”

As the nation's health care industry has become more concentrated amid a steady clip of mergers in recent decades, it's common for one large system to dominate a market. In this case, the deal would be Indiana's first merger under the COPA law, short for Certificate of Public Advantage, that the state enacted in 2021. Such laws allow deals that the Federal Trade Commission otherwise considers illegal because they reduce competition and often create monopolies. To mitigate the negative effects of a monopoly, the merged hospitals typically agree to conditions imposed by state regulators.

Union Hospital leaders said it's time to move “beyond competition” for the sake of the region, which has struggled to keep jobs and raise life expectancy rates. Hospital spokesperson Neil Garrison said the merger would ultimately improve care, increase access, and cut costs. Leaders of Regional Hospital, which is owned by for-profit chain HCA Healthcare, did not respond to questions about the proposal.

One unusual implication arises, though: If the merger is approved, the surrounding county would lose tax revenue from one of its larger businesses. Union Hospital, which as a nonprofit is exempt from paying taxes, would be acquiring tax-paying Terre Haute Regional, which paid roughly $508,000 in county taxes for 2023, said Vigo County Auditor Jim Bramble. That's the equivalent of the starting salaries of about nine sheriff's deputies, per the county's $83 million 2024 budget.

Garrison said the hospital system is aware of the tax implications for the county and is “exploring opportunities” to address it.

Meanwhile, Roland Kohr, formerly a pathologist at Regional and a county coroner, frets about erasing competition that forced the hospitals to add services or match the other. “The push to introduce new technologies, to recruit more physicians, that may not happen,” he said.

The FTC has urged states to avoid COPAs, pointing to research that found they “have resulted in significant price increases and contributed to declines in quality of care.” The fallout of similar mergers has triggered federal sanctions in North Carolina and pushback from locals and legislators in Tennessee.

“A merged hospital system that faces little remaining competition after the merger usually has little incentive to follow through with its promises because patients have no other choice,” wrote Chris Garmon, a University of Missouri-Kansas City economist who has studied COPA mergers, in a warning to Indiana health officials about the proposed merger.

Indiana already has among the highest hospital prices in the country, according to a study by the Rand Corp. research organization. The Indiana Legislature spent the past year trying to rein in prices. Gloria Sachdev, CEO of Indianapolis-based Employers' Forum of Indiana, which pushed for those pricing limits on behalf of frustrated business leaders, is worried a Union-Regional merger would undo those gains and raise prices further.

Indiana's COPA restricts how much the hospital could increase charges, Garrison said.

Elsewhere, the largest COPA-created hospital system in the country, Ballad Health, has reported that the time patients spend in its ERs in Virginia and Tennessee before being hospitalized has more than tripled, reaching nearly 11 hours, in the six years since that monopoly of 20 hospitals formed. Still, Tennessee has awarded Ballad top marks even when certain quality metrics, including its ER speed, fall below established benchmarks.

Ballad Health spokesperson Molly Luton said the system's performance has improved since those statistics were gathered.

Last fall, some Tennesseans unsuccessfully urged a county board to call on the state to better regulate the hospital system. This spring, state lawmakers refused to hear testimony from residents who drove five hours to Nashville to testify for a bill that sought to limit future COPA mergers in the state — which ultimately didn't make it to a full vote.

Problems have also occurred when a COPA — and its oversight — are removed, leaving the merged hospital system as an “unregulated monopoly.” After North Carolina repealed its COPA in 2015, a subsidiary of HCA Healthcare bought Mission Health, a COPA-created monopoly in Asheville, for $1.5 billion in 2019. The monopoly in Asheville remained but none of the COPA's conditions applied to the new owner.

Last year, government inspectors found “deficiencies” at Mission Health that contributed to four patient deaths and posed an “immediate jeopardy” to patients' health and safety, according to the 384-page federal inspection report. North Carolina Attorney General Joshua Stein sued HCA's subsidiary last year, alleging the ER was “significantly degraded,” and that the company failed to maintain certain critical services, including oncology care, a violation of a purchase agreement Stein's office negotiated with it because the company acquired a nonprofit.

HCA said it promptly addressed the issues and denied Stein's allegations in its legal response to the ongoing lawsuit, arguing it has expanded services since its purchase. HCA also argued that the agreement is silent about maintaining the quality of care.

Back in Indiana, Union Hospital laid the groundwork for its merger more than three years ago when its leaders provided the language for COPA legislation to then-state Sen. Jon Ford, a Republican in Terre Haute, believing he would be “the best champion for this proposal,” according to legislative testimony from Taylor Hollenbeck, an RJL Solutions consultant on the merger. Ford, listed on the legislature's site as the bill's co-author, did not respond to requests for comment.

Union CEO Steve Holman testified in the bill's hearings that the county's public health rankings — with an average life expectancy ranking 68th out of 92 counties in the state — should be a “call to action” to do something “big and bold.”

Terre Haute Mayor Brandon Sakbun agrees the merger could help what he called the county's “abysmal” public health statistics. Last year, he was elected the city's youngest mayor at age 27 on a promise to “turn Terre Haute around.” The region's workforce has steadily declined and local leaders have pinned their hopes on a new casino and a manufacturer of battery parts for electric vehicles to reverse this trend.

Sakbun's father is an OB-GYN at Union, but the mayor said that doesn't color his opinion and that he supports the hospital merger despite the loss of the tax base. He believes it will help recruit medical and other professionals to an area that has struggled to attract top talent.

“Do I believe that this is the one that bucks the research?” Sakbun said. “I truthfully do.”

KFF Health News correspondent Brett Kelman contributed to this article.

——————————
By: Samantha Liss
Title: Indiana Weighs Hospital Monopoly as Officials Elsewhere Scrutinize Similar Deals
Sourced From: kffhealthnews.org/news/article/indiana-copa-hospital-monopoly-scrutiny/
Published Date: Fri, 14 Jun 2024 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/california-lawmakers-preserve-aid-to-older-disabled-immigrants/