North Carolina Health News
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Need a Ramp in NC? Here are Some Resources to Check Out


Since publishing a story on a ramp-building program in 2012, North Carolina Health News has received multiple inquiries about how to get a ramp built. So, we talked to several physical therapists for ideas and resources.

Getting a ramp built cheaply, or for free:

Inquire with your local Boy Scout Troop. There’s almost always an Eagle Scout looking for a project.

Baptist Men’s Association – located in most counties. Statewide information number: (800) 395-5102 ext. 5599

Local high schools – kids need service projects, they also need projects for shop classes. Call your local principal.

Your church.

If you can afford to build or buy your own ramp:

The materials can be costly: For every 1 inch of rise, you need a foot of run. That means, for one 6-inch step, you need 6 feet of ramp. So, space can be an issue.

Ramp leading to the first of a flight of steps.

Creating a ramp that’s the correct height and at the correct angle can be more complicated than you think! Photo credit: Richard Elzey, Flickr Creative Commons

If you’re a renter you may have to pay full cost of construction and installation AND pay the cost of removing it when you leave.

Who’ll build it for you?

Go to Lowe’s or Home Depot and ask around in the wood section. All the local construction guys hang out there and the people who work there may just know someone.

Am-ramp is a company you can rent or purchase a ramp from, but according to the physical therapists we spoke to, they can be pricey.

Craigslist – some people have used ramps and no longer need them.

Local “durable medical equipment” companies. Put those words into Google with your town’s name, they may have a 6’-10’ pre-fabricated ramps for sale.

People With Obamacare Plans Filled More Prescriptions, But Had Lower Costs


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By Shefali Luthra

Kaiser Health News

The 2010 health law was meant to expand insurance coverage so that Americans could get medical care they would otherwise go without — and not spend a fortune doing so. Though it’s still early, new evidence suggests this scenario is playing out.

Research published online by Health Affairs last week examines what happened when people got insurance through the law — either with a private plan purchased via the online marketplaces or through Medicaid, the state-federal program for low-income people. The study specifically focuses on how many medical prescriptions they filled.

hand with pills

People who got insurance through the health law were significantly more likely to get prescription medications than they were before. Photo credit Okko Pyykkö, flickr creative commons

The researchers analyzed data from more than 6.7 million people who filled prescriptions in January 2012 and followed their patterns of medication use and out-of-pocket spending through December 2014. One third of those people had no health insurance before the Obamacare coverage took effect in January 2014. It tracked how people’s insurance status changed, compared how many prescriptions they filled after the switch and tracked how consumers’ out-of-pocket costs were affected.

The takeaway: People who got insurance through the health law were significantly more likely to get prescription medications than they were before. And when they did, they typically ended up spending less of their own money for those drugs.

“People who gain coverage filled more prescriptions and spent a lot less out of pocket. It speaks to the potential health benefits from gaining coverage,” said Andrew Mulcahy, the study’s lead author and a health policy researcher at the RAND Corp., a non-profit think tank based in California. “It speaks to the barriers to getting care when you don’t have insurance.”

That said, those gains aren’t uniform: Lower-income people were far more likely to benefit. Specifically, people who went from being uninsured to enrolling in Medicaid filled 13.3 more prescriptions on average. They also spent 58 percent less out of pocket for those drugs. Those who got private insurance, by comparison, filled four more prescriptions on average and spent 29 percent less out of pocket.

The idea, Mulcahy said, is that those who now qualify for Medicaid are more likely to go without health care if money is an obstacle. They are also more likely to have health conditions that require prescription drugs.

“Paying cash for your prescriptions is a barrier to your care. It’s more of a barrier for people who are low-income,” he said.

The findings help illuminate the law’s effectiveness, especially in terms of improving access to medication, said Jonathan Kolstad, an assistant professor of economic analysis and policy at the University of California, Berkeley. But it’s important to note that it only looks at a select group: people who were willing and able to buy at least some drugs before 2014, even if they had no insurance and had to pay the full costs themselves. That suggests they might need the drugs more, or be more motivated to manage their health — a quality that possibly guides their ability to select an appropriate health plan and then use it.

“If you have people who have such a strong demand for health care service … that’s a group we’re intrinsically interested in from a policy perspective,” said Kolstad, who wasn’t involved with the Health Affairs study but has researched how people navigate and use health insurance. “It’s not representative. But it’s a piece in the broader puzzle.”

There’s also the question of what prescriptions are necessary — whether, for instance, people are getting vital care they previously couldn’t afford, or if they are now buying drugs they don’t need because they don’t see the costs.

That remains open, Mulcahy said. But there are clues. Here, for instance, the researchers looked at people with chronic illnesses: diabetes, breast cancer, depression, asthma and high cholesterol. Those people saw a similar proportional increase in prescriptions filled and probably do need the medication.

“If you have diabetes or one of these other conditions, there’s a pretty compelling argument that you should be on some kind of treatment,” he said.

And, importantly, the growth in prescriptions can be used as a proxy to answer other questions, Mulcahy said, such as if people who get health insurance then use it to get medical care. After all, filling a prescription means the patient also visited at least one doctor. From that vantage, he said, the results are promising.

“These people are more than getting coverage,” he said. “They’re using coverage to get care.”

But getting care isn’t the same as getting healthier. Though the researchers found people were more likely to get drugs, Kolstad noted, the research doesn’t have enough evidence in it to figure out long term outcomes.  For instance, are these newly insured people being compliant with their medications? And are the drugs helping them manage their conditions and improve their wellbeing? Or are they having unintended side effects that could later be damaging?

And there’s the sampling issue, which the authors note as a limitation on their study. Because the people surveyed here were already getting prescriptions — even when it posed a greater financial hardship — they could have, for instance, been more likely to seek out a doctor than the average consumer.

Previous research, for instance, has suggested getting insurance means people are more likely to see a doctor. But there’s no proof they’ll do other things that might matter, such as eating healthier, exercising or quitting smoking. Other experts have suggested more time is necessary to understand how expanding health care coverage could actually improve health and lead to system-wide cost savings.

As more data becomes available, researchers can tackle those questions, Mulcahy said. But the findings underscore a meaningful growth.

“If the goal of the coverage expansion was to reduce the financial burden of being insured, this is direct evidence of that happening. If the goal was to improve health, we’re one step short of that,” he said. “But the signs align. We have some direct evidence it’s offering financial benefits. And there are signs it’s helping on the health side.”

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Wilkes Regional Medical Center to Affiliate with Wake Forest Baptist


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By Thomas Goldsmith

Wake Forest Baptist Health is taking on a 30-year lease of Wilkes Regional Medical Center in North Wilkesboro, following negotiations among county commissioners, the town, the hospital operating corporation and the Winston-Salem based hospital system.

The parties signed a non-binding letter of intent toward a long-term lease of Wilkes Regional Medical Center during an August town board meeting.

The 130-bed Wilkes Regional Medical Center was founded in 1952.

The 130-bed Wilkes Regional Medical Center was founded in 1952. Photo credit: Wikimedia Creative Commons

The process is expected to last several months, but under the proposed lease, Wake Forest Baptist would invest $238 million to support the hospital, town and patients during the first lease term.

“We announced our intentions to move forward with Wake Forest Baptist back in April,” Debbie Ferguson, a North Wilkesboro town commissioner, said in statement. “The time spent during these more than three months on reaching this agreement reassures us we have the best partner to navigate Wilkes Regional Medical Center through the growing health care needs of the North Wilkesboro community.”

The projected deal continues a trend in which smaller, community-based hospitals in North Carolina affiliate with larger hospital systems as insurance against health care and compensation trends which can be perilous for independent hospitals in largely rural areas.

The agreement stipulates that Wake Forest Baptist will move Wilkes Regional Medical Center and Wilkes Physician Network, an affiliate, onto its electronic medical record system as soon as possible.

“The transition period we are entering is a key step in the evolution of our partnership with Wake Forest Baptist,” said Eric Cramer, board chairman of the operating corporation of Wilkes Regional Medical Center.

The transition should not disrupt the operations of the hospital, physicians network or the care or safety of patients, principals said. Carolinas HealthCare System, which has managed the hospital since 2007, will continue to support the hospital’s operation during the transition, said Cramer, describing Carolinas HealthCare System as “a great partner.”

The letter outlines several months of due diligence and information technology changeover, with Wake Forest Baptist supplying advanced IT tools.

“We see a great opportunity to grow clinical programs and continue effective recruitment and engagement of physicians that will ensure excellent care for Wilkes County citizens and benefit the Wilkes region,” Wake Forest Baptist CEO John D. McConnell said.

Wake Forest Baptist expects the deal to close on July 1, 2017.

In a May 2015 public notice, the North Wilkesboro Board of Commissioners sent out a request for proposals from companies interested in leasing the hospital. Parties notified included Carolinas HealthCare System, Duke LifePoint, Mission Health, Novant Health, RegionalCare Hospital Partners and Wake Forest.

The current management company, Carolinas HealthCare, did not submit a proposal.

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

Coal Ash & Water: Timeline of a Controversy


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By Catherine Clabby & Rose Hoban

++ February 2014: Storm water pipe breaks under a 27-acre coal ash pond, spilling 38,000 tons of coal ash into the Dan River and sending a plume downstream in the direction of municipal water intake.

The pipe that spilled coal ash into the Dan River, Feb. 2014. Photo courtesy Catawba Riverkeeper

The pipe that spilled coal ash into the Dan River. Photo courtesy Catawba Riverkeeper

++ August 2014: North Carolina General Assembly passes Coal Ash Management Act (CAMA). It requires Duke Energy to shut down coal ash waste dumps on 14 properties and a survey of drinking wells near the waste.

++ February 2015: Department of Health and Human Services attorney Chris Hoke briefs division of public health officials on CAMA’s requirements for assessing risk from potential coal ash contaminants in well water.  Since no state or federal standards exist for unsafe levels of hexavalent chromium, they develop new ones, based on latest research. (Source: Rudo deposition, page 75)

++ As directed by CAMA, state health and environmental officials use state groundwater regulations to assess health risk levels in well water near coal ash plants. That involves a formula establishing the level above which hexavalent chromium poses a one-in-a-million risk of causing cancer. (Source: Davies deposition, page 82).

++ Two DEQ toxicologists calculate the level, which is .07 parts per billion. DHHS toxicologists, including Ken Rudo, review and agree with level. (Source: Megan Davies resignation letter.)

Excerpt from Megan Davies' resignation letter where she outlines the procedures followed to determine minimum levels of chromium 6 and vanadium in drinking water wells neighboring Duke Energy coal ash dumps.

Excerpt from Megan Davies’ resignation letter where she outlines the procedures followed to determine minimum levels of chromium 6 and vanadium in drinking water wells neighboring Duke Energy coal ash dumps.

++ Mina Shehee, an environmental program manager at DHHS, has the Agency for Toxic Substances and Disease Registry at the Centers for Disease Control and Prevention confirm that North Carolina level uses the correct “cancer slope” calculation. (Source: page 53, Shehee deposition)

++ DHHS leaders, including then-DHHS Secretary Aldona Wos, review and approve the approach used to set levels for hexavalent chromium. (Source: Davies resignation letter.) North Carolina joins California in having the lowest health levels for metal in the country.

Tom Reeder candid headshot

DEQ Undersecretary Tom Reeder. Photo credit: Coastal Review Online

++ March 2015: DEQ Assistant Secretary Tom Reeder wants DHHS to add language in do-not-drink advisory letters for owners of wells near coal ash waste with levels of hexavalent chromium above the new screening level. Language stresses that the contamination don’t exceed federal standards for public drinking water supplies. (Source: Rudo deposition, page 37)

++ March 2015: Rudo summoned to the governor’s mansion for a meeting with press secretary Josh Ellis to discuss the wording of the letters sent originally to warn well owners of contaminants. He says McCrory called Ellis during the meeting. (Source: Rudo deposition, page 42)

++ March 2015: Rudo refuses to have his name included on state health risk evaluation letters due to the added language, which does not note that, currently, no federal standards exist for hexavalent chromium in public drinking water. (Source: Rudo deposition, page 3)

After the Senate Health Care Committee meeting Tuesday, State Health Director Randall Williams makes a point to lobbyist John Del Giorno, who represents the pharmaceutical industry.

State Health Director Randall Williams after a meeting at the North Carolina General Assembly. Photo credit: Rose Hoban

++ July 2015: Randall Williams takes over as state health director; state epidemiologist Megan Davies briefs him on process used to reach new health screening level for hexavalent chromium. (Source: Davies resignation letter)

++ Williams meets with staff members of Senate Pro Tem and Assembly Speaker who tell him letters advising people not to drink well water have alarmed people in ways disproportionate to the risks. (Source: Williams deposition, page 24)

++ January 2016: Williams grows concerned that people who live far from coal ash are needlessly worrying that levels of hexavalent chromium and a second metal, vanadium, in public drinking water supplies pose dangers. He alerts staff that the do-not-drink recommendations are disproportionate and unwarranted. (Source: Williams deposition, page 68)

++ March 2016: Letter signed by Reeder and Williams sent to well owners who were previously advised not to drink water due to elevated levels of hexavalent chromium or vanadium. The new letter says: “We updated our recommendation after extensive study of how other cities, states and the federal government manage the elements … we have now concluded that water out of your well is as safe as the majority of public water systems in the country.”

++ April 2016: Reeder speaks at public appearance at UNC Institute for the Environment saying letters rescinding do-not-drink advisories came after DHHS decided to revise its health risk evaluations and make them consistent with federal rules.

Well owner Deborah Graham holds up a photograph of the coal ash pit that’s several hundred yards from her home in Salisbury while at a press conference at the General Assembly in Raleigh. Photo credit: Rose Hoban

Well owner Deborah Graham holds up a photograph of the coal ash pit that’s several hundred yards from her home in Salisbury while at a May press conference at the General Assembly in Raleigh. Photo credit: Rose Hoban

++ May 2016: In her sworn deposition, Davies reveals discord among health officials saying that she opposed the letter rescinding the do-not-drink advisories because the language saying well water with elevated hexavalent chromium or vanadium compared to cities did not match data she saw from Raleigh and Charlotte. (Source: Davies deposition, page 58)

++ August 1, 2016: Rudo’s deposition released, the news that Gov. McCrory participated by phone in meeting discussing language in the letters causes a stir.

++ August 2, 2016: In a hastily called, late-evening press conference McCrory Chief of Staff Thomas Stith accuses Rudo of perjury, insisting the governor did not participate in the meeting. Rudo stands by his statement.

++ August 9, 2016: Reeder and Williams issue a letter to media outlets criticizing Rudo for “questionable and inconsistent scientific conclusions.”

++ August 10, 2016: Megan Davies resigns “Upon reading the open editorial yesterday evening, I can only conclude that the Department’s leadership is fully aware that this document misinforms the public. I cannot work for a Department and Administration that deliberately misleads the public.”

Excerpt from Davies' resignation letter.

Excerpt from Davies’ resignation letter.

Resignation Fuels Suspicion

At protests in Raleigh on Thursday, critics of the state’s response to possible coal ash risks to well water praised Megan Davies and Ken Rudo, while calling for Williams’ and Reeder’s resignations. Photo credit: Catherine Clabby

Few Young Doctors Are Training To Care For U.S. Elderly


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By Kara Lofton

West Virginia Public Broadcasting

At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg.

“He’s sure got a lot to do,” she said, “and does it so well.”

According to the Kaiser Family Foundation, North Carolina spent close to $1.2 billion on nursing homes for elderly Medicaid recipients in 2013.

According to the Kaiser Family Foundation, North Carolina spent close to $1.2 billion on nursing homes for elderly Medicaid recipients in 2013. Image courtesy Derrick Tyson, flickr creative commons

West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.

“With the growing elderly population across America and West Virginia, obviously we need healthcare providers,” Goldberg said.

That includes geriatricians — physicians who specialize in the treatment of adults age 65 and older — as well as nurses, physical therapists and psychologists who know how to care for this population.

“The current workforce is inadequately trained and inadequately prepared to deal with what’s been called the silver tsunami — a tidal wave of elderly people — increasing in the population in West Virginia, across America and across the world really,” Goldberg said.

The deficit of properly trained physicians is expected to get worse. By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older.

Goldberg also teaches at the Charleston division of West Virginia University and runs one of the state’s four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.

Last year, 11 out of North Carolina’s potential 16 geriatrician residency positions were filled.For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.

“This is not just our local program, or in West Virginia,” said Goldberg. “This is a national problem.”

The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled. With that kind of competition, Goldberg laments, why would a resident apply to a West Virginia School, when they could get into a program like Yale or Harvard?

Adding to the problem, the average medical student graduates with $183,000 in debt, and every year of added education pushes that debt higher.

Dr. Shirley Neitch, head of the geriatrics department at Marshall University Medical School in Huntington, W.Va., says students express interest in geriatrics almost every year. But, “they fear their debt,” she said, “and they think that they need to get into something without the fellowship year where they can start getting paid for their work.”

This trend troubles many people, including Todd Plumley, whose mother, Gladys, has dementia and lives in West Virginia.

“It’s kind of scary that [older patients] don’t have the care that they really need to help them through these times, and help them prolong their life and give them a better life,” Plumley said.

There are no geriatricians in the family’s hometown of Hamlin, so Plumley drives his mother almost 45 minutes to another town, Huntington, to see one. He says seeing this specialist has helped stabilize his mother’s symptoms.

“Right now, if we didn’t have the knowledge and resource,” he said, “I believe my mother would have progressed a lot further along, quicker.”

Plumley is in his 50s. He worries that if he needs the care of a geriatrician as he gets older, driving even 45 minutes may not be an option.

Dispatch From the International AIDS Conference: Social Media, Isolation and Risky Behavior


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Lee Storrow, the head of the NC AIDS Action Network, is in Durban, South Africa for the 2016 International Conference on AIDS to present his own research. This week, NC Health News will be featuring some stories from Lee about the conference and where North Carolina fits into the global fight against HIV/AIDS.

By Lee Storrow

The poster presentation section at the International Conference on AIDS is overwhelming. The five sections line the perimeter of the second floor of the convention center, a space twice the size of Raleigh’s Halifax Mall. Hundreds of posters are on display each day.

You can read the details of the results on LaGrand’s abstract here.On Tuesday, I spoke with Dr. Sara LeGrand, Assistant Research Professor of Global Health at the Duke Global Health Institute. She was presenting her research on whether the use of social networking (Facebook, Instagram) and dating/hook-up sites (Grindr, Jack’d) in young black men who have sex with men (MSM) in North Carolina could predict whether these men felt socially isolated.

Apps such as Grindr and Instagram are here to stay. The question is how HIV prevention advocates can get their messages out to users.

Apps such as Grindr and Jack’d are here to stay. The question is how HIV prevention advocates can get their messages out to users. Image courtesy: Grindr

The study reveals that young black MSM are, indeed, using social networking accounts and using those accounts may reduce these men’s feelings of social isolation.

Across the survey of N.C. teens, participants reported an average of 7.35 hours of Internet use per day and the average number of social networking platforms – such as Facebook or Grindr –  that participants used was 3.62. The study found that the more social network sites used translated into decreased feelings of social isolation, as well as increased searching for sex partners online.

“I think the results of this study are especially important for young people in rural areas of North Carolina who often face greater stigma around their sexuality,” said Dr. LeGrand.

Dr. Mehri McKellar and Dr. Jessica Seidelman present their research on the willingness of primary care providers to prescribe PrEP at the International Conference on AIDS in Durban, South Africa.

Dozens of North Carolina researchers are at the 2016 International AIDS Conference in South Africa this week. Here, Drs. Mehri McKellar and Jessica Seidelman from Duke University present their research on the willingness of primary care providers to prescribe PrEP at the International Conference on AIDS in Durban, South Africa. Photo credit: Lee Storrow

There’s been a lot of chatter about the rise of dating and hook-up apps and their potentially negative role in changing the nature of gay sex. At the same time, gay men in rural parts of North Carolina have limited support systems and often live in homophobic environments. If Grindr can provide even a limited outlet to remind a closeted gay man that he is not alone, it might be beneficial.

Dating and hook-up apps aren’t going away any time soon. HIV prevention advocates need to think about how to harness those apps to disseminate positive prevention messages and build support systems for those most at risk.

A Traumatic Brain Injury Survivor’s Trail of Ups and Downs


Many sudden trips to emergency departments, long stays in myriad hospitals, and countless interactions with health-care and government professionals have marked the past four and a half years for the Irby family of Burlington.

Their goal was continuing rehabilitative treatment for son Zack, 27, who emerged from a January 2013 car wreck with traumatic brain injury. Parents Jeannie and Rick Irby have met with a mixture of helpful professionalism, red tape and seemingly contradictory regulations with all the stamina they can muster.

Zack retains the ability to talk and joke, follows pro and college sports and enjoys ‘90s pop music like “MMMBop” by Hanson.

Zack Irby, 27, was an active, busy young man before he had a horrific wreck in January 2013.

Zack Irby, 27, was an active, busy young man before he had a horrific wreck on I-85 in January 2013. Photo credit: Thomas Goldsmith

He’s a paraplegic who uses a wheelchair to get around but needs help with bathing, grooming, meds and eating.

But Mom Jeannie Irby said she knows, “Zack would be working on a walker, if he had just been rehabbed without letting his regressions happen.”

Click here for a detailed account of the Irbys’ journeyAn outline of Zack’s treatment history makes plain the ordeal a family can face in the wake of a severe brain injury.

Jan. 28, 2013: After Zack’s accident, he is taken by helicopter, in a coma, to Wake Forest Baptist Hospital, where he stays for 11 or 12 weeks, receiving treatment for injuries to his brain, a fractured left pelvis and other results of the accident.

While there, Zack develops pneumonia, then Clostridium difficile, a bug that causes diarrhea and more serious intestinal problems. He maintains a fever of 104.5 for two days before doctors treat the infection by flushing his colon every two hours with zygomycin, an antibiotic.

Late May-early June 2013: Zack is discharged to Carolinas Medical Center in Charlotte, where he receives intensive rehabilitation for 59 days, the amount covered by insurance. “He was making phenomenal progress,” Jeannie said. “By the time he left, he was sitting up straight, he was able to eat and drink thin liquids. He was standing in a standing frame for more than an hour. Then they sent him home with in-home therapy.”

Snapshot of Zack Irby as a boy with basketball superstar Michael Jordan.

Snapshot of Zack Irby as a boy with basketball superstar Michael Jordan. Photo courtesy Irby family.

June-July 2013: After going through evaluations, Zack starts treatment at Alamance Regional Hospital, where the family is told that he will only receive therapy in his wheelchair, a condition they turn down. During a rare family trip, to Myrtle Beach, Zach has to be admitted to an ICU at Grand Strand Medical Center. “He had a very severe respiratory pneumonia and shower of pulmonary embolisms due to being so sedentary and not receiving therapy,” Jeannie said. Readmitted to Wake Forest Baptist, Zack is in worse shape than he was immediately after his accident, doctors tell them.

August 2013: The family is elated when representatives of the Shepherd Center in Atlanta say Zack will be admitted to the private, not-for-profit hospital, which specializes in treatment, research and rehabilitation for people with brain and spinal cord injuries. Their hopes are soon crushed when the decision is reversed because Zack’s injury is not a new one.

September 2013: Zack is admitted to WakeMed in Raleigh, where, after an initial attempt to send him home, Blue Cross and Blue Shield of North Carolina agrees to pay for the hospital to treat both his medical problems and to provide rehab. Jeannie stays with a high school friend in Raleigh so she can be at her son’s side.

“They fought for him week after week. They had Zack up initiating walking. He was able to vocalize. His swallow was getting stronger,” Jeannie said. “Not only was the team at WakeMed motivated, but Zack was motivated.”

Dec. 2, 2013: After allowing three extra weeks of rehab, the insurance company declines to pay for more therapy and WakeMed discharges Zack, sending him home, 10 months after his initial injury.

Before his wreck, Zack Irby studied this Bible, held here by his mother. Zack underlined and starred crucial passages.

Before his wreck, Zack Irby studied this Bible, held here by his mother. Zack underlined and starred crucial passages. Photo credit: Thomas Goldsmith

“The first year ended up costing Blue Cross Blue Shield $4 million,” Rick Irby said. “If they had just rehabbed him, it probably would have cost less than a million.”

Zack is again accepted at the Shepherd Center, but in an outpatient treatment program. Jeannie and later Rick move to Atlanta and live in an apartment provided by the center. “We started doing outpatient therapy at the Shepherd Center, but they were not prepared, nor were they equipped, for someone at his level of care,” Jeannie said.

January 2014: The Irbys bring Zack home. They are out of money and ideas.

Zack continues to have medical problems and is admitted at Memorial Hospital at UNC-Chapel Hill, but does not receive rehab. He spends two weeks back at Wake Forest, but is sent home, to go through months of periodic hospitalizations for medical problems.

September 2014: After Zack has another stint at Alamance Regional Hospital, an exhausted Jeannie refuses to take him back home: “He stayed at Alamance Regional for probably about a month. They couldn’t find a nursing home, they couldn’t find any place to take him. He was having outbursts; he was also getting very frustrated.”

It’s around this time that Jeannie learns about Money Follows the Person, a federal program that allows patients to return home and receive services through a Medicaid waiver.

October 2014: Zack enters an Alamance County nursing home, but receives poor treatment, including being left in his own feces and urine. Meanwhile, the family remodels a former garage to suit Zack’s needs. A $13,000 ceiling lift-system to transport Zack to his bathroom with roll-in shower gets funded through state traumatic brain injury funds, but the family bears the rest of the $100,000 cost themselves.

April 2015: With the house revamped, Zack comes home. He is able to receive 50 hours a week of assistance from an in-home aide through a North Carolina Medicaid waiver program called Community Alternatives Program for Disabled Adults. Under the program, he receives 30 visits a year for rehab, or fewer than one per week.

Jeannie, Rick and daughter Meghan spend a lot of time with Zack. Older daughter Julie Anne spent many hours helping care for Zack, but she’s moved out.

Zack is present in conversations, though sometimes blurting out inappropriate language. The stint in a nursing home brought about more regression, Jeannie said.

“He was absolutely crazy by the time he came home, he was absolutely insane,” she said, while maintaining that Zack’s intellect and real self live on inside him.

“He’s locked in a body,” she said.

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

North Carolinians React to Supreme Court Abortion Ruling


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By Rose Hoban

By a 5-3 margin, justices on the U.S. Supreme Court overruled a Texas law restricting the size and configuration of abortion clinics. The bill, known as HB2, has resulted in the closure of about half of Texas abortion clinics since it was passed and enacted in 2013, mandated that abortion providers have admitting privileges at nearby hospitals and that facilities providing the procedure come up to standards of ambulatory surgical centers.

NARAL/Pro-Choice North Carolina head Tara Romano spoke at a rally in front of Gov. Pat McCrory's mansion Monday afternoon. Photo credit: Rose Hoban

NARAL/Pro-Choice North Carolina head Tara Romano spoke at a rally in front of Gov. Pat McCrory’s mansion Monday afternoon. Photo credit: Rose Hoban

North Carolina lawmakers have not passed similar legislation, known as TRAP (for Targeted Regulation of Abortion Provider) laws. In her concurring opinion, Justice Ruth Bader Ginsburg stated that such laws, “do little or nothing for health, but rather strew impediments to abortion.”

“The idea behind a TRAP law is that it’s something you wouldn’t do for another procedure,” said NARAL /Pro-Choice North Carolina head Tara Romano. “There’s no legislation that says this is what we’re going to need when someone gets a colonoscopy.”

Pro-choice advocates point out, however, that some North Carolina proposals have been similar to those adopted by Texas.

In 2004, North Carolina’s abortion rate was 16.0 per 1,000 women of child-bearing age. In 2013 (the most recent year of data), the rate was 10.1.“[In 2013], the Senate started with a bill that was not substantially different from what Texas enacted; the standards that just got struck down,” said ACLU policy director Sarah Preston, referring to a 2013 measure that would have required that clinics meet ambulatory surgical clinic standards.

That bill was substantially changed, eventually requiring the Department of Health and Human Services to review and rework many of its regulations concerning abortion clinics. It also restricts sex-selective abortions and forbids publicy funded health plans from covering the procedure.

Sarah Preston from the ACLU of North Carolina speaks at a rally in front of Gov. Pat McCrory's mansion to mark the Supreme Court decision. Photo credit: Rose Hoban

Sarah Preston from the ACLU of North Carolina speaks at a rally in front of Gov. Pat McCrory’s mansion to mark the Supreme Court decision. Photo credit: Rose Hoban

What remained after that review was an increased regimen of abortion-clinic inspections with state funding for more DHHS inspectors.

Last year, the legislature passed a bill requiring women to wait 72 hours before they can obtain an abortion. In addition, the Women and Children’s Protection Act requires physicians performing abortions after 16 weeks gestation to send their notes and copies of ultrasounds to the Department of Health and Human Services for review.

An earlier regulatory act, the 2011 “A Woman’s Right to Know” Act, requires the “voluntary and informed consent” of a woman before an abortion can be performed. Specific conditions must be met for consent to be considered “voluntary and informed” under state law. Providers are required to orally inform patients of nearly a dozen points of information in the 24 hours before the procedure.

All those restrictions remain standing in North Carolina, and no laws will be repealed as a result of Monday’s decision.

“It would stop us from doing that same regulation, but it we don’t have anything like that in our law today,” said Rep. Paul Stam (R-Apex), who has championed bills limiting abortions at the General Assembly.

Stam said he had not yet read the ruling, but was dismissive.

“For some reason, whenever abortion is the subject of a Supreme Court case, they just put their finger in the air and make a new law,” he said. “The women of Texas will not be as safe as they were yesterday.”

Pro-choice advocates celebrated at a rally in front of the residence of Gov. Pat McCrory.

“The Supreme Court decision will help will politicians think twice about putting these [kinds of laws] through,” Romano said. “The Supreme Court said, ‘We recognize that these are needless laws.’

“You have to do more than say that they’re for the health and safety of a woman, you have to prove it.”

Ending Solitary for Juveniles, Prison Commissioner Cites Use of Evidence-Based Alternatives


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By Rose Hoban

Juveniles under the age of 18 who are incarcerated in North Carolina prisons will no longer be subjected to solitary confinement starting this fall, prison commissioner David Guice announced last week.

In a statement accompanying a 16-page policy document, Guice wrote that “it is of paramount importance that, while these youth are in our care, their unique needs are accurately identified and addressed in the most effective way possible.”

Foothills Correctional Institution in Morganton from the air. Photo courtesy Irakli Rakeman, flickr creative commons

Foothills Correctional Institution in Morganton from the air. Photo courtesy Irakli Rakeman, flickr creative commons

The policy, which will be fully in place by Sept. 1, will apply to about 70 juvenile offenders currently housed at the Foothills Correctional Institution in Morganton. Those juveniles are the last 16- and 17-year-olds being held in “restrictive housing,” where inmates are confined to a cell for 22 or 23 hours a day.

According to the advocacy group Disability Rights NC, being segregated in solitary confinement can cause deterioration in mental health, producing paranoia, post-traumatic stress disorder, self-harm, and thoughts of suicide.

Guice said that a few more months are needed to get enough staff and get them trained for the new housing regimen that will address inmates with behavioral issues in a different way. And his department is working to create a similar facility in Pasquotank County that will open in the near future.

Positive reinforcement

“Although 16- and 17-year-olds are adjudicated as adults, they should not be treated the same as adults in the prison system,” Guice told NC Health News in an interview last week.

The new regimen at Foothills consists of creating smaller housing “pods” where inmates are given positive reinforcements to engage in good behavior. The policy document describes an evidence-based approach that emphasizes “rational thinking, appropriate communication and behaviors.”

Key to the approach are incentives ranging from receiving books, extra movies, popcorn or nachos, to participation in field days and access to music.

Inmates who do display behavior problems, instead of being confined in solitary, will be placed in “modified housing,” with more intense supervision and tiered losses of privileges.

There’s also the opportunity for inmates to learn trade skills and an increased emphasis on addressing the mental-health needs of teen inmates.

“We’ve actually set up programs where even those who have the worst behavioral issues in the system, we’re now placing those people in programs that we believe are going to be successful,” he said.

Prison commissioner David Guice told mental health advocates Photo credit: Rose Hoban

Prison commissioner David Guice. Photo credit: Rose Hoban

North Carolina is one of only two states in the country — the other is New York — that still charges 16- and 17-year-olds as adults, even when their crimes are for minor offenses such as littering.

For years, advocates have been pushing for legislation to “raise the age” of incarceration in the prison system. A bill passed the House in 2014, but the legislation has stalled in the Senate.

A cost-benefit analysis performed by the Vera Institute of Justice in 2009 found that raising the age of adult incarceration would cost $70.9 million but provide $123.1 million in benefits and savings per year.

Until the legislature acts, the new policies will make for more age-appropriate incarceration, Guice said.

Remissioning

Guice also said his department is in the process of “remissioning” all of the state’s correctional facilities, and an effort that includes getting adults out of solitary confinement as well.

“About six months ago we had about 5,500 inmates who fell into that category, and today we have less than 2,500,” he said.

For advocates, the changes can’t happen fast enough, especially because other young people in the correction system are still subject to solitary confinement.

“Today, for example, 20 percent of 18-year-olds in NC prisons are in segregation as well as hundreds of adults who have mental illness,” Vicki Smith, head of Disability Rights NC, said in a statement. The organization has long pushed for raising the age, and for ending solitary for all inmates.

“Commissioner Guice has identified solutions, but his progress will be stifled without adequate funding from the General Assembly,” she said.

Guice said he’s doing what he can with what he’s got. He has gotten some funding from the legislature over the past few years, a result of the Justice Reinvestment Act, which was signed in 2011.

He stressed the fact that more than 90 percent of people who end up in prison will eventually return to the community, and this is what’s driving his reform efforts.

“It is truly my goal to insure that the person who comes to us… that we provide them with a pathway that’s going to give them an opportunity to leave us better off than they came,” said Guice, who pointed out this means addressing mental-health needs and housing and work for newly released inmates.

“I know what we need to do and it’s creating a pathway to address those underlying issues,” he said. “I believe that the system fails if we release someone and we do not provide a pathway that that individual can be successful.”

Patient Advocates Push for Limits on Step-Therapy Prescription Practices


Patients, doctors and family members affected by the prescription practice called “step therapy” brought personal stories to the General Assembly Thursday in support of a bill that would prohibit it in some cases and limit it in others.

Pills

Photo credit: Rose Hoban

The bill, House Bill 1048, defines step therapy as an approach “under which patients are required to try one or more prescription drugs before coverage is provided for a drug selected by the patient’s health care provider.” The practice has been widely adopted by insurance companies, in part in response to demand for specific new drugs targeted to consumers by advertising.

Thursday’s event, put on by the National Patient Advocate Foundation, was part of an advocacy day designed to bring legislators’ attention to the bill, which is being called “Reduce Barriers to Improve NC Health and Safety.’ The bill has passed the House, but not the Senate.

Proponents of step therapy describe the practice as a necessary cost-saving measure. At an earlier legislative hearing this year, Tom Friedman, North Carolina State Health Plan policy liaison, said step therapy saves the plan for state employees about $10 million in its $700 million annual prescription-drug budget.

Panelists — including two physicians, a patient advocate who has rheumatoid arthritis and a state lobbyist for the American Cancer Society Cancer Action Network — resisted assertions that efforts to limit step-therapy represent a “mandate” that would harm providers.

“I suggest that they disregard the label of ‘mandate,’ when it is a word that is thrown around haphazardly when we are talking about lives at stake,” said rheumatologist Dr. Gwenesta Melton.

Protracted conflict with insurance companies and third-party vendors over step-therapy prescriptions has taken a toll on Melton’s practice, she said: “They are upset because they think that we are going to run amok and put all these people on these expensive drugs.”

Before some patients are approved for the most efficacious drug for their conditions, they can spend months or years taking the less expensive drugs that make up the first steps of the process, Melton said.

On the other hand, many patients may come into their doctors asking for a new, expensive, medication they saw in an advertisement, when an older, generic drug can suffice.

The legislation, sponsored by Rep. David Lewis (R-Dunn), would require insurers to allow exemptions from step therapy in cases where doctors find that the drug required by the insurer is not in the patient’s best interest.

A section of the bill specifically endorsed by Duke physician Dr. Steven Prakken prohibits step therapy when a doctor has prescribed abuse-deterrent opioids. These relatively new painkillers are designed to lose their potency if altered for potential abuse by crushing or cooking them.

“That’s a deterrent to abuse,” Prakken said. “Since they are more expensive, you can’t use them first” under step-therapy protocols, he said.

The federal Food and Drug Administration recently urged pharmaceutical companies to develop generic equivalents of abuse-deterrent drugs, while noting that some questions persist about how effectively the medications actually keep people from misusing them.

“Abuse-deterrent properties make certain types of abuse, such as crushing a tablet in order to snort the contents or dissolving a capsule in order to inject its contents, more difficult or less rewarding,” a March FDA statement said.

“It does not mean the product is impossible to abuse or that these properties necessarily prevent addiction, overdose or death – notably, the FDA has not approved an opioid product with properties that are expected to deter abuse if the product is swallowed whole.”

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