Category: medical

Thousands of veterans deluge VA with claims for toxic exposure benefits, health care

Posted on by NC Policy Watch

Governor Roy Cooper Comments on Judge Reinstating 20-Week Abortion Ban

Posted on by Press Release

Raleigh

Today, Governor Roy Cooper issued the following statement in response to a judge reinstating North Carolina’s 20-week abortion ban:

“Although I disagree with this ruling, the vast majority of patients will still be able to access reproductive health care in North Carolina, and I remain committed to protecting it.

“The significant problem with this ruling is that it will criminalize important health care that’s needed in certain extraordinary circumstances. Abortion past 20 weeks in pregnancy is exceptionally rare and happens because of a devastating health emergency or diagnosis. Denying women necessary medical care in extreme and threatening situations, even if rare, is fundamentally wrong, and we cannot let politicians mislead people about the real world implications of this harmful law.”

Fentanyl in NC: An epidemic within the opioid epidemic

Posted on by NC Policy Watch

By Joe Killian – 8/15/2022
NC Policy Watch

A year ago this month, Barb Walsh was enjoying a feeling of pride for which every parent longs.

Sophia, the second of her four daughters, had come through the COVID-19 pandemic, graduating from Appalachian State University’s business school in 2020 and getting a good job with Milwaukee Tool.

Barb Walsh lost her daughter Sophia (pictured) to fentanyl. (Courtesy photo)
Driven, competitive and self-sufficient, Sophia was never the sort of kid her mother had to worry about. While many in her generation struggled in their early 20s, Sophia had just been promoted, from working in a territory in Myrtle Beach to one in Charlotte. She had her own apartment there and was proud of having saved $20,000 toward a down-payment on her own home and $5,000 in a growing 401K.

“She was at the beginning,” Walsh said. “And she had a bright future.”

On the weekend of Aug, 14, Sophia was visiting someone in Banner Elk, just outside her college town of Boone. Exactly what happened there is still the subject of an open investigation. But early on the morning of Aug, 16, two police officers knocked on the door of the family home in Cary. Sophia was dead. A drug overdose.

“They had no details,” Walsh said. “There were no signs she had a drug habit, that she had been depressed, that her death was intentional. Nothing added up.”

It took nearly five months for the toxicology results to come back. When they did, Sophia’s cause of death was revealed. A word her mother couldn’t have spelled or properly pronounced before then. Fentanyl.

“You heard about the opioid epidemic,” Walsh said. “But what you heard about was pills or heroin. What was fentanyl?”

Though it killed more than 3,000 North Carolinians last year, fentanyl isn’t widely understood by the public. The drug’s unique characteristics and ubiquity in illicit drug manufacturing has led to overdose deaths in long-time, habitual drug users, as well as college students doing their first line of cocaine at a party. Many don’t even know they’re using it.

As communities across North Carolina decide how to spend $758 million from the historic national opioid settlement, much of the conversation has centered on prescription painkillers and heroin. But state medical experts, recovery advocates and those who have lost loved ones say fentanyl is a problem even more difficult to address.

Cheaper, stronger, deadlier

Fentanyl is a synthetic opioid created in the 1960s and widely used in anesthesia and to manage pain, especially after surgeries and cancer treatment. Its popularity among doctors came from its utility. It can be taken by mouth, via the skin or intravenously. Its potency was also attractive for medical pain management, roughly 100 times stronger than morphine, studies have shown.

In the ’90s and early 2000s an emphasis on patient satisfaction and pain management led doctors to overprescribe opioids in general, said Dr. Abhi Mehrotra, clinical professor at the UNC School of Medicine’s Department of Emergency Medicine.

Dr. Abhi Mehrotra
When that contributed to a nationwide epidemic of opioid addiction, the pendulum swung in the other direction, Mehrotra said. Doctors began to rethink how they helped patients manage pain. Policy changes and lawsuits curbed overprescription.

But opioid demand didn’t go away.

“That opened the door for the manufacturing of synthetic opioids on the illicit market,” Mehrotra said.

Fentanyl’s chemical structure makes it massively adaptable. Change a chemical group here, get a fentanyl analog that is three times less potent. Make a different change there, get one that is 100 times more potent.

The same factors that made the drug popular in medicine — ease of use, potency, adaptability — quickly made fentanyl and its analogs popular in the illicit drug trade. Cheaper and easier to produce than heroin — and up to 50 times more potent — fentanyl allows illicit drug manufacturers and traffickers to adulterate drugs like heroin, cocaine and methamphetamine, reaping greater profits from products that could be far less pure but dramatically more powerful. Pills sold as Molly (MDMA), or even Vicodin are increasingly found to be substantially or entirely fentanyl.

“It’s cheap and easy for them to manufacturer powdered and liquid fentanyl and add it to cocaine, heroin, anything to add potency and fill it up,” said Dr. Padma Gulur, anesthesiologist, pain medicine specialist with Duke Health. “You hear about it all the time, 35 people overdosing because they were doing what they thought was cocaine but it had been adulterated with fentanyl. They didn’t know any better until they stopped breathing.”

Illicit drugs have never come with reliable quality control or ingredient lists, Gulur said. But with fentanyl, people getting something for which they are unprepared can quickly become fatal.

Dr. Padma Gulur
“People who may just be at a party and think ‘What’s one time?’ or who may even take it unknowingly because someone dropped in their drink, those people end up dying because they don’t have the knowledge or awareness of what is in there,” Gulur said.

In the first decade of the new century, medical examiner’s offices in the nation’s largest cities began reporting fentanyl’s presence in an overwhelming number of overdose deaths. Even those who had successfully managed drug habits for years were overdosing from drugs they didn’t realize were now far more potent.

Before long, it was being seen nationwide.

U.S. opioid overdose deaths quadrupled from 8,050 in 1999 to 33,091 in 2015, according to statistics from the Centers for Disease Control and Prevention. They accounted for 63% of drug overdose deaths in the United States in 2015, driven by heroin and illicitly manufactured fentanyl.

From May 2020 to April 2021, that overdose death number topped 100,000 for the first time, with 64% of deaths involving synthetic opioids other than methadone — mainly fentanyl and its analogs, either as an adulterating agents in other drugs or on their own.

“We had no idea this was going on here in North Carolina,” Barb Walsh said. “It wasn’t something we heard about.”

In North Carolina, death certificates don’t have a specific code for fentanyl’s involvement in a drug overdose. There is a code – T40.4 — for “other synthetic narcotic overdose.” The Epidemiology, Surveillance and Informatics unit of the NC Division of Public Health’s Injury and Violence Prevention Branch notes that most of these cases are “due to illicitly manufactured fentanyl and fentanyl analogues,” but can also include prescription fentanyl and other, less potent synthetic narcotics like Tramadol.

An analysis of statistics from the NC Office of Chief Medical Examiner finds overdose deaths with that code went from 442 in 2016 (the first year for which the office had such statistics) to 3,163 last year — an increase of 616%.

As of May of this year, there have been 1,342 deaths bearing the code — on track to beat last year’s record number.

“This is becoming more and more common in North Carolina, these overdoses — in Wilmington, in Fayetteville, all over the state,” Gulur said. “And this isn’t going to be a bad time. This will kill you.”

The empathy gap

Stories like those of Barb Walsh’s daughter Sophia tend to catalyze the public and policy makers — a sudden, shocking death in the white middle-class in which there was no known history of drug use or addiction.

But doctors and recovery advocates say that’s indicative of an “empathy gap” by which the deaths of those who struggled for years with substance abuse are shrugged off as the inevitable result of moral weakness, a fate common to people who don’t want to get better.

Patricia Drewes bristles at that. Like Walsh, she lost a daughter — Heaven Leigh Nelson — at 24. But when her daughter died of a fentanyl overdose in 2019, it was after several tough years of battling addiction, including a stint in rehab in Kentucky.

Like Walsh, Drewes didn’t know what fentanyl was before it killed her daughter. Now, as co-founder of the group Forgotten Victims of Vance, Granville, Franklin and Warren Counties, NC, she is working to increase awareness around the dangers of fentanyl and to change the way people think about addiction and those who struggle with it.

Dr. Robyn Jordan
“Everybody just thinks, ‘Well, they were drug addicts,’” Drewes said. “That’s their stance. I don’t even say ‘addicts.’ This is substance use disorder. To me, addict is a nasty, ugly word.”

In Vance, a county of about 45,000 people, 38 people died of overdoses in the last two years. Of those, 28 — or about 78% — involved fentanyl.

That’s far too many lives to write off, Drewes said.

“There are the sudden, one-use overdoses,” said Dr. Robyn Jordan, an addiction medicine specialist and assistant professor at the UNC School of Medicine. “But fentanyl is also a huge problem for people who are in recovery and doctors trying to help them.”

That’s because drugs used in medical assisted treatment for addiction, like buprenorphine, the active ingredient in Suboxone, react very differently depending on what analog of fentanyl someone may have taken.

“What people are using is so unpredictable,” Jordan said. “We don’t know who is using prescribed fentanyl vs. the fentanyl analogs vs. the fentanyl in heroin. Some people might not have any trouble getting onto buprenorphine while other people might have a huge amount of trouble.”

Raising awareness, finding solutions

One thing doctors do know is that Naloxone, a drug used to treat overdoses in an emergency, is a vital tool in saving lives in the ongoing opioid epidemic. That holds true for fentanyl overdoses. Unfortunately, they say, it is not available widely enough among law enforcement and the public.

“I have three other daughters,” Walsh said. “I want them to have it with them all the time. Not just for them, but in case they’re somewhere at a party or anywhere and someone overdoses. It could save a life. But between the price and just getting your hands on it, it’s hard for people to do that.”

Making it easier to get and to use is an essential step in curbing overdose deaths, said Dr. Mehrotra.

“Price, price gouging, availability, prescription access, learning how to use it, what situation to use it in, those are all barriers,” Mehrotra said. “We need to make it easier.”

Parents and loved ones of those who have overdosed will advocate for these issues on Sunday, Aug. 21, from 2 to 4 p.m. at a rally at the State Capitol Building. Walsh and Drewes are among the mothers helping to organize the event, which they hope will bring awareness to the public and pressure on lawmakers and law enforcement to address a danger they didn’t see until it was too late.

“There are things we can be doing that we’re not, from the sheriff’s offices and the DAs to the lawmakers and the hospitals and pharmacies,” Drewes said. “This shouldn’t be costing any more of our children their lives.”

—

In the next few weeks, Policy Watch will talk with lawmakers, law enforcement officials, medical professionals and others on the front lines of addiction and recovery in a series of stories examining ways to address the large and growing number of opioid deaths in North Carolina.

We’ll look at the potential benefits and pitfalls of various approaches to dealing with the problem, including how North Carolina communities plan to spend hundreds of millions in opioid settlement dollars over the next 18 years.

Winterville woman charged with seven counts of Insurance Fraud

Posted on by Press Release

RALEIGH

Jul 29, 2022

North Carolina Insurance Commissioner Mike Causey today announced the arrest of Shaquon Lashawn Burrus, 30, of 2375 Vineyard Drive, Winterville. Burrus was charged with seven counts of insurance fraud and seven counts of obtaining property by false pretense, all felonies.

Special agents with the Department of Insurance’s Criminal Investigations Division accuse Burrus of obtaining $10,107.50 by filing false medical records to support accidental insurance claims with Aflac.

The offenses occurred between Aug. 10, 2019, and Aug. 1, 2020.

Burris was arrested on July 18. She was given a $25,000 secured bond. She is due in Pitt County District Court on Aug. 16.

Commissioner Causey encourages North Carolinians to help keep insurance premiums low by reporting suspicious fraud.

“Insurance fraud is not a victimless crime,” Commissioner Causey said. “It hits all of us in the pocket through higher premiums.”

If you suspect insurance fraud or other white-collar crimes, please report it. You may anonymously report fraud by calling the N.C. Department of Insurance Criminal Investigations Division at 919-807-6840.

The Lifeline and 988

Posted on by Press Release

 988 has been designated as the new three-digit dialing code that will route callers to the National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline), and is now active across the United States.

When people call, text, or chat 988, they will be connected to trained counselors that are part of the existing Lifeline network. These trained counselors will listen, understand how their problems are affecting them, provide support, and connect them to resources if necessary.

The previous Lifeline phone number (1-800-273-8255) will always remain available to people in emotional distress or suicidal crisis.

The Lifeline’s network of over 200 crisis centers has been in operation since 2005, and has been proven to be effective. It’s the counselors at these local crisis centers who answer the contacts the Lifeline receives every day. Numerous studies have shown that callers feel less suicidal, less depressed, less overwhelmed and more hopeful after speaking with a Lifeline counselor.

Answer the call! These centers are looking to bring on new volunteers and paid employees. You will receive training, so if you are a caring person who wants to help those in crisis, apply today. Find your opportunity: samhsa.gov/988-jobs

For ways to support your local Lifeline network crisis center, visit our Crisis Centers page here.

To learn about the impact of the Lifeline, visit our new By the Numbers page.

To learn about what happens when you call, text, or chat with the Lifeline, click here.

To learn more about the history of 988, visit here.

To learn how Vibrant Emotional Health, the nonprofit administrator of the Lifeline, has been supporting states’ implementation planning for 988 through grants, check here.

NCDHHS Again Expands Eligibility for Monkeypox Vaccination, Encourages Steps to Reduce Spread

Posted on by Press Release

“Get Checked. Get Tested. Get Protected.”

Raleigh

The North Carolina Department of Health and Humans Services has expanded the list of higher-risk people who are eligible to receive the monkeypox vaccine to help prevent spread in the state.

Vaccinations to protect against monkeypox are now available for:

  • Anyone who had close contact in the past two weeks with someone who has been diagnosed with monkeypox, and
  • Gay or bisexual men or transgender individuals who report any of the following in the last 90 days:
    • Having multiple sex partners or anonymous sex
    • Being diagnosed with a sexually transmitted infection
    • Receiving medications to prevent HIV infection (PrEP)

While monkeypox can affect anyone through close skin to skin contact, our data show that currently almost all cases in North Carolina and across the country have been in gay, bisexual and other men who have sex with men,” said NCDHHS Secretary Kody H. Kinsley. “Everyone in our health system across the state should be working quickly to increase use of testing and vaccinating those most at risk so we can contain this outbreak.”

To date, 533 doses have been administered across the state. The federal government has allocated 4,548 doses of vaccine to North Carolina enough to fully vaccinate approximately 2,300 individuals with the recommended two-dose vaccination series. These doses have been distributed to nine local health departments (contact information below) that are offering vaccine and working with other health departments and clinics to ensure availability of vaccine throughout the state. More vaccine is expected in the coming weeks. Vaccine is free and available for individuals meeting the criteria above.

Vaccination after recent exposure may reduce the chance of getting monkeypox and can reduce symptom severity if you do get monkeypox. Those interested in receiving the vaccine should contact their local health department to find out whether they are eligible and to schedule an appointment.

Data shared by NCDHHS indicates more than 60% of monkeypox cases reported so far in North Carolina have been in Black/African American men.

“It’s very concerning to see disparities emerging in our monkeypox cases,” said State Epidemiologist Zack Moore, M.D., MPH. “We are working with our partners to raise awareness of monkeypox in LBGTQ+ communities of color and to making sure vaccines and other resources are reaching this community so they can take steps to decrease their chances of getting monkeypox.”

Earlier this month, NCDHHS released the 2022 Monkeypox Outbreak Response Plan (Spanish) encouraging people to get checked, get tested and get protected.

  • First, get checked. If you’ve had skin-to-skin contact — including sex — with someone with monkeypox, see a health care provider. If you have bumps, sores or a rash that looks like blisters or pimples, see a health care provider. Call your local health department if you don’t have a provider.
  • Second, get tested. Testing is widely available and encouraged if you have symptoms of monkeypox. Samples must be collected by a health care professional. NCDHHS recommends providers be vigilant and test any patient with a suspicious lesion or sore.
  • Third, get protected. Vaccines are available for those who meet the criteria above. These criteria will be reassessed and likely expanded as more vaccines become available over the coming weeks. Most people with monkey pox infection get better on their own. Therapies are available and may be recommended for people with a high risk of severe illness.

“Health care providers are the key link in getting checked, getting tested and getting protected,” said Elizabeth Cuervo Tilson, M.D., MPH, State Health Director and NCDHHS Chief Medical Officer. “We want to emphasize that testing is widely available, and anyone with symptoms should be tested.”

More information on testing, vaccines, treatment and where to find additional resources and contact information for local health departments is below.

Testing
There is plenty of testing capacity. The NC State Laboratory of Public Health, many commercial labs and some health systems have testing capability, and more labs will have testing capability soon. Health care providers can send tests to the State Laboratory of Public Health or a commercial lab. Every healthcare provider should have a plan for getting their patients tested for monkeypox when they need it.

Vaccines
Vaccine, known as Jynneos, has been allocated by the federal government and distributed to nine local health departments. The locations are sharing vaccine with other health departments and various clinics within North Carolina to ensure availability of vaccine throughout the state. Vaccine is free and available for individuals meeting the criteria above. Vaccination after recent exposure may reduce the chance of getting monkeypox and can reduce symptom severity if you do get monkeypox. People interested in receiving the vaccine can schedule an appointment through their local health department or one of the nine LHDs listed below. Currently, pharmacies are not able to administer the vaccine.

Treatment
Most infections last two to four weeks, and most people with monkeypox get better on their own without treatment. Antiviral therapies are available for those who are more likely to be severely ill, including people with lesions in the mouth, eye area, genitalia or rectum, and people with weakened immune systems. Monkeypox is rarely fatal, and no deaths have been reported related to this outbreak worldwide. The North Carolina interim therapeutic guidance for physicians can be found here. North Carolina physicians who wish to order tecovirimat can do so here.

For more information on symptoms and transmission of monkeypox, visit the NCDHHS Division of Public Health PH website here.

Additional Resources
NCDHHS is maintaining additional resources on its monkeypox web page. A count of North Carolina cases is now displayed at the top of the page. A communications toolkit is available, as well as guidance for providers and local health departments.

Contact Information
The health departments where vaccine is currently located are:

  • Buncombe (828) 250-5300
  • Cumberland (919) 433-3600
  • Durham (919) 560-9217
  • Forsyth (336) 703-3100
  • Guilford (336) 641-3245
  • Mecklenburg (980) 314-9400
  • New Hanover (910) 798-6800
  • Pitt (252) 902-2300
  • Wake (919) 250-4462

Monday numbers: A closer look at COVID exhaustion and how it’s affecting our response to the pandemic

Posted on by NC Policy Watch

By

 NC POLICY WATCH

– 7/25/2022

The latest poll results from the the Axios/Ipsos Coronavirus Index show that Americans are exhausted with COVID-19 and its variants, with a majority saying they don’t believe they will ever be rid of the virus in their lifetimes.

The results, released last week, are the latest indication that while the current BA-5 variant continues to spike infection levels and spur new waves of hospitalizations, fewer Americans are wearing masks, are familiar with the latest treatments or are inclined to get a booster shot if they became available.

Last week, Gov. Roy Cooper announced he would lift the state of emergency related to the pandemic in North Carolina.

This week Dr. David Wohl, professor in the Division of Infectious Diseases at the UNC School of Medicine, told Policy Watch there is an obvious divide between the statistics and medical realities of the pandemic and public perception and sentiment.

“What we’ve seen over the last several months, if not longer, is a disconnect between what may make sense from a public health perspective and what the perspective is of the public,” Wohl said. “Regardless of the way the curves look, whether we’re talking about peaks or valleys, in general, the public has said, ‘We’re going to move on. We’re going to take it on the chin if we’re seeing more cases. We’ll take it on the chin if we see more hospitalizations, maybe even more deaths.’”

Listen to Rob Schofield’s entire conversation with Wohl here.

 

Today, a by-the-numbers look at COVID exhaustion nearly three years into pandemic that has killed more than a million people in America alone.

78 – the percentage of poll respondents who somewhat or strongly agreed with the statement “we will never fully be rid of the coronavirus in my lifetime”

46 – the percentage who said they have had or suspect they have had COVID-19 since the onset of the pandemic.

71 – percentage who said they believe they have had it once

25 – percentage who said they believe they have had it twice

3 – percentage who said they believe they’ve had it three times

61 – percentage who said their most recent COVID infection came after they were fully vaccinated

33 – percentage who said they personally know someone who has been reinfected in the last few weeks

36 –  percentage who said they sometimes or always wear a mask when they are outside their own homes — that is the lowest percentage the polling has found since the onset of the pandemic

36 – percentage who said they never wear a mask outside their homes — a number that is up 14 percent since this time last year

36 – percentage who said they feel as though those around them have moved on from the pandemic but they haven’t

26 – percentage who said they were familiar with the antiviral pill treatment Paxlovid

27 – percentage who said their greatest concern was potentially passing the virus to someone with a higher risk of serious illness

17 – percentage who said their greatest concern was developing long COVID (the next highest concern)

85 – percentage of those fully vaccinated who said they would be very likely get a fourth shot if it were available

74 – percentage who said they would be likely to get another booster if it was recommended annually

76 – percentage if the booster was one that protected against new variants

54 – percentage who said other Americans are behaving in ways that are making the country’s recovery from the pandemic worse

Army Veteran Is Sentenced To Prison For Receiving Nearly $1 Million In Veteran Benefits For Fraudulent Service-Connected Disabilities

Posted on by Press Release

Monday, July 18, 2022

ASHEVILLE, N.C. – Today, U.S. District Judge Max O. Cogburn Jr. sentenced John Paul Cook, 58, of Marshall, N.C. to ten months in prison, five of which the defendant will serve in home confinement, for defrauding the U.S. Department of Veterans Affairs (the VA) by receiving nearly $1 million in veteran benefits based on fraudulent claims of service-connected disabilities, announced Dena J. King, U.S. Attorney for the Western District of North Carolina. In addition, Cook was ordered to serve three years of supervised release and to pay restitution of $930,762.53 to the VA.

Kim Lampkins, Special Agent in Charge of the Mid-Atlantic Field Office, Washington, D.C., of the U.S. Department of Veterans Affairs, Office of Inspector General (VA-OIG), joins U.S. Attorney King in making today’s announcement.

According to court records and today’s sentencing hearing, Cook enlisted in the United States Army (the Army) in November 1985. Six months later Cook sustained an accidental injury while on duty. Following the incident, Cook complained that as a result of the accident and injuries he sustained, a preexisting eye condition had worsened. According to court documents, in 1987, following a medical evaluation, Cook was discharged, placed on the retired list, and began receiving VA disability-based compensation at a rate of 60%. Over the next 30 years, Cook’s disability-based compensation increased, following Cook’s repeated false claims of increased visual impairment and unemployability due to “severe visual deficit.” As Cook previously admitted in court, in 2005, based on his claims of severe visual impairment, the VA declared Cook legally blind and he began receiving disability-based compensation at the maximum rate. Cook also began to receive additional benefits, including Special Monthly Compensation (an extra monetary allowance paid to a qualifying veteran due to the severity of his disability), Specially Adapted Housing (a grant that goes toward paying for adaptations in a new home), and Special Housing Adaptation (a grant that goes toward remodeling an existing home).

According to court records, Cook’s monthly VA disability payments in 1987 were $1,411 per month. With the incremental increases in his disability rating, as well as cost-of-living adjustments and his Special Monthly Compensation, these payments steadily increased over the years. By 2016, the monthly payment had risen to $3,990. In total, from 1987 through 2017, Cook received approximately $978,138 in VA disability payments due to his claimed blindness, to which he was not lawfully entitled.

According to court documents, contrary to Cook’s filed claims with the VA seeking additional disability claims and his complaints of increased visual impairment, Cook repeatedly passed DMV vision screening tests to renew or obtain a driver’s license in North and South Carolina. Furthermore, during the relevant time period, court documents show that Cook purchased and registered over 30 different motor vehicles which Cook routinely drove, including on long-distance trips and to perform errands. Court records further show that, from 2010 to 2016, during a time period that Cook was receiving maximum VA disability benefits for his visual impairment, Cook was actively involved with the Boy Scouts of America (BSA), including serving as a Den Leader and a Cubmaster. Among the courses the defendant completed with the BSA were courses qualifying him to be a range officer for BB guns and for archery. He was also certified for land navigation, which involves reading maps and using a compass.

On July 19, 2021, Cook pleaded guilty to theft of public money. He will be ordered to report to the federal Bureau of Prisons upon designation of a federal facility.

In making today’s announcement U.S. Attorney King thanked the VA-OIG for their investigation of the case.

The U.S. Attorney’s Office in Asheville prosecuted the case.

Hampered by opposition from doctors’ groups, nurse practitioners want to change state law to give them more freedom to treat patients

Posted on by NC Policy Watch

By

– 4/7/2022

NC POLICY WATCH

Michelle Skipper has a doctorate in nursing practice and diagnoses and treats patients in Laurinburg.

Cindy Cross was diagnosed with breast cancer about 15 years ago and found compassionate medical care when she first visited Michelle Taylor Skipper’s office in Laurinburg.  

Cross has been a patient of Skipper’s ever since, and her two adult daughters see her, too. In Skipper, Cross has found a trusted medical provider who goes out of her way to answer questions during unhurried appointments. “She’s a phenomenal doctor,” Cross said. “I would rather go to her than anyone.” 

Skipper has a doctorate degree in nursing practice. An advanced practice registered nurse, she diagnoses and treats patients in Laurinburg one day a week. She also directs the Doctor of Nursing Practice program at East Carolina University in Greenville.  

But there are limits to what Skipper can do. 

She was frustrated, for instance, by what she viewed as regulatory bureaucracy when she wanted to see patients at a mobile medical center that rolled into her town of St. Pauls in Robeson County. She couldn’t treat the patients because the doctor in charge at the mobile center was not listed as her supervisor on the documentation nurse practitioners must maintain. 

“I was never able to care for my own community as a nurse practitioner because of those barriers,” she said during an interview at the church in St. Pauls that her late husband led. “Super frustrating.” 

When Kohn retires, Skipper said, she will have to retire too, or find another doctor to supervise her and agree to monthly quality improvement meetings.  

“When he retires and I change supervising docs, I have to start a relationship with that physician like I was a brand new graduate.”

A debate over state law

State law requires advanced practice registered nurses like Skipper to have a medical doctor as a supervisor. “Advanced practice registered nurses” is an umbrella term covering four nursing specialists who hold advanced degrees: nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists. Together and separately, these groups of nurses have tried for years to convince the legislature to allow them to practice independent of doctors’ supervision.  

Many nurses, including Skipper, want autonomy for advanced practice registered nurses written into law via legislation, and most legislators back it.  

Nurse practitioners and the doctors who supervise them don’t have to collaborate on the treatment of each patient. Skipper describes her professional relationship with her supervisor, OB/GYN Dr. Harvey Kohn, as more like a partnership. Skipper has her own patients. Kohn sometimes checks her patient charts, when she isn’t there to review lab results, for example. But he’s not double-checking her work, she said. It’s not uncommon for advanced practice nurses to open their own medical practices. Their supervising doctors must be available for consultation but don’t have to work on site. In some cases, doctors work for the practices under contract. Doctors do not have to routinely review patient charts.  

The nurses maintain that cutting this thin thread of supervision will attract more advanced practice nurses to rural areas with doctor shortages. Doctors, however, want to maintain their role as supervisors, and dispute the claim that advanced practice nurses will help relieve shortages of health care providers in rural areas. Opposition from doctors’ groups has helped stonewall efforts to provide more leeway for advanced practice registered nurses.

Source: The Sheps Center for Health Services Research

Twenty-four states and Washington, D.C., allow nurse practitioners to diagnose and treat patients without doctors’ supervision. Supporters see a new opportunity that could win advanced practice nurses autonomy in North Carolina. A legislative committee on Medicaid expansion and health care access is digging into questions of current and anticipated shortages of medical workers. 

Source: The Sheps Center for Health Services Research

Doctors are concentrated in urban counties. In 68 of the state’s 100 counties the number of primary care doctors per 10,000 residents fell below the overall state rate of 7.06, according to 2019 data from the Sheps Center for Health Services Research at UNC. Two small counties had no primary care doctors. Nurse practitioners are more widely distributed, although they are also easier to find in urban counties and those with major hospitals. One county in the state’s northeast corner, Camden, had no nurse practitioner in 2020, according to Sheps Center data.

Source: The Sheps Center for Health Services Research

The state is adding nurse practitioners more quickly than it is primary care doctors, according to the Sheps data.  

Dr. Karen Smith, a family doctor with her own practice in Hoke County, said it’s important to continue to require collaborative agreements between doctors and nurse practitioners.

Although a federal study using information from 2010 found that nurse practitioners were more likely than primary care physicians to practice in rural areas, Smith cited information from the American Medical Association from three states that showed allowing nurses to practice independently doesn’t increase the likelihood they’ll work in rural areas.  

“It has been a difficult struggle to encourage nurse practitioners and physician assistants to serve in our rural areas,” she said.  

Smith is medical director for the Hoke County health department and supervises the nurse practitioner and physician assistant who work there.  The mix of experience and education on the team are important to patient treatment, she said.  

It’s important as the supervisor for her to know what advanced practice providers are comfortable doing, she said. For example, she said, the advanced practice providers she supervises are not comfortable prescribing opiates. And understanding how those providers work informs Smith about often they need to meet to review patient charts. 

“If the experience, education, skills and comfort level mean we are going to review charts every week, we’ll review charts every week,” she said. 

Different approaches in different communities

Certified registered nurse anesthetists, or CRNAs, must work under a doctor’s supervision, but what that looks like depends on the hospital. Eleven hospitals in the state have only CRNAs who do the work of anesthetizing patients, monitoring them in the operating room, and waking them up, said Stacy Yancey, president of the NC Association of Nurse Anesthetists. Some hospitals in the eastern part of the state have anesthesiologists, medical doctors, who work during the day, with CRNAs on duty nights and weekends, she said, and a majority of plastic surgery practices and endoscopy centers hire only CRNAs.  

Yancey works for a staffing agency, and has experience working in a variety of settings. In a rural hospital, she’s responsible for assessing patients before surgeries, administering anesthesia, and waking them up.  

When she works in a hospital with an anesthesiologist, that doctor does the preoperative assessments and fills out all the forms.  

Again, depending on the hospital, the anesthesiologist may not enter the operating room. At some hospitals the anesthesiologists come into the operating room shortly before or while Yancey is administering general anesthesia; those doctors leave when the patient is stable, and Yancey stays there.  

“Sometimes they will come and check on me during long cases to see if I need anything,” Yancey said. 

“The standard of care in the O.R. is the same no matter who is providing the anesthesia,” she said, and a law allowing CRNAs to work without supervising doctors would clear up gray areas.  

Skipper, the nurse practitioner from St. Pauls, is convinced that advanced practice nurses from rural areas will want to stay there, as she has. Independence for advanced practice nurses will also advance entrepreneurship, she said. 

Schquthia Peacock, a nurse practitioner in Cary, has co-owned her practice with a doctor for 22 years. “I have had my own panel of patients – patients who call me their primary healthcare provider,” she said.  

The decision to become a practice owner was sudden and came shortly after the medical practice where she had taken a job went bankrupt.  

“We didn’t want to lose the practice and the patients,” she said. “We felt it would be best to continue the practice as it was.” 

The office is arranged so Peacock, her physician partner and the nurse practitioners the practice employs can meet during the work day to discuss patient care. “We call it a collaboration,” she said. “We consider ourselves a team working toward patient care.”  

Jennie Mayo, a patient of  Skipper’s in Laurinburg, chooses care from nurse practitioners. “They listen to me,” she said. “Doctors sometimes dismiss you.” 

Mayo first saw Skipper in 1992. Mayo left the state in 2010 but sought out Skipper again upon returning to Laurinburg in 2017.  

“We just hit it off,” Mayo said. “She’s funny. She remembers you.” 

“I was lucky enough that she took me back,” Mayo said. “In a small town, it’s often hard to find a family doctor, an OB/GYN – it’s hard to find medical care.” 

Mayo knows that advanced practice nurses are pushing to be able to practice independent of doctors’ supervision. She thinks they should have that autonomy.  

“They’re educated adults and perfectly capable of making informed medical decisions,” she said. 

Rural healthcare providers feel the pain of North Carolina’s Medicaid gap

Posted on by NC Policy Watch

By

– 3/22/2022

On her morning commute to work, Dr. Laura Ucik, a rural family physician in the northern Piedmont of North Carolina, thinks about the patients who could have avoided serious illness and injury had they qualified for Medicaid years ago.

One such patient with severe stomach pain couldn’t afford an ultrasound to identify whether or not they had gallstones.

Another arrived with a swollen leg, a common but urgent symptom of a blood clot. Unable to pay for imaging and blood thinning medication, they left without a diagnosis.

“I have a patient who had rectal bleeding for over a year, and they were eventually diagnosed with rectal cancer,” Ucik said. “Recently, they found out the cancer had begun to metastasize to other parts of the body. It all could have been avoided if they had had insurance to cover a colonoscopy.”

While thousands of North Carolinians struggle to keep their health in check, healthcare providers across the state are being pushed to their limits as people with no coverage flood their offices.

North Carolina is one of only 12 states that still hasn’t expanded its Medicaid coverage. With almost 2.7 million North Carolina residents already enrolled in Medicaid, up to 626,000 are now in what is called the Medicaid coverage gap.

Graphic by Keyshawn Garrett.

The gap refers to people whose income is too high to qualify for Medicaid, but not enough to afford other insurance. In addition, all childless non-disabled adults are ineligible regardless of how low their income is.

Medicaid was created to provide health insurance to low-income families and individuals in 1965. However, 12.9% of North Carolina’s population remained uninsured in 2018.

For healthcare providers, the gap has meant struggles to provide care for patients who wait too long or don’t have the ability to afford testing and treatment. It means long hours trying to find care.

Dr. Joel L. Gallagher is an allergist-immunologist with offices in Reidsville and Greensboro, North Carolina. About two-thirds of his patients are either uninsured or covered by federally funded insurance like Medicaid or Medicare.

“Scrambling to find the cheapest option adds a lot more time to providing healthcare, which isn’t ideal when you’re treating asthma,” Gallagher said. “Many of my patients need medication everyday just to breathe.”

When Gallagher’s office can’t find an affordable solution, they often send patients home with drug samples. For some, these samples are the only way to get medication because they can’t afford a prescription. However, these samples only last a few weeks.

As a result, some patients ration their medications at home. When an asthmatic isn’t properly dosed for their condition, they can have asthma attacks, which are more serious and can be traumatizing to patients.

Although Gallagher can occasionally waive the charges for a breathing test or other procedure, he has to be careful that his office isn’t writing off too much. “We still have to worry about paying our staff’s salaries at the end of the day,” he said.

Still others have taken up a personal campaign to persuade North Carolina politicians to approve expansion. The political atmosphere has held talk of expanding for years, but so far, the majority of legislators in the state remain in opposition. However, support for expansion is shifting, and although the change is slow, more representatives are beginning to show their support.

At the forefront of this movement in North Carolina is Casey Cooper, the CEO of the Cherokee Indian Hospital. There, Cooper and his staff serve all members of the tribe, as well as select other groups, including spouses of a tribe member and all children under the age of 19.

Casey Cooper, CEO of the Cherokee Indian Hospital, speaking to the Macon County Board of Commissioners. Photo by Brittney Lofthouse, the Western Region Educational Coordinator at Care 4 Carolina.

Although activism isn’t in his job description, Cooper recounts a personal story about how the lack of health insurance impacted a childhood friend.

Cooper and Albert Hartline went to high school together in Jackson County. Hartline suffered from depression and substance use disorders, the combination of which eventually led to his unemployment and lack of health insurance.

Several years later, Hartline was diagnosed with cancer. He knew he didn’t have the resources to pay for his treatment, and his mental health and addiction spiraled out of control. According to Cooper, life became unbearable for Hartline because he knew he couldn’t afford treatment for his potentially terminal illness.

In December 2020, Hartline died by suicide shortly after killing his neighbor. Hartline got caught in a situation that could have been avoided had he been able to get insurance, said Cooper. In his office at the hospital, a plaque memorializing Hartline sits on the windowsill.

In the following years, Cooper set up meetings to talk with conservative county commissioners across the state about Medicaid expansion. He persuaded Swain, Jackson, Macon, Clay and Graham county commissioners to change their stance on Medicaid coverage, he says. But Cherokee, Transylvania and Haywood county commissioners did not sign a resolution after meeting with him.

“People think that folks without insurance are choosing not to work, which is a horrible misunderstanding,” Cooper said. “The majority of uninsured people are working, and they are working poor.”

In addition to the stereotype that uninsured people are unmotivated to improve their situation, Medicaid expansion carries another generalization regarding what, and who, it was related to in the past.

“For a lot of Republican officials, Medicaid expansion is tied to Obamacare, which they’re against, and maybe that’s that,” said Madeline Guth, a policy analyst in the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. “State politics can vary, but there’s a lot of long-standing opposition in North Carolina.”

Since the U.S. Supreme Court’s decision to make participation in Medicaid expansion optional for states in 2012, the number of people who would qualify has increased.  In many of North Carolina’s 78 rural counties, health care clinics and doctor’s offices are few and far between, making it difficult for people to get the care they need before their condition takes a turn for the worst.

As part of its efforts to provide universal care, the Cherokee Indian Hospital administers treatment regardless of the patient’s ability to pay. While this relieves the financial stressor from members of the tribe, the hospital is spending millions of dollars every year that could be used elsewhere.

In some cases, adding a financial burden can mean the difference between someone living and dying because of their condition; a situation Ucik knows all too well.

On a daily basis, she sees upward of 10 patients living with medical issues that could be treated if they had insurance. However, most can’t afford the cost out of pocket and are unable to receive proper treatment day after day.

“It is unbelievable the things we are doing as healthcare workers to try and provide for our patients without the proper resources,” Ucik said. “Every day I am bending over backwards to solve problems that can only be diagnosed and treated with tests, medications and referrals to specialists.”

After another long day of finding temporary solutions to long-term problems, Ucik reflects on how her job would be so much easier if her patients had the ability to get help before their situation turned desperate.

“The money we aren’t spending now when people come in without insurance doesn’t even compare with the money we spend later on once their conditions have worsened,” Ucik said. “This isn’t healthcare; people will continue to suffer until the legislation changes.”

UNC Media Hub reporter Lauren Ketwitz is a senior from Polk County, North Carolina majoring in journalism and minoring in Hispanic studies. Keyshawn Garrett is a rising senior from Enfield, majoring in Journalism and concentrating on graphic design in the UNC Hussman School of Journalism and Media.