Tag Archives: Articles and Investigations – ProPublica

Why Do Border Deaths Persist When the Number of Border Crossings Is Falling?

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In July, a sweltering tractor trailer ride in Texas became the latest harrowing example of the perils of crossing the U.S. border illegally. From the hospital, one survivor told authorities that he had paid smugglers to get him across the Rio Grande and then cram him on a northbound truck with what he guessed were nearly 100 people. The survivor managed to keep breathing in the pitch black trailer without food or water. But when the doors were opened in a San Antonio Walmart parking lot, eight migrants were dead, their bodies “lying on the floor like meat,” the truck’s driver subsequently said. Another two expired later.

Those 10 deaths are among the 255 known migrant fatalities recorded by the International Organization for Migration in the first eight months of 2017. That’s up from 240 in the same period last year. Experts aren’t certain what’s causing the recent increase; verifying numbers is inherently difficult when it comes to an endeavor whose very mission is to avoid detection by the authorities.

However, academics and the U.S. Border Patrol largely agree on the long-term trends, which reveal a clear pattern. Between 1998 and 2016, the number of unauthorized border-crossers who were captured — which is viewed as the best proxy for the rate of illegal crossings — has plunged 70 percent in the southwest U.S. border region, according to data from the Border Patrol. During that same period, yearly immigrant deaths have risen some 20 percent. (The increase in death rate, which was steady for many years, was interrupted for several years by a temporary surge in migrants from Central America, which we’ll explain, only to resume its upward march.)

The result is a significant increase in the chances of dying in an illegal border crossing over the past two decades. A key cause: efforts by the Border Patrol to push migrants away from easy-to-cross, hard-to-police urban corridors and into barren, isolated terrain. That’s the conclusion of “Why Border Enforcement Backfired,” a 2016 paper whose lead author, Douglas Massey, is a professor at Princeton’s Woodrow Wilson School of Public and International Affairs and the cofounder of the Mexican Migration Project. A spokesman for the Border Patrol echoed the view that the change in policy contributed to the increase in deaths (but disagreed that the policy backfired).


If somebody had been trying to slip across the border through Texas in the early ’90s, he might have just forded a narrow canal or hopped a chain-link fence from Juarez into El Paso. Back then, the vast majority of unauthorized crossings followed easy routes into big cities like El Paso or San Diego, where illegal immigrants could, to the frustration of authorities, quickly blend into the local population. Border deaths were relatively rare, said Daniel Martinez, an associate professor of sociology at the University of Arizona and a researcher on a project called the Migrant Border Crossing Study.

Things began to change when the Clinton administration, seeking to burnish its tough-on-illegal-immigrant credentials, swelled the Border Patrol’s ranks and adopted a strategy known as Prevention Through Deterrence. The initiative, adopted in 1994, clamped down on popular crossing routes through San Diego and El Paso.

The document laying out the strategy at the time predicted that “with traditional entry and smuggling routes disrupted, illegal traffic will be deterred, or forced over more hostile terrain, less suited for crossing and more suited for enforcement.” Migrant flow would shift to sectors in South Texas and Tucson, it anticipated, while acknowledging that “illegal entrants crossing through remote, uninhabited expanses of land and sea along the border can find themselves in mortal danger.”

That’s precisely what happened when the administration implemented Prevention Through Deterrence. Starting in the mid-’90s, the Border Patrol effectively sealed off the well-traveled crossing paths of the San Diego and El Paso Border Patrol sectors. From 1998 to 2008, deaths in these sectors — which had hovered between 20 and 40 annually — tailed off, eventually dropping to a handful in recent years.

Tens of thousands of migrants began shifting to lengthier, more dangerous, unpopulated routes, according to experts. The location of many fatalities shifted accordingly.

Memorial crosses decorate the border wall that separates Arizona from Nogales, Mexico.
(Susan Schulman/Barcroft Media)

Arizona became a hotbed for migrant crossings and deaths in the first years of the new millennium. In the Tucson sector, which stretches over 262 miles of border, much of it desert terrain, migrant fatalities jumped from 11 in 1998 to a peak of 251 in 2010.

But as the Border Patrol deployed more resources to the Tucson sector, migrants targeted other entry points and deaths began declining, to 84 last year. (As the sector became more heavily patrolled, the percentage of migrants whose cause of death was overheating and other environmental factors rose, according to University of Arizona researchers who examined autopsy data.)

“It’s like a balloon: If you cinch down on the left and the right, it’ll go elsewhere,” said Robert Daniels, a spokesman for the Border Patrol. “So after we cinched down on San Diego and El Paso, that led flow to Arizona. Then, as Arizona was cinched down, that led to flow further south in Texas.”

The latter change is visible in recent years in two Texas sectors. The relatively small Laredo area has seen deaths rise from 20 in 1998 to 68 last year. Meanwhile, in the Rio Grande Valley sector, which includes 320 miles of border and some formidable river crossing points, annual deaths rose from 26 in 1998, peaked at 156 in 2013 then tailed off to 130 last year. The Rio Grande is now the most common site of migrant deaths, according to Border Patrol data. Since January 2009, the remains of more than 550 migrants have been found in just one jurisdiction, Brooks County, where migrants attempting to bypass Border Patrol’s inland checkpoints hike for days through dry ranch land, often getting lost and dehydrated in the flat, arid brush.


When it implemented the Prevention Through Deterrence policy, the Border Patrol did not anticipate so many people would attempt to cross the deadly terrains left to them, said Doris Meissner, the head of the Immigration and Naturalization Service who signed off on the strategy in 1994. “Border Patrol believed the hostile conditions [in] the really new geographies that had not been typical crossing areas would create their own built-in deterrence, and that didn’t turn out to be true,” said Meissner, now a senior fellow at the Migration Policy Institute. “The shift to those areas happened more quickly than the Border Patrol realized that it would.”

The Border Patrol’s Daniels agreed that the extreme climates of migrants’ crossing paths were the primary cause of the increased deaths, but also blamed smugglers. “We saw the smugglers taking the aliens to more remote locations to cross with the thought that there would be no Border Patrol,” said Daniels, who began his career in Tucson in 1994. “I haven’t heard of any theories for this outside of the extreme weather.” Daniels noted that other possible factors, like shootings and general border violence, could not explain the deaths.

Once it became clear that environmental deterrence was not stopping migrants, however, authorities did not reverse their strategy. “That always has always been one of the major criticisms,” said Meissner. To make up for the increased risks, she said, the Border Patrol trained agents for emergency response operations and deployed agents, paramedics, helicopters and surveillance equipment to hazardous areas.

These rescue effort have saved lives, but they haven’t brought migrant crossing death rates back down to levels seen in the 1990s. The Prevention Through Deterrence strategy “directly led to the exponential increase in deaths in Southern Arizona,” according to Martinez, the researcher on the Migrant Border Crossing Study. “The data speaks for itself: There’s a direct correlation between the border buildup and the deaths. It’s undeniable.”

Minors from violence-plagued El Salvador, Honduras and Guatemala will no longer be permitted to reunite with their parents in the United States.

As this shift took place, border crossings dropped regularly, and from 2012 to 2014, so did migrant death rates. But the latter figures were skewed by a surge of migrants from Central American countries at the same time that illegal entries by Mexicans dipped. Many of the Central Americans, fleeing violence in their countries, intentionally placed themselves in U.S. custody in an attempt to seek asylum. Since the migrant death rate is defined as fatalities as a percentage of apprehensions, the spike in apprehensions had the effect of lowering death rates.

Since 2014, however, those rates have been on the rise again. Some of the rise in deaths in 2017 may have to do with South Texas’ unique environmental factors, wrote Julia Black, project coordinator for the International Organization for Migration’s Missing Migrants Project, in an email to ProPublica. “It is not yet clear why the migrant death rate has increased this year,” she said. “Some part of this can be attributed to an increase in rainfall, which has led to more deaths in the Rio Grande, but it cannot explain the rise in deaths in e.g. the Arizona desert.”

Martinez argued that it is more important to look at the longer-term shifts than trying to identify one or two elements. People have been forced to take ever more demanding and precarious routes.

“We’re seeing more and more remains being recovered on trails at higher elevations than ever seen before,” said Martinez. “Rather than crossing for a couple hours, people cross for days, pushed farther away from the pick-up points, so they literally just can’t carry enough water anymore.”

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California Regulators Require Auto Insurers to Adjust Rates

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by Julia Angwin and Jeff Larson

California regulators said they have required Nationwide and USAA to adjust their auto insurance rates as a result of a report by ProPublica and Consumer Reports that many minority neighborhoods were paying more than white areas with the same risk.

The regulators said their review confirmed our finding that linked the pricing disparities to incorrect applications of a provision in California law. The statute allows insurers to cluster neighboring zip codes together into a single rating territory.

“The companies were making some subjective determinations,” as a basis for calculating rates in some zip codes, said Ken Allen, deputy commissioner of the rate regulation branch of the California Department of Insurance. Nationwide and USAA are two of the 10 largest auto insurance providers in the country by market share.

The department said that the adjustments would largely erase the racial disparities we found in the two companies’ pricing. According to our analysis, USAA charged 18 percent more on average, and Nationwide 14 percent more, in poor, minority neighborhoods than in whiter neighborhoods with similarly high accident costs. Allen said it’s not possible to quantify how these adjustments would affect customers’ premiums because the revisions are too complex. In addition, they’re taking effect at the same time as an overall rate increase.

Allen said the department is now requiring more justification from insurers for their measurements of risk in the poor, minority neighborhoods that California designates as “underserved” for auto coverage.

California’s action marks a rare regulatory rebuke of the insurance industry for its longtime practice of charging higher premiums to drivers living in predominantly minority-urban neighborhoods than to drivers with similar safety records living in majority-white neighborhoods. Insurers have traditionally defended their pricing by saying that the risk is greater in those neighborhoods, even for motorists who have never had an accident. 

The department’s investigation was prompted by a ProPublica and Consumer Reports analysis published in April of car insurance premiums in California, Texas, Missouri and Illinois. ProPublica found that some major insurers were charging minority neighborhoods rates as much as 30 percent more than in other areas with similar accident costs.

The disparities were not as widespread in California, which is a highly regulated insurance market, as in the other states. Even so, within California, we found that units of Nationwide, USAA and Liberty Mutual were charging prices in risky minority neighborhoods that were more than 10 percent above similar risky zip codes where more residents were white.

California regulators said they approved rate increases from Nationwide and USAA last week that contained corrections to the disparities revealed by ProPublica. The regulators said they are still investigating the proposed rates of Liberty Mutual, which had the largest disparities in ProPublica’s analysis. Liberty Mutual spokesman Glenn Greenberg said the company is cooperating with the investigation.

The rate changes will only affect premiums charged from now on. The insurance commission chose not to look into whether, or the extent to which, drivers in California’s underserved neighborhoods may have been mischarged in the past.

Department spokeswoman Nancy Kincaid said there was no need to examine past rates. “After hundreds of hours of additional analysis, department actuaries and analysts did not find any indication the ProPublica analysis revealed valid legal issues,” she said.

Some consumer advocates disagreed with this approach. “We think the commissioner should go back and seek refunds for people who were covertly overcharged by the discriminatory practices that ProPublica uncovered,” said Harvey Rosenfield, founder of Consumer Watchdog. Consumers Union, the policy and action arm of Consumer Reports, has also sent a letter to the department, urging it to examine if any rates were calculated improperly in the past.

The insurance commissions in Missouri, Texas and Illinois did not respond to questions about whether they had taken any actions to address the disparities highlighted in ProPublica’s article. A spokesman for the Illinois Department of Insurance said in a statement that it urges consumers to shop around for the best price on automobile insurance.

ProPublica and Consumer reports analyzed more than 100,000 premiums charged for liability insurance — the combination of bodily injury and property damage that represents the minimum coverage drivers buy in each of the states. To equalize driver-related variables such as age and accident history, we limited our study to one type of customer: a 30-year-old woman with a safe driving record. We then compared those premiums, which were provided by Quadrant Information Services, to the average amounts paid out by insurers for liability claims in each zip code.

When ProPublica published its investigation, the California Department of Insurance criticized the article’s approach and findings, saying that “the study’s flawed methodology results in a flawed conclusion” that some insurers discriminate in rate-setting. Nevertheless, the department subsequently used ProPublica’s methodology as a basis for developing a new way to analyze rate filings. It used its new method to examine the recent Nationwide and USAA rate filings.

In California, when insurers set rates for sparsely populated rural zip codes, which tend to be relatively white, they are allowed to consider risk in contiguous zip codes of their own choosing. In some cases, these clusters led higher risk zip codes to be assigned a lower risk — and therefore, lower premium prices — than the state’s comprehensive analysis of accident costs warranted. The use of contiguous zip codes is also common in Missouri, Texas and Illinois but is less regulated there than in California.

In an interview, deputy insurance commissioner Allen said that Nationwide had made a “procedural error” in its use of the contiguous zip codes provision, and that the regulators required the company to rely more heavily on the state’s risk estimates in those areas.

Nationwide acknowledged that the state required a rate adjustment, but disputed the association with ProPublica’s reporting. “It is inaccurate and misleading for anyone to conclude or imply any connection between Nationwide’s recently approved rating plan and ProPublica’s unsubstantiated findings,” spokesman Eric Hardgrove said. He added that Nationwide is committed to nondiscriminatory rates and “disagrees with any assertion to the contrary.”

On page 2,025 of Nationwide’s most recent California insurance filing, the company disclosed that it provided premium quotes for the “ProPublica risk example” to the California insurance commission.

The improper use of the contiguous zip codes provision was also a factor in the USAA filing, Allen said in an interview. “USAA had failed to apply the updated industry wide factors where they had insufficient data,” he said.

USAA spokesman Roger Wildermuth acknowledged when the company filed its rate plan in August 2016, it did not use California’s most up-to-date risk numbers, which were published eight months earlier in December 2015. The reason, he said, was that the insurer had already “completed months of calculations prior to that update.”

He noted that the department approved that filing, including USAA’s decision to rely on its own data, and has now approved the company’s revised calculations using updated data.

“The department has consistently validated our approach to this rate filing,” he said.

California officials said they will more closely police the clustering algorithms, and their impact on poor and minority neighborhoods, as they review future rate filing applications.

“We will use this analysis going forward,” said Joel Laucher, chief deputy commissioner of the department. “We don’t need to change any rules to do that.” 

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Failing Charter Schools Have a Reincarnation Plan

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by Annie Waldman

This past June, Florida’s top education agency delivered a failing grade to the Orange Park Performing Arts Academy in suburban Jacksonville for the second year in a row. It designated the charter school for kindergarten through fifth grade as the worst public school in Clay County, and one of the lowest performing in the state.

Two-thirds of the academy’s students failed the state exams last year, and only a third of them were making any academic progress at all. The school had had four principals in three years, and teacher turnover was high, too.

“My fourth grader was learning stuff that my second grader was learning — it shouldn’t be that way,” said Tanya Bullard, who moved her three daughters from the arts academy this past summer to a traditional public school. “The school has completely failed me and my children.”

The district terminated the academy’s charter contract. Surprisingly, Orange Park didn’t shut down — and even found a way to stay on the public dime. It reopened last month as a private school charging $5,000 a year, below the $5,886 maximum that low-income students receive to attend the school of their choice under a state voucher program. Academy officials expect all of its students to pay tuition with the publicly backed coupons.

Reverend Alesia Ford-Burse, an African Methodist Episcopal pastor who founded the academy, told ProPublica that the school deserves a second chance, because families love its dance and art lessons, which they otherwise couldn’t afford. “Kids are saying, ‘F or not, we’re staying,’” she said.


While it’s widely known that private schools convert to charter status to take advantage of public dollars, more schools are now heading in the opposite direction. As voucher programs across the country proliferate, shuttered charter schools, like the Orange Park Performing Arts Academy, have begun to privatize in order to stay open with state assistance.

A ProPublica nationwide review found that at least 16 failing or struggling charter schools in five states — Florida, Wisconsin, Indiana, Ohio and Georgia — have gone private with the help of publicly funded voucher programs, including 13 since 2010. Four of them specialize in the arts, including Orange Park, and five serve students with special needs.

“The voucher just is a pass through in order to provide additional funding for private schools to thrive and to continue to work,” said Addison Davis, superintendent of schools in Clay County. Changing a school’s status “isn’t going to stop the process where we continue to see kids who are declining academically and not being able to demonstrate mastery and proficiency.”

The Orange Park Performing Arts Academy was the only charter school in Clay County, Florida, that focused on the arts.
(Charlotte Kesl for ProPublica)

Two key factors underlie these conversions. The number of voucher and voucher-like programs across the country has more than tripled over the past decade from 16 to 53. And charter schools, which became popular as a way to spur educational innovation with reduced regulation, have increasingly faced more stringent oversight. Jeanne Allen, founder and CEO of the Center for Education Reform and a longtime supporter of charter schools, lamented in a recent op-ed that increased government regulation is turning them into “bureaucratic, risk-averse organizations fixated on process over experimentation.”

“Why not just be a private school if the kids qualify for the scholarships?” said Christopher Norwood, a consultant for the Orange Park school, in an interview. “With 90 percent fewer regulations, schools can be independent and free, and just deal with the students.”

As private schools, the ex-charters are less accountable both to the government and the public. It can be nearly impossible to find out how well some of them are performing. About half of the voucher and voucher-like programs in the country require academic assessments of their students, but few states publish the complete test results, or use that data to hold schools accountable.

While most states have provisions for closing low-quality charter schools, few, if any, have the power to shut down low-performing voucher schools.

“Public money is being handed out without oversight,” said Diane Ravitch, a New York University education historian and public schools advocate, who served as assistant secretary of education under President George H.W. Bush. “The fundamental voucher idea is that parents are choosing the schools and they know better than the state. If they want to send their kids to a snake-charming school, then that’s their choice.”


The type of voucher program that rescues failed charter schools like Orange Park in Florida may soon be replicated nationwide. Visiting a religious school in Miami last April, Secretary of Education Betsy DeVos praised the state’s approach as a possible model for a federal initiative.

Typically, voucher programs are directly funded with taxpayer dollars. Florida’s largest program pursues a different strategy. Its “tax-credit scholarships” are backed by donations from corporations. They contribute to nonprofit organizations, which, in turn, distribute the money to the private schools. In exchange, the donors receive generous dollar-for-dollar tax credits from the state. This subsidy indirectly shifts hundreds of millions of dollars annually from the state’s coffers to private schools. More than 100,000 students whose families meet the income eligibility requirements have received the tax-credit coupons this year.

Of the nearly 2,900 private schools in Florida, over 1,730 participated in the tax-credit voucher program during 2016-17, according to the most recent state Department of Education data. On average, each school received about $300,000 last year.

While more than two-thirds of these schools are religious, the roundabout funding approach protects the vouchers against legal challenges that they violate the separation of church and state. Earlier this year, the state Supreme Court dismissed a lawsuit by the Florida Education Association, a teacher’s union, challenging the constitutionality of the voucher program.

In an education budget proposal from May, DeVos detailed her voucher plans, pitching a $250 million plan to study and expand individual state initiatives. She has since suggested that the administration may also create a federal tax-credit voucher scheme through an impending tax overhaul.

School choice advocates like DeVos have long contended that vouchers improve educational opportunities for low-income families. They reason that competition raises school quality, and that parents, given more options, will select the best school for their children.

A growing body of research, though, casts doubt on this argument. It shows voucher-backed students may not be performing better than their public school counterparts, and may do worse.

A recent Department of Education study compared students who attended private schools with vouchers in Washington, D.C., from 2012 through 2014 with those who qualified for the program but were turned down due to a lack of available slots. The private schoolers performed significantly worse than their public school peers in math, and no better in reading.

According to a February 2017 analysis by Martin Carnoy, a Stanford University education professor, most studies of voucher programs over the past quarter-century found little evidence that students who receive the coupons perform better than their public school peers.

The lack of evidence on the benefits of vouchers, Carnoy wrote, “suggests that an ideological preference for education markets over equity and public accountability is what is driving the push to expand voucher programs.”


Across the Florida panhandle from Orange Park, another troubled charter school for the arts has reinvented itself as a voucher-funded private school.

Founded in 2010, the A.A. Dixon Charter School of Excellence had the worst academic record in Escambia County, and the school board raised questions about its financial accounting.

“Every month they came before the board and there was a problem,” said Jeff Bergosh, a school board member at the time, adding that he supports school choice. “They tried to make it work, but they didn’t. There were serious issues that jeopardized student safety, like sanitation issues and not having supervision [for the students].”

After Dixon received two failing grades from the state — which triggers termination of a school’s charter under Florida rules — Reverend Lutimothy May, a Baptist pastor who chaired its board, appealed to state education authorities. They allowed the school to operate for at least one more year, but he began to seek other options.

Around the same time, a local beverage distributor, David Bear of the Lewis Bear Company, told May that he was considering contributing to the state tax-credit program. If the Dixon school privatized, Bear told May, donations could help save it. In 2013, May turned the charter, which had recently been renamed the Dixon School of the Arts, into a private Christian arts academy located inside his church. Nearly all current students at Dixon receive the tax-credit vouchers, bringing the school more than $500,000 a year, according to the most recent data from the state’s department of education.

“Our goal is still the same,” but the conversion has “untied some of the strings on education,” May said.


Dixon School of the Arts, a private arts academy in Pensacola, Florida. Dixon began as a public charter school, but after receiving two failing grades from the state, it converted to a private school with the help of tax-credit vouchers. (Annie Waldman/ProPublica)

Some of the untied “strings” to which May referred were state educational requirements. By converting from a charter to private status, Dixon and other schools largely shield themselves from accountability.

For instance, while Florida requires all private schools to test students who receive vouchers, the schools face no consequences for weak academic performance. The University of Florida publishes an annual report analyzing the test scores of students that receive vouchers, but data from only a small fraction of the schools is made public. The report excludes many schools that don’t have test results for enough students in consecutive years.

The latest report released the academic performance of only 198 schools in 2014-15, out of the more than 1,500 schools that enrolled voucher-funded students that year. Most Florida families that receive vouchers do not have access to test data on their schools. The Dixon data was not published. Dixon’s principal, Donna Curry, maintained that the school has improved since its conversion from charter status, but declined to provide exam results to ProPublica, saying they were “for internal use.”

Curry added that state test results are not necessarily reflective of student success. “I will not accept the fact that our children are not learning because they are not normalized on the state test,” she said. Her staff “knows more than what the test evaluates.”

The state also has little control over how private, voucher-funded schools foster learning. There are no requirements on curriculum or teacher certification, other than the criminal background checks that are required for personnel at all private schools.

Because Dixon receives more than $250,000 in voucher money, it does have to file a financial accountability report. Only about 40 percent of all voucher-funded schools met this threshold to undergo such an audit in 2016. The reports, including Dixon’s, aren’t publicly posted.

Even an official at Step Up For Students, the largest nonprofit distributor of voucher money to Florida’s private schools, acknowledges the need for closer supervision of educational quality. “As the program matures and more students are enrolled and as inevitably we see some schools continue to have what most people would consider to be poor performance year-in and year-out, we will be having more and more discussions about whether there should be some kind of regulatory accountability mechanisms to respond to that,” said Ron Matus, the organization’s director of policy and public affairs.


Indiana’s largest voucher program, unlike Florida’s, is directly backed by taxpayer dollars and has stricter accountability requirements. A private school that accepts vouchers can be sanctioned if its performance dips low enough. Last year, 10 schools lost their access to new vouchers, according to Adam Baker, the spokesman for the Indiana Department of Education.

The tighter supervision, though, didn’t deter Padua Academy in Indianapolis. Originally a private Catholic school, Padua had become a “purely secular” charter in 2010, under an unusual arrangement between the local archdiocese and the mayor’s office. The school initially performed well, but soon sank from a solid A-rating to two consecutive F-ratings.

“These performance issues sounded alarm bells at the mayor’s office,” said Brandon Brown, who led the mayor’s charter office at the time. Leadership issues with the school’s board and at the archdiocese, he added, caused the school to falter. After receiving $702,000 from a federal program that provided seed money for new charter schools, the school’s board relinquished its charter.

In the meantime, Indiana had established a voucher program. So, instead of shutting down, the school rebranded itself as St. Anthony Catholic School, nailing its crucifixes back onto the walls and bringing the Bible back into the curriculum. Last year, more than 80 percent of its students were on vouchers, from which the school garnered at least $1.2 million.

Its academic performance has improved, but still lags behind the state average. Only 25 percent of St. Anthony students passed both math and reading assessments this year, versus about half of all publicly funded students on average at both private and public schools, according to the state’s education data from 2017. Last year, the state gave St. Anthony a C grade.

Gina Fleming, superintendent of schools for the Archdiocese of Indianapolis, said through a spokesman that “significant staff turnover” at St. Anthony’s “made for a difficult start these past two years.” As a result, the archdiocese “has been studying ways in which we can recruit, retain and reward high-quality teachers and leaders.” It has also “made shifts in scheduling, resources, diagnostic analyses and personnel to better accommodate the learning needs of our students.”

In Fort Wayne, Indiana, two other charter schools went private. Both Imagine MASTer Academy and Imagine Schools on Broadway were associated with a national for-profit charter chain, Imagine Schools, which has been under scrutiny elsewhere. In 2012, the Missouri Board of Education shut down all six Imagine charter schools in St. Louis for financial and academic woes. In response to such setbacks, Imagine Schools has moved toward “an even deeper commitment to increasing the consistency of our network-wide performance,” said Rhonda Cagle, a spokeswoman for the chain.

The two Fort Wayne schools performed well initially, but by the time their charters were up for renewal, they had some of the worst test results in the area, said Robert Marra, executive director of the charter office at Ball State University, which was responsible for the schools’ oversight. Imagine MASTer received a D grade from the state in 2013 and Imagine Schools on Broadway, an F.

The data for the two schools “showed clear room for improvement but indicated consistent growth,” Cagle told ProPublica.

In 2013, Imagine merged its two failing charters with a local parochial school, Horizon Christian Academy. Since then, the Christian academy’s enrollment has soared from 23 students to 492. About 430 students paid their tuition with the help of state vouchers last year, totaling about $2.4 million in public funds.

While some of Imagine’s students and staff have stayed on, Cagle said that Imagine has no involvement in the merged academy, other than owning the building.

“We could have allowed the buildings to just be empty, but we felt like if there was an interest by another entity for the purposes of education, that would be doing the right thing,” she said. Imagine “does not utilize vouchers for any of our schools,” she added.

Academically, Horizon Christian is far below average. Only 7 percent of its students passed both state exams this year, according to state data. One of its campuses received a D grade last year, and its other two failed. The academy did not respond to questions.

“Low-performing operators in Indiana and elsewhere have skirted accountability by converting their charter schools to private schools either right before or right after a charter revocation or nonrenewal,” said Brown, the former Indianapolis official. “I can say unequivocally that any attempt to keep a low-performing school open by evading rigorous accountability is not good for students, families, or the broader school choice movement.”


“Sometimes when you’re knocked down the hardest, you come back the hardest,” said Kelly Kenney, who started as the new principal of the Orange Park Performing Arts Academy this year, after the district terminated its charter contract this summer.
(Charlotte Kesl for ProPublica)

As it awaits its first infusion of voucher funds later this month, the Orange Park Performing Arts Academy is strapped. The district has repossessed most of the former charter school’s instructional supplies, including 200 Chromebooks, 34 laptops, 27 iPads and hundreds of textbooks. The arts — the school’s core mission — have been cleaned out: ten easels, nine digital pianos, eight heartwood djembes and four conga drums, all gone. Once lined with silver bleachers, the walls of the cavernous gym are now bare.

Many children have left, too. While the school had about 170 students last year, only 94 enrolled this fall. At least one quarter are kindergarteners, who didn’t attend the charter school. Tanya Bullard, who pulled her three daughters out of Orange Park, predicted it would slide further as a private school, because there will be “no one to keep an eye on it and issues will be swept under the rug.”

The school’s new principal, Kelly Kenney, isn’t deterred. She said that she has already made significant strides to separate the school from its failed days as a charter. Most of the teachers and administrators are new hires, although half of the teachers are uncertified. Kenney plans to get the school accredited, and strengthen the board of directors. “It can’t be a board of friends,” she said. She has been working with each teacher individually to raise standards and improve curriculum.

“Most people would have been defeated,” Kenney said. “Sometimes when you’re knocked down the hardest, you come back the hardest. And so for parents that have been skeptical, I’m like ‘This will be the best year of education your child will ever have. We’re going to be looking at every detail of their progress, every detail of their learning gap to make sure that we’re closing it.’”

Even though it’s not required, Kenney intends to publish her students’ performance data on the school’s website. “It’s important for us to show how we did compared to last year,” she said.

To recruit students this past summer, Kenney went door to door in nearby apartment complexes, hosting information sessions in laundry rooms. Believing that they couldn’t afford a private school, many families were reluctant to send their children to Orange Park — until Kenney told them about vouchers. For weeks, she and her staff have worked around the clock to sign up all the students in the voucher program, even helping them organize, fill out and fax in the necessary paperwork.

Bria Joyce is a loyalist. When her son started kindergarten at the local public school, she says he was “bumping heads” with classmates and she worried that he wasn’t receiving enough attention from teachers. She transferred him to the Orange Park charter school, where he took piano lessons and played Grandpa Joe in a production of “Charlie and the Chocolate Factory.”

When Joyce heard that the school was converting to a private school, she was nervous that she wouldn’t be able to afford the tuition. But the school reached out to her immediately and walked Joyce through the voucher process. Now Joyce’s son is starting fourth grade there.

“They were prepared and made it as easy as they could, considering everything,” she said. “I believe in what they’re trying to get done.”

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Attorneys General in 37 States Urge Insurance Industry to Do More to Curb Opioid Epidemic

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Attorneys general for 37 states sent a letter Monday to the health insurance industry’s main trade group, urging its members to reconsider coverage policies that may be fueling the opioid crisis.

The letter is part of an ongoing investigation by the state officials into the causes of the opioid epidemic and the parties that are most responsible. The group is also focusing on the marketing and sales practices of drug makers and the role of drug distributors.

On Sunday, ProPublica and The New York Times reported that many insurance companies limit access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications. The safer drugs are more expensive.

In their letter to America’s Health Insurance Plans, the trade group based in Washington, D.C., the attorneys general urged insurers to revise their rules “to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain.”

“The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable,” the letter said. “We ask that you quickly initiate additional efforts so that you can play an important role in stopping further deaths.”

The signatories include the attorneys general of California, Florida, New York, Pennsylvania and Michigan.

While opioids, such as hydrocodone and morphine, are often prescribed to relieve pain, they also have been linked to abuse and dependence. Drug overdoses are now the leading cause of death among Americans under 50, and more than 2 million Americans are estimated to misuse opioids. While the crisis has placed the practices of drug makers, pharmaceutical distributors, pharmacies and doctors under scrutiny, the role of insurers in enabling access to cheap, addictive opioids has received less attention.

The Department of Health and Human Services is now studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that insurers are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.

Last week, the New York state attorney general’s office sent letters to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.

In a written statement to ProPublica, Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, said that, “We share the state attorneys general’s commitment to eradicating the opioid epidemic in America.”

“Health plans cover comprehensive, effective approaches to pain management that include evidence-based treatments, more cautious opioid prescribing, and careful patient monitoring,” Donaldson wrote. “Recent research shows that non-opioid medications, even over-the-counter medication like ibuprofen, can provide just as much relief as opioids.”

Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. A number of companies say they have seen marked declines in monthly opioid prescriptions in the past year or so. Moreover, at least two large pharmacy benefit managers, which run insurers’ drug plans, announced this year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply.

“Patients and their care providers should talk openly and honestly about pain and how to manage it — from lifestyle changes and exercise to over-the-counter options and clearly understanding the dangers of opioids,” Donaldson said.

Drug companies and doctors have been accused of fueling the opioid crisis, but some question whether insurers have played a role, too.

Nonetheless, ProPublica and The New York Times found that companies are sometimes refusing to cover less risky drugs prescribed by doctors while putting no such restrictions on opioids.

We analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them.

Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. And even if they do approve coverage, some insurance companies have set a high out-of-pocket cost for Suboxone, rendering it unaffordable for many addicts, a number of pharmacists and doctors said.

“Everyone — including and especially insurance companies — have an obligation to address the opioid epidemic,” New York Attorney General Eric T. Schneiderman said in a press release today. “Insurers must take a hard look at the systemic problems in our healthcare system that result in the over-prescription of opioids and fuel the cycle of addiction.”

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The Trumps Say They’re Opening Hotels in Dallas, Nashville and Elsewhere. We Couldn’t Find Evidence of Them.

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by Matt Drange, Forbes, Alan Huffman, special to ProPublica, and Derek Kravitz, ProPublica

Earlier this summer, the Trump Organization announced big plans to open a line of hotels across the country. The new brand, American IDEA, would be modestly priced and patriotically themed. “The product is very hometown and fits in every hometown in the United States,” Trump Hotels CEO Eric Danziger said during a presentation at Trump Tower in Manhattan, the same place where Donald Trump had announced his presidential campaign two years earlier.

American IDEA would be part of a wider rollout with another higher-end hotel line, Scion, that the Trumps had already unveiled. Progress on the hotels would be swift, Danziger said.

The Trump Organization had said it signed deals for Scion hotels in Nashville, Dallas, Cincinnati, Austin and New York. At various times, company officials have cited anywhere from 10 to 39 impending deals.

The Trumps declined to release any details about the deals. The Trump Organization wouldn’t name the developers partnering with it, or where the planned hotels would be. So we asked readers and journalists to help us figure out who the president’s company was working with and where.

What we’ve found are false starts, fizzled-out partnerships and, for a number of cities that the Trumps said they had deals in, no evidence of deals at all.

Nashville faced petitions after the Trump Organization said it was coming to town. But development and tourism officials we spoke to said they were unaware of any Trump hotel being planned. Bobby Bowers, senior vice president of operations for Hendersonville, Tennessee-based hotel industry research firm STR, said his company has no information about a Trump hotel partnership in Nashville, even among its “unconfirmed” listings. A spokesperson for the city’s convention and visitors bureau said the same thing.

In Dallas, a developer who had been working with the Trumps had declared the deal dead two months before the Trump Organization identified the city as a hotel site. (He also had plans for a Trump hotel in downtown St. Louis before political pressure and protests derailed it.)

The developer, Mukemmel “Mike” Sarimsakci, did not respond to a request for comment. If the plan is back on with Sarimsakci or a different partner in Dallas, city officials don’t appear to know about it. Requests for correspondence between the city and representatives of the Trump Organization, as well as requests submitted to Dallas’ Office of Economic Development, turned up no records.

Officials and hotel developers in Cincinnati also said they had not heard of any deals involving Trump.

And in Austin, the deal “died before Trump was elected,” the head of a firm that had been working on the project told the Austin Business Journal. “It’s absolutely 100 percent dead.”

Danziger declined to comment for this story. Other representatives for the Trump Organization’s hotel business did not respond to requests for comment.

As we previously detailed, the Trumps are moving forward on four hotels in the Mississippi Delta. The deals are in partnership with a pair of Indian-American hoteliers, one of whom had met Donald Trump on the campaign trail and later gave money to his presidential campaign.

Suresh Chawla met Trump at a private fundraiser in August 2016 and donated $50,000, split between Trump’s campaign and the Republican National Committee. Months later, Chawla, along with his business partner and brother Dinesh, reached an agreement with the Trump Organization on a $20 million Scion hotel and three other franchise agreements to convert existing hotels to the American IDEA brand.

We also found a few other cities where the Trumps have had early conversations about partnering with local developers.

Jon Willis, a politically active developer in Mesa, Arizona, said he met Donald Trump Jr. through a mutual connection at Turning Point USA, a conservative PAC, and started working on the Trump campaign last year. When Willis spent time with Donald Jr. at a campaign event in Arizona last year, he said they discussed expansion plans that the Trump Organization had in Las Vegas, where it has a condo-hotel tower in partnership with billionaire Phil Ruffin. “That was the extent of what we talked about,” Willis said, adding that the two “mostly just talked about our kids.”

Willis added that while he wasn’t working with the Trumps on their new hotel line, he would be more than open to it: “I’d love to be involved.”

Three other established hoteliers and financiers in the South told us they’d also welcome working with the Trumps. The Trump Organization has said it is meeting with potential partners in Mississippi.

Len Blackwell, an attorney in Gulfport, Mississippi, said he had heard rumors of the Trumps “poking around” on the coast. (The Trump Organization has said it is meeting with potential partners in Mississippi.)

Blackwell has had experience working with the Trumps. He represented Trump in a planned $80 million casino and hotel project in Gulfport in the mid-1990s. Trump abandoned the deal before ground was broken.

One issue, according to Blackwell, was that Trump’s representatives were reticent about following through on a required $250,000 deposit they had negotiated with the city.

“My experience with the Trump Organization and its attempt to put a casino in Gulfport was: Its representatives, including Mr. Trump, came to town and had a lot of public relations activity, and did in fact work toward a project but, when it came down to it, chose not to go forward,” he said.

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Why Are Drug Prices So High? We’re Curious, Too

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This story was co-published with The New York Times.

This much is clear: The public is angry about the skyrocketing cost of prescription drugs. Surveys have shown that high drug prices rank near the top of consumers’ health care concerns.

What’s not as clear is exactly why prices have been rising, and who is to blame.

For the last four months, The New York Times and ProPublica, the nonprofit investigative journalism organization, have teamed up to answer these questions, and to shed light on the games that are being played to keep prices high, often without consumers’ knowledge or consent. Katie reports from the health desk at The Times, and Charles is a senior reporter at ProPublica.

Our reporting journey has turned up some counterintuitive stories, like how insurance companies sometimes require patients to take brand-name drugs — and refuse to cover generic alternatives — even when that means patients have to pay more out of pocket.

Along the way, we’ve asked readers to share their stories about their struggles with high drug costs. We’ve heard from nearly 1,000 people.

In recent weeks, a few stories caught our eye. A woman in Texas, for example, told us that the company that manages her drug benefits, OptumRx, was going to start asking her to pay more out of pocket for Butrans, a painkilling patch that contains the drug buprenorphine. As a “lower cost alternative,” OptumRx, which is owned by UnitedHealth Group, suggested she try painkillers like OxyContin, even though they carry a higher risk of dependence.

A letter sent by OptumRx, a pharmacy benefit manager, to a member in Texas, suggesting she consider switching from the Butrans painkilling skin patch to drugs that carry a higher risk of abuse and dependence.
(Letter obtained by ProPublica)

“The whole point of pain management is to take the least amount of medication possible to manage your pain, so that you always have somewhere to go when the pain increases or changes,” she wrote to us. “This is irresponsible and scary ‘cost management.’ ” She did not want to use her name, saying her employer prohibited her from identifying herself, but she allowed us to share OptumRx’s redacted letter.

Her pharmacy benefit manager, she wrote, is “effectively contributing to the ‘opioid crisis’ with its own policies.”

A spokesman for UnitedHealth, Matthew N. Wiggin, said it takes the crisis seriously and wants to ensure that people with chronic pain get the appropriate treatment.

We’ve closely followed the opioid crisis and efforts to hold various parties accountable, among them drug manufacturers, pharmacies and emergency room doctors.

But these stories — about patients who believed their insurers were placing roadblocks in the way of less risky painkillers — felt new to us.

We followed up with several of the readers, and searched social media to see if other patients were talking about this.

Drug companies and doctors have been accused of fueling the opioid crisis, but some question whether insurers have played a role, too.

Then we asked for documents: billing statements from insurers, denial letters, call logs and doctors’ records. In the case of our lead example, a woman named Alisa Erkes, she also agreed to sign a privacy waiver allowing her insurer, UnitedHealthcare, to comment on her case.

Charles enlisted ProPublica’s deputy data editor, Ryann Grochowski Jones, to analyze data from Medicare prescription drug plans. The results showed that insurers were indeed placing more barriers to drugs like Butrans and lidocaine patches than to cheaper generic opioids.

Insurers say that they are doing their part by placing limits on new prescriptions for addictive painkillers, and that they are also doing more to monitor doctors’ prescribing patterns and to catch abuse by patients. Several insurers said they had seen declines in monthly opioid prescriptions, a sign of progress.

But their behavior has infuriated many patients, who say they want to avoid taking opioids if possible. They argue that insurers are too focused on a drug’s cost, since many of the painkillers with a lower risk of addiction are more expensive.

Our project examining high drug costs is not over. We are already digging into other corners of the prescription drug world, hoping to shed light on more of the hidden forces that are keeping drug costs high. Stay tuned, as well, for more stories that were inspired by our readers.

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Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers

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This story was co-published with The New York Times.

At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.

The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.

Drugmakers, pharmaceutical distributors, pharmacies and doctors have come under intense scrutiny in recent years, but the role that insurers — and the pharmacy benefit managers that run their drug plans — have played in the opioid crisis has received less attention. That may be changing, however. The New York State attorney general’s office sent letters last week to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.

ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.

In contrast, almost every plan covered common opioids and very few required any prior approval.

The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.

Alisa Erkes lives with stabbing pain in her abdomen that, for more than two years, was made tolerable by Butrans. But in January, her insurer, UnitedHealthcare, stopped covering the drug, which had cost the company $342 for a four-week supply. After unsuccessfully appealing the denial, Erkes and her doctor scrambled to find a replacement that would quiet her excruciating stomach pains. They eventually settled on long-acting morphine, a cheaper opioid that UnitedHealthcare covered with no questions asked. It costs her and her insurer a total of $29 for a month’s supply.

Erkes, who is 28, is afraid of becoming addicted and has asked her husband to keep a close watch on her. “Because my Butrans was denied, I have had to jump into addictive drugs,” she said.
(Kevin D. Liles for The New York Times)

The Drug Enforcement Administration places morphine in a higher category than Butrans for risk of abuse and dependence. Addiction experts say that buprenorphine also carries a lower risk of overdose.

UnitedHealthcare, the nation’s largest health insurer, places morphine on its lowest-cost drug coverage tier with no prior permission required, while in many cases excluding Butrans. And it places Lyrica, a non-opioid, brand-name drug that treats nerve pain, on its most expensive tier, requiring patients to try other drugs first.

Erkes, who is 28 and lives in Smyrna, Georgia, is afraid of becoming addicted and has asked her husband to keep a close watch on her. “Because my Butrans was denied, I have had to jump into addictive drugs,” she said.

UnitedHealthcare said Erkes had not exhausted her appeals, including the right to ask a third party to review her case. It said in a statement, “We will work with her physician to find the best option for her current health status.”

Matthew N. Wiggin, a spokesman for UnitedHealthcare, said that the company was trying to reduce long-term use of opioids. “All opioids are addictive, which is why we work with care providers and members to promote non-opioid treatment options for people suffering from chronic pain,” he said.

Dr. Thomas R. Frieden, who led the Centers for Disease Control and Prevention under President Obama, said that insurance companies, with few exceptions, had “not done what they need to do to address” the opioid epidemic. Right now, he noted, it is easier for most patients to get opioids than treatment for addiction.

Faced with competition, some pharmaceutical companies are cutting deals with insurance companies to favor their brand-name products over cheaper generics. Insurers pay less, but sometimes consumers pay more. Adderall XR, a drug to treat attention-deficit hyperactivity disorder, is a case in point.

Leo Beletsky, an associate professor of law and health sciences at Northeastern University, went further, calling the insurance system “one of the major causes of the crisis” because doctors are given incentives to use less expensive treatments that provide fast relief.

The Department of Health and Human Services is studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that they are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.

Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. “We have a very comprehensive approach toward identifying in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids,” said Dr. Mark Friedlander, the chief medical officer of Aetna Behavioral Health who participates on its opioid task force.

Aetna and other insurers say they have seen marked declines in monthly opioid prescriptions in the past year or so. At least two large pharmacy benefit managers announced this year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply. And bowing to public pressure — not to mention government investigations — several insurers have removed barriers that had made it difficult to get coverage for drugs that treat addiction, like Suboxone.

Experts in addiction note that the opioid epidemic has been changing and that the problem now appears to be rooted more in the illicit trade of heroin and fentanyl. But the potential for addiction to prescribed opioids is real: 20 percent of patients who receive an initial 10-day prescription for opioids will still be using the drugs after a year, according to a recent analysis by the CDC.

Several patients said in interviews that they were terrified of becoming dependent on opioid medications and were unwilling to take them, despite their pain.

In 2009, Amanda Jantzi weaned herself off opioids by switching to the more expensive Lyrica to treat the pain associated with interstitial cystitis, a chronic bladder condition.

But earlier this year, Jantzi, who is 33 and lives in Virginia, switched jobs and got a new insurer — Anthem — which said it would not cover Lyrica because there was not sufficient evidence to prove that it worked for interstitial cystitis. Jantzi’s appeal was denied. She cannot afford the roughly $520 monthly retail price of Lyrica, she said, so she takes generic gabapentin, a related, cheaper drug. She said it does not manage the pain as well as Lyrica, which she took for eight years. “It’s infuriating,” she said.

Jantzi said she wanted to avoid returning to opioids. However, “I could see other people, faced with a similar situation, saying, ‘I can’t live like this, I’m going to need to go back to painkillers,’ ” she said.

In a statement, Anthem said that its members have to meet certain requirements before it will pay for Lyrica. Members can apply for an exception, the insurer said. Jantzi said she did just that and was turned down.

Erkes, who is petting her dog, Kallie, once visited her pain doctor every two months. Since her insurer denied coverage of Butrans, she has gone back much more frequently, and once went to the emergency room because she could not control her pain.
(Kevin D. Liles for The New York Times)

With Butrans, the drug that Erkes was denied, several insurers either do not cover it, require a high out-of-pocket payment, or will pay for it only after a patient has tried other opioids and failed to get relief.

In one case, OptumRx, which is owned by UnitedHealth Group, suggested that a member taking Butrans consider switching to a “lower cost alternative,” such as OxyContin or extended-release morphine, according to a letter provided by the member.

Wiggin, the UnitedHealthcare spokesman, said the company’s rules and preferred drug list “are designed to ensure members have access to drugs they need for acute situations, such as post-surgical care or serious injury, or ongoing cancer treatment and end of life care,” as well as for long-term use after alternatives are tried.

Butrans is sold by Purdue Pharma, which has been accused of fueling the opioid epidemic through its aggressive marketing of OxyContin. Butrans is meant for patients for whom other medications, like immediate-release opioids or anti-inflammatory pain drugs, have failed to work, and some scientific analyses say there is not enough evidence to show it works better than other drugs for pain.

Dr. Andrew Kolodny is a critic of widespread opioid prescribing and a co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. Kolodny said he was no fan of Butrans because he did not believe it was effective for chronic pain, but he objected to insurers suggesting that patients instead take a “cheaper, more dangerous opioid.”

“That’s stupid,” he said.

Erkes’s pain specialist, Dr. Jordan Tate, said her patient had been stable on the Butrans patch until January, when UnitedHealthcare stopped covering the product and denied Erkes’s appeal.

Without Butrans, Erkes, who once visited the doctor every two months, was now in Tate’s office much more frequently, and once went to the emergency room because she could not control her pain, thought to be related to an autoimmune disorder, Behcet’s disease.

Tate said she and Erkes reluctantly settled on extended-release morphine, a drug that UnitedHealthcare approved without any prior authorization, even though morphine is considered more addictive than the Butrans patch. She also takes hydrocodone when the pain spikes and Lyrica, which UnitedHealthcare approved after requiring a prior authorization.

Erkes acknowledged that she could have continued with further appeals, but said the process exhausted her and she eventually gave up.

While Tate said Erkes had not shown signs of abusing painkillers, her situation was far from ideal. “She’s in her 20s and she’s on extended-release morphine — it’s just not the pretty story that it was six months ago.”

Many experts who study opioid abuse say they also are concerned about insurers’ limits on addiction treatments. Some state Medicaid programs for the poor, which pay for a large share of addiction treatments, continue to require advance approval before Suboxone can be prescribed or they place time limits on its use, both of which interfere with treatment, said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse. Drugs like Suboxone, or its generic equivalent, are used to wean people off opioids but can also be misused.

Dr. Shawn Ryan, who runs an addiction treatment practice in Cincinnati, said too many insurance companies put onerous barriers on patients needing medications to treat their addictions.
(Andrew Spear for The New York Times)

The analysis by ProPublica and The Times found that restrictions remain prevalent in Medicare plans, as well. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. Even when such requirements do not exist, the out-of-pocket costs of the drugs are often unaffordable, a number of pharmacists and doctors said.

At Dr. Shawn Ryan’s addiction-treatment practice in Cincinnati, called BrightView, staff members often take patients to the pharmacy to fill their prescriptions for addiction medications and then watch them take their first dose. Research has shown that such oversight improves the odds of success. But when it takes hours to gain approval, some patients leave, said Ryan, who is also president of the Ohio Society of Addiction Medicine.

“The guy walks out, and you can’t blame him,” Ryan said. “He’s like, ‘Hey man, I’m here to get help. What’s the deal?’”

ProPublica deputy data editor Ryann Grochowski Jones contributed to this report.

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