Whistleblower: Monterey Park-Based Medicaid Managed-Care Firm Improperly Denied Care To Thousands

December 8, 2017 by · Leave a Comment 

In early October, an executive at one of the nation’s largest physician-practice management firms handed her bosses the equivalent of a live grenade — a 20-page report that blew up the company and shook the world of managed care for poor patients across California.

For years, she wrote, SynerMed, a behind-the-scenes administrator of medical groups and managed-care contracts, had improperly denied care to thousands of patients — most of them on Medicaid — and falsified documents to hide it.

The violations were “widespread, systemic in nature,” according to the confidential Oct. 5 report by the company’s senior director of compliance, Christine Babu. And they posed a “serious threat to members’ health and safety,” according to the report, which was obtained by Kaiser Health News.

Days later, someone sent the report — labeled as a “draft” — anonymously to California health officials. Within weeks, state regulators had launched an investigation, major health insurers swept in for surprise audits, the company’s chief executive announced the firm would close and doctors’ practices up and down the state braced for a tumultuous transition to new management.

Jennifer Kent, California’s health services and Medicaid director, said her agency received the whistleblower’s report Oct. 8 and, working with health plans, confirmed “widespread deficiencies” at SynerMed, which manages the care of at least 650,000 Medicaid recipients in the state.

“I think it’s pretty egregious actions on the part of that company,” Kent said in an interview this week.

In a Nov. 17 order issued to insurers, state Medicaid officials said “members are currently in imminent danger of not receiving medically necessary health care services” due to SynerMed’s conduct. The state ordered insurers to determine how many enrollees experienced delayed or unfulfilled services.

Consumer advocates expressed alarm at the whistleblower’s findings and questioned why these problems went undetected for so long. Some said it underscores a lack of accountability among companies involved in Medicaid managed care — which receive billions in taxpayer dollars and have expanded significantly under the Affordable Care Act.

SynerMed headquarters in Monterey Park, Calif. The management firm oversaw care for 1.2 million patients. (Chad Terhune/California Healthline)

SynerMed headquarters in Monterey Park, Calif. The management firm oversaw care for 1.2 million patients. (Chad Terhune/California Healthline)

Linda Nguy, a policy advocate at the Western Center on Law and Poverty in Sacramento, called the situation “outrageous.”

“It raises questions about oversight by the state and the health plans,” she said.

Besides managing care for Medicaid patients, SynerMed also oversaw managed care services for people on Medicare and commercial insurance — 1.2 million patients in all. Physician groups it managed have contracts with most of the state’s largest insurers, such as Health Net, Anthem and Blue Shield of California.

SynerMed, founded in 2001 and based in the Los Angeles area, served as a key middleman in the managed-care industry between health plans and independent physician practices, and its role only grew after Medicaid was expanded under the ACA. Most, if not all, of the patients whose care it managed were in California.

Under Medicaid managed care, the government pays a fixed rate per patient to health plans, whose job is to coordinate patient care effectively and efficiently. In this case, health plans passed a share of their money — along with the financial risk of a fixed budget — to physician practices under SynerMed management.

As is typical in the managed-care industry, SynerMed and the physician practices could pocket whatever money they did not spend on patients and other expenses.

The whistleblower’s report does not address what the motivation was for falsifying denial letters to patients — except to note that the small team of employees felt intense pressure from their supervisors to clear a backlog of paperwork dating back months.

But Babu made clear that this was not a rogue operation. The methods they used were outlined in written training materials and knowledge of the procedures extended at least as high as a senior vice president, she wrote. After her investigation, other top executives were informed of her findings.

According to the report, she became aware of the problems in late September when a compliance manager heard about an employee falsifying a patient letter for an upcoming health plan audit.

Through interviews with sometimes tearful staffers, Babu wrote, she learned that an overworked team routinely fabricated denial letters without supervision from doctors or others with clinical training. The report suggested some cases were reviewed by medical personnel, but “staff members who are not clinicians could drastically misrepresent the medical director’s instructions.”

Some employees interviewed said they did not know what they did was wrong and said they were fearful of their bosses. One supervisor told Babu that these practices at SynerMed had persisted for many years and “that it had become normal for her,” according to the internal report.

Patients in Medicaid managed care and commercial plans are entitled to a written denial notice within two business days of the decision, giving them the ability to appeal to their health plan and then to regulators. Industry-wide, treatment denials were overturned in nearly 70 percent of all medical review cases handled by the state last year.

But the compliance department found that affected patients were not properly informed, and the violations “resulted in thousands of members unaware of their appeal rights going back years past. As such, members may experience delays in care, lapse in coverage, delay in access to care and or financial hardship.”

The denial letters fabricated by employees to satisfy auditors often were not sent to patients, according to Babu’s internal investigation. Employees also used software to backdate faxes to doctors’ offices to suggest physicians were informed promptly and properly about the denials.

The compliance investigation focused on activities at SynerMed and didn’t address what occurred at physician offices, so it is unclear what doctors knew and what patients actually were told when care was not authorized.

Babu said that “the severity of the conduct is magnified by the fact that a large number of SynerMed’s patient population is low-income, and likely unable to afford medical services not covered by their insurance.”Key Dates Whistleblower Kaiser Health News

In her report, Babu said she felt threatened and pressured to drop the matter during conversations with her boss, the general counsel and chief compliance officer. That person is identified elsewhere in the report as Renee Rodriguez.

During a meeting in her office on Oct. 3, Babu said “it seemed as if [Rodriguez] was trying to convince me to drop the case.”

The following day, Babu wrote “there is a likelihood that they [leadership of SynerMed] would terminate me. … I indicated that I would not stop fighting for what is just, and that I was prepared to involve the authorities as I now felt uneasy about everything.”

Babu couldn’t be reached for comment. Rodriguez didn’t return calls.

In a Nov. 6 email to employees, SynerMed’s chief executive, James Mason, said the company was shutting down. In a statement Wednesday to Kaiser Health News, apparently in reference to Babu, he said: “It is unfortunate that one of our employees jumped the gun and disclosed confidential information regarding our clients and members.”

Mason said the company suspended “this individual immediately so we could investigate exactly what information was transmitted,” including whether it included confidential patient information. That person and others were later laid off, he said, as health plan auditors stepped in and the company’s operations wound down.

He said the company took the allegations seriously and quickly investigated them.

In a separate statement, SynerMed’s chief medical officer, Dr. Jorge Weingarten, did not directly address whether rules were broken. Instead he emphasized that the company had protocols in which “all denials on the basis of medical necessity must be made by licensed physician or a licensed health care professional who is competent to evaluate the specific request.”

Health plans that contract with SynerMed’s medical groups condemned the alleged wrongdoing and said they were committed to helping any patients who may have been affected.

“There was a pattern of deception this organization was willing to engage in that raises integrity questions about the entire operation,” said John Baackes, chief executive of L.A. Care Health Plan. “For them it was better to cheat than follow the rules. We take it extremely seriously, particularly when lives are at stake in terms of getting timely access to care.”

Anthem Blue Cross, the nation’s second-largest health insurer, said some physician groups will be terminating their contracts with SynerMed due to the allegations. The company said it’s working closely with state officials and physicians “to ensure a smooth transition for all of our members affected by these changes.”

State Medicaid officials said health plans, at their own cost, also must collectively hire an independent firm to monitor activities at SynerMed during its shutdown to ensure an orderly transition and “retention of records.”

Nearly 11 million people in California’s Medi-Cal program, or 80 percent, are enrolled in managed-care plans, rather than the traditional fee-for-service system.

SynerMed billed itself as “one of the largest Medicaid/Medicare management service organizations in the nation.” Given its size and growing stature, insurers, doctors and regulators were caught off guard by the company’s sudden change of fortune.

“SynerMed has been at the forefront in how Medicaid expansion has moved forward in California,” said Bill Barcellona, senior vice president for government affairs at CAPG, a national trade group for physician organizations.

Unlike in private health insurance and Medicare Advantage, Barcellona said Medicaid managed care is more dependent on smaller physician groups that are less organized.

“SynerMed figured out they could create scale to provide some of the necessary infrastructure,” he said. “It has grown tremendously, and this has been a shock and a real setback.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Enriched By The Poor: Calif. Health Insurers Make Billions Through Medicaid

November 10, 2017 by · Leave a Comment 

Medicaid is rarely associated with getting rich. The patients are poor, the budgets tight and payments to doctors often paltry.

 

But some insurance companies are reaping spectacular profits off the taxpayer-funded program in California, even when the state finds their patient care is subpar.

 

A unit of Centene Corp., the largest Medicaid insurer nationwide, raked in $1.1 billion in profits from 2014 to 2016, according to state data obtained and analyzed by Kaiser Health News. Anthem, another industry giant, turned a profit of $549 million from California’s Medicaid program in the same period.

 

Overall, Medicaid insurers in the Golden State made $5.4 billion in profits from 2014 to 2016, in part because the state paid higher rates during the inaugural years of the nation’s Medicaid expansion under the Affordable Care Act. Last year, they made more money than all Medicaid insurers combined in 34 other states with managed care plans.

“Those profits are gigantic — wow,” said Glenn Melnick, a health economist and professor at the University of Southern California.

 

Alan Sager, a health-policy professor at Boston University, was surprised — and dismayed.

 

“California is being wildly open handed and excessively generous with insurers,” he said.

 

Jennifer Kent, California’s Medicaid director, said that health plan profits were higher than anticipated during the ACA expansion. But she said the state expects to recoup a significant amount of money within the next year, once audits are complete and retroactive rate adjustments are made.

 

“We’re going to be taking a lot of money back. We’re talking billions of dollars,” Kent said in an interview last week. No one should think “these plans just made off like bandits and we’re not going to see them again … We are very mindful we use taxpayer money.”

 

Health insurers who profited substantially from Medicaid, known as Medi-Cal in California, defend their good fortune. They say these surpluses follow losses in earlier years, and they always run the risk of red ink if medical costs jump.

 

“The expansion may have been a little rich in the beginning,” said Jeff Myers, chief executive of the Medicaid Health Plans of America, an industry trade group. But “you are starting to see margins come back down.”

 

More than 1 in 3 Californians, or 13.5 million people, are covered by Medicaid — more than the entire population of Pennsylvania. About 80 percent of those in California’s program are enrolled in a managed-care plan, in which insurers receive a fixed rate per person to handle their medical care. The goal is to control costs and better coordinate care.

 

In anticipation of the Obamacare rollout, officials in California and elsewhere boosted their payments to managed-care companies because they expected Medicaid costs to increase as newly insured patients rushed to the doctor or emergency room after going years without coverage. But those sharply higher costs didn’t materialize — and insurers pocketed more money as a result.

 

Moreover, California’s payments keep flowing steadily even when patients fare poorly. Two of the most profitable insurers in California — Centene and Anthem — run some of the worst-performing Medicaid plans, according to medical quality scores and complaints in government records.WEB1-quality-ratings-highted4

 

“If there is that much extra money sloshing around in California, then it’s worth asking whether you could expect more in terms of performance,” said Andy Schneider, a research professor with Georgetown University’s Center for Children and Families.

 

California officials acknowledge they need to do a better job of connecting money and quality.

 

“We are looking at alternative payment methods and those types of things that we can do to help improve and to tie quality to payment,” said Lindy Harrington, a deputy director at the California Department of Health Care Services, which runs Medi-Cal. “But as you can imagine, it’s a difficult ship to turn.”

 

Medi-Cal Suddenly A Cash Cow

 

 

Before the ACA expansion, California’s Medicaid plans collectively were barely in the black, with $226 million of net income for 2012 and 2013 combined. Traditionally, these insurance contracts have yielded slim profit margins of 2 percent to 3 percent. California said it aims for 2 percent when setting rates, based on prior claims experience and projected costs.

 

But in the years since the health law took effect, many health insurers have posted margins two or three times that benchmark.

 

Centene’s Health Net unit in California enjoyed a profit margin of 7.2 percent from 2014 to 2016. Centene acquired Health Net for $6.3 billion in March 2016. Anthem’s profit margin in California’s Medicaid program was 8.1 percent for 2014 to 2016.

 

Investors have cheered those results. Shares in Anthem have more than doubled since January 2014, when the Medicaid expansion began. Centene shares are up 50 percent since the company purchased Health Net last year.

 

“We have proven our ability to provide high-quality, cost-effective healthcare to state beneficiaries while saving states money and delivering strong returns to our shareholders,” Michael Neidorff, Centene’s chairman and chief executive, told investors in February.

 

In a statement, Health Net said its profit margins are comparable to other Medi-Cal health plans and the company has made major investments to improve Californians’ health and access to care.

WEB2-profits-healthnet2

Anthem declined to comment on its financial results. The company said in a statement that it has worked with the state to meet the needs of Medicaid patients by extending clinic hours and helping with transportation to appointments. The company said it’s committed to providing “high quality care to our Medi-Cal members.”

 

Charles Bacchi, chief executive of the California Association of Health Plans, said they deserve some credit for making the Medicaid expansion work.

 

“The expansion was an incredible lift and we can’t do it for nothing,” he said. “It would be a shame to look at one snapshot in time and ignore the success of California’s expansion that has helped millions of people.”

 

Overall, Centene has 7 million Medicaid enrollees across the country, with about 2 million in California. Anthem is close behind with 6.4 million Medicaid members, about 1.3 million in the state.

 

With so many people’s healthcare at stake, state officials say they did not want to risk having health plans come up short during the expansion.

 

As it turned out, they need not have worried.

 

A nationwide study published in September found that average monthly spending on newly eligible Medicaid enrollees was 21 percent less than the amount spent on those who were already eligible. It helped that many of the new enrollees appeared to use fewer medical services than those already on the program, researchers said.

 

In 34 states and the District of Columbia, Medicaid managed-care profits more than tripled to $3.9 billion in 2015 from $1.1 billion in 2013, according to consulting firm Health Management Associates’ analysis of insurance filings. Those figures don’t include California.

 

By 2016, profits dropped as some states reduced Medicaid rates to insurers to reflect the lower costs incurred during expansion. Kent, the California Medicaid director, said the state’s rates paid to insurers for enrollees in the expanded program have decreased by 38.5 percent since January 2014.

 

The federal government footed the entire bill for Medicaid expansion during the first three years, instead of taking the usual approach of splitting the costs with states. Now, states have more incentive to rein in spending, as their share of the costs grows to 10 percent by 2020.

WEB3-medicaid_profitslosses

 

Quality Not In The Equation

 

In the meantime, however, some evidence suggests that in California, richer plans provided care of poorer quality.

 

The state scores Medi-Cal insurers from zero to 100 percent on how they perform on dozens of measures, such as diabetes testing, cancer screenings and checkups for children. Statewide, the average score was 63 percent for 2016.

 

For Centene and its Health Net unit, seven of its 10 regional health plans in Medi-Cal scored below average on quality. The company’s San Joaquin health plan ranked last statewide at 31 percent. State officials have ordered the company to improve in areas such as ensuring women get postpartum care and providing routine eye exams and other tests for diabetics.

 

Among patients, a chief complaint is how hard it is to find a specialized doctor. In a March audit, Medi-Cal said Health Net “did not maintain an adequate number of specialists within its network.” The state found that “member grievances on referral for services and availability of appointments with specialists were among the highest complaints.”

 

Five months later, after reviewing the company’s corrective actions, the state said Health Net was back in compliance.

 

Chandra Marshall, a Medicaid patient in Modesto, Calif., said she has suffered from limited access to specialty care.

 

She said her primary-care doctor in her Health Net plan recently recommended she visit a dermatologist for a biopsy. But she said the only available dermatologist on her plan was 90 miles away in San Francisco.

 

Worried she might have skin cancer, Marshall agreed to go but still hasn’t heard back about an appointment.

 

“Why can’t Health Net afford more specialists in the area?” said Marshall, who also suffers from kidney disease. “If Health Net doesn’t provide access to dermatologists and other specialists, people may just risk [not going].”

 

Her Health Net plan in Stanislaus County scored below 50 percent on quality care measures.

 

In a statement, Health Net said it is “committed to helping improve the quality and availability of healthcare services for our members that produce enhanced health outcomes. We work diligently with our contracting medical groups to help ensure our members get care that is easy to access.”

 

In the case of Anthem, eight of its 12 regional Medi-Cal plans scored below average on patient care. The state has told Anthem to do better at providing prenatal care, controlling patients’ high blood pressure and monitoring medications for asthma patients, among other issues.

 

In a written response to questions, Anthem said its scores have improved over time and two of its plans, in San Francisco and Tulare counties, are among the top 10 statewide.

 

While not tied directly to payments, California officials said they do reward insurers with higher quality scores by assigning more Medicaid enrollees to those plans.

 

 

Profits A Political Hot Button

 

 

The profits of managed care plans feed into Republican criticism of the ACA’s costs and its expanded Medicaid rolls. President Donald Trump has called for the law’s repeal, in part, because it enriches health insurers.

 

“They have made a fortune,” Trump tweeted on Oct. 13.

 

Sen. Ron Johnson (R-Wis.) has demanded that California and seven other states account for how they spent federal Medicaid expansion dollars. Johnson, chairman of the Senate Homeland Security and Governmental Affairs Committee, asked California officials in a letter Sept. 27 whether they have conducted audits and requested information on insurance company payouts.

 

In an Oct. 11 response, Kent said the state spent $6,181 per expansion enrollee in 2015, below the national average of $6,365.

 

“California is a cost efficient Medicaid program,” she wrote.

 

By one standard measure, the state’s oversight has been less than efficient.

Starting in 2014, the federal government required that 85 percent of Medicaid expansion funding be spent on care and quality improvement efforts, rather than administrative overhead and profits. But three years in, California officials acknowledged they have just started audits to determine whether companies might have to return excess money.

 

What’s clear is that insurers’ spending on both expansion and traditional Medicaid enrollees often falls short. Eight of California’s 22 Medicaid insurers failed to hit 85 percent in medical spending for the year ending June 30, 2016, according to state data obtained by Kaiser Health News. Anthem ranked lowest at 77 percent; Health Net spent 81 percent of Medicaid premiums on medical care, state records show.

 

Each percentage point below the threshold can amount to tens of millions of dollars that should have been spent on behalf of patients.

 

In July, a federal rule went into effect establishing 85 percent as a national benchmark for all Medicaid managed care. Three months later, California Gov. Jerry Brown signed a law mandating that same percentage. But the state requirement doesn’t kick in fully until 2023.

 

Michael McCue, a professor at Virginia Commonwealth University who studies Medicaid managed care, said the profit margins in California “raise a lot of red flags.” He said government officials owe it to taxpayers and patients to do more to hold insurers accountable.

 

“You have to make sure you’re getting a bang for your buck,” McCue said. “Right now, [for insurers] California’s Medicaid program is the golden nugget.”

 

 

2 Senators Reach Deal On A Health Law Fix, But Bringing Congress Along Is Tricky

October 19, 2017 by · Leave a Comment 

After nearly two months of negotiations, key senators said Tuesday they have reached a bipartisan deal on a proposal intended to stabilize the Affordable Care Act’s insurance market, which has been rocked by recent actions by President Donald Trump.

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), respectively the chairman and the top Democrat of the Senate Health, Education, Labor and Pensions Committee, negotiated the emerging deal. The milestone agreement, they said, would guarantee payment of “cost-sharing reduction” subsidies that help some policyholders with low incomes afford their deductibles and other out-of-pocket costs for two years, 2018 and 2019.

Trump announced last week that he would stop funding the subsidies, which have been the subject of a long-running lawsuit. These subsidies are separate from the tax credit subsidies that help eligible consumers pay for their premiums. Those premium subsidies are not affected by Trump’s action.

Even if it fails to become law, the deal marks a singular achievement that has been almost completely missing in Congress for the past eight years — a bipartisan compromise on how to make the nation’s health insurance system work.

“This is an agreement I am proud to support,” said Murray on the Senate floor, “because of the message it sends about how to get things done.

The proposal — which will require 60 votes to pass the Senate and agreement from a still-dubious House of Representatives — would also restore $110 million in “outreach” funding cut by the Trump administration. That funding would help guide eligible individuals to sign up for coverage on the health insurance exchanges during the open enrollment period that runs from Nov. 1 to Dec. 15.

In exchange for those provisions, urged by Democrats and state officials, Republicans will win some changes to make it easier for states to apply for “waivers” that would let them experiment with alternative ways to provide and subsidize health insurance. The deal would also allow the sale of less comprehensive “catastrophic” plans in the health exchanges. Such plans currently can be sold only to those under age 30.

On the Senate floor Tuesday afternoon, Alexander said, “This agreement avoids chaos. I don’t know a Democrat or a Republican who benefits from chaos.”

Senate Majority Leader Mitch McConnell (R-Ky.) reserved judgment about the deal.

Sens. Patty Murray, (D-Wash.) and Lamar Alexander (R-Tenn.) brokered a bipartisan healthcare fix, but getting it through Congress could prove difficult.

Sens. Patty Murray, (D-Wash.) and Lamar Alexander (R-Tenn.) brokered a bipartisan healthcare fix, but getting it through Congress could prove difficult.

Both parties still have some major disagreements when it comes to health care, Senate Minority Leader Chuck Schumer (D-N.Y.) told reporters Tuesday afternoon, but “I think there’s a growing consensus that in the short term we need stability in the markets. So we’ve achieved stability if this agreement becomes law.”

More than 60 senators have already participated in the meetings that led to the deal, Alexander said on the Senate floor. But the path to passage in the House is uncertain — with many conservatives vehemently opposed to anything that could be construed as helping the law they call “Obamacare” succeed.

Tweeted Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee, Tuesday: “The GOP should focus on repealing & replacing Obamacare, not trying to save it. This bailout is unacceptable.”

Both Murray and Alexander said Tuesday they were still struggling over language to make sure that if the cost-sharing payments are resumed, insurers would not receive a windfall by keeping both those payments and the higher premiums that many states are allowing in anticipation of the payments being ended.

“We want to make sure that the cost-sharing payments go to the benefit of consumers, not the insurance companies,” Alexander said.

Trump, who as recently as Monday called the cost-sharing subsidies “a payoff” to insurance companies, took credit for the negotiations. “If I didn’t cut the CSR’s, they wouldn’t be meeting,” he said. That was not, in fact, the case. The negotiations had picked up some weeks ago after being called off earlier in September while the Senate tried for one last-ditch repeal vote.

On Friday, White House Budget Director Mick Mulvaney told Politico that the president would not allow a short-term fix, calling a restoration of the cost-sharing reduction funds “corporate welfare and bailouts for the insurance companies.”

But on Tuesday the president hailed the deal. “We think it’s going to not only save money, but give people much better health care with a very, very much smaller premium spike,” he told reporters.

 

This story was produced by Kaiser Health News, an editorially independent service of the California Health Care Foundation.

Para los ‘anti-vacunas’, hay otras Formas de Evitar requisito Escolar

September 28, 2017 by · Leave a Comment 

El año pasado, padres inundaron a la doctora Tara Zandvliet con llamadas y correos electrónicos, después que California aprobara una ley poniendo fin al uso de las creencias personales como una exención para las vacunas de la escuela. De repente, muchos padres solicitaron exenciones por razones médicas.

Alguien incluso falsificó dos formularios de exención médica supuestamente escritos por el pediatra de San Diego, copiando un documento legítimo que había proporcionado para una paciente y escribiendo los nombres de estudiantes a quienes nunca había tratado, dijo. Se enteró de las falsificaciones sólo cuando la escuela le pidió una verificación.

Sólo una de cada 10 familias que la contactaron para tales exenciones podría citar una razón legítima, como una reacción alérgica grave a una vacuna anterior, aseguró Zandvliet. De los niños con problemas de salud válidos, estima que sólo un tercio merecía la exención.

Las familias que se oponen a la vacunación obligatoria para los estudiantes pueden estar buscando exenciones médicas para evitar la nueva ley estatal, según un estudio publicado en la revista JAMA, de la Asociación Médica Americana. La ley exige que los niños de kinder que ingresan a las escuelas públicas y privadas reciban todas las vacunas, independientemente de las creencias personales de las familias.

Antes del año escolar 2016-17, padres que se oponían a la vacunación, o como se los llama con frecuencia en inglés los “anti-vaxxers”, podían inscribir a sus hijos no vacunados en la escuela solicitando una exención por creencias personales – basada, por ejemplo, en convicciones religiosas o filosóficas.

Después de un brote de sarampión que se originó en Disneyland en 2014, y que resultó en 147 casos notificados en siete estados, California desechó la excepción por creencias personales. La ley, que fue fuertemente resistida por algunos padres, sí preservó las exenciones por razones médicas.

El aumento de las exenciones médicas sugiere que los padres que están en contra de la vacunación pueden encontrar médicos dispuestos a eximir a sus hijos del mandato, según los investigadores.

El estudio, que utilizó datos del Departamento de Salud Pública de California, muestra que el número de exenciones médicas entre los niños de kinder, aunque pequeño, se triplicó a 2.850 en 2016 respecto del año anterior. Mientras tanto, el número de exenciones por creencias personales en 2016 fue aproximadamente un cuarto de lo que había sido el año anterior (no bajaron a cero porque algunos pre-kinder tenían exenciones que se mantuvieron).

Sin embargo, la ley estatal da a los médicos más espacio para autorizar exenciones médicas, por ejemplo, para los niños con antecedentes familiares de reacciones adversas a las vacunas.

Paul Delamater, profesor asistente de la Universidad de Carolina del Norte-Chapel Hill y autor principal del estudio de JAMA, dijo que exenciones basadas en esta razón son incompatibles con la recomendación de la Academia Americana de Pediatría. La entidad afirma que las exenciones médicas deben reservarse para los estudiantes que realmente podrían ser perjudicados por la vacunación, como aquellos con un sistema inmune débil debido a la quimioterapia o una reacción peligrosa conocida a un ingrediente de la vacuna.

Muchos de los condados de California con los mayores aumentos de exenciones médicas desde que la ley entró en vigor están en el norte del estado, incluyendo Shasta, Plumas, Sonoma y Marin. Algunos que tenían altos porcentajes de exenciones por creencias personales antes de la ley tuvieron los mayores aumentos en exenciones médicas después que se aprobara la nueva norma, dijo Delamater.

En el condado de Orange, en el sur de California, el número de exenciones médicas pasó de 92 en el año escolar 2015-16 a 348 en 2016-17, según los datos estatales. El número de exenciones por creencias personales disminuyó de 1.270 a 269 en el mismo período.

“El aumento de la exención médica es preocupante”, dijo Catherine Flores-Martin, directora ejecutiva de la California Immunization Coalition, una asociación público-privada que promueve las vacunas y copatrocinó la ley de vacunas del estado.

Flores-Martin dijo que los profesionales de salud esperaban un aumento a corto plazo de las exenciones médicas, porque los padres con niños que realmente tenían razones médicas para no vacunarse anteriormente podrían haber obtenido exenciones por creencias personales, que eran más fáciles de obtener.

Pero el aumento de las exenciones médicas es mayor de lo que ella misma había anticipado, dijo Flores-Martin, agregando que algunos médicos pueden estar ofreciéndoselas incorrectamente a muchos padres.

“Sería inusual que un niño esté exento de todas las vacunas para siempre, porque eso es bastante extremo. Se ve patrones [para tales exenciones] en algunas de estas escuelas. No creo que sea una coincidencia”, dijo.

Su grupo está animando a la gente a contactar a la Junta Médica de California si se encuentran con médicos que escriben exenciones médicas para afecciones como el asma que no están incluidas bajo la ley estatal.

“Realmente no depende de los padres”, dijo Flores-Martin. “Algunos médicos pueden sentirse empoderados si… sienten que pueden hacerlo sin escrutinio ni consecuencias. Es un problema que los médicos deben abordar con sus colegas, y vamos a ayudar a iniciar esa conversación. Corresponde a los médicos comportarse profesionalmente”.

Muchos padres que no quieren vacunar a sus hijos, incluyendo a algunos opositores fuertes de regiones ricas y bien educadas del estado, dicen que les preocupa que las vacunas estén relacionadas con el autismo, a pesar de la abrumadora evidencia científica que demuestra que no están relacionadas.

Zandvliet, la doctora de San Diego, intenta adoptar un enfoque juicioso. A diferencia de otros médicos, ella no cobra extra por exenciones por escrito. Pero sí les pide a las familias que solicitan una exención proporcionar documentación médica de la condición del niño.

Aunque dijo que aún no ha escrito una exención médica permanente para todas las vacunas, ha escrito “exenciones médicas leves”, que exime a los estudiantes de una o más vacunas por un período limitado. A veces, escribe una exención para los estudiantes con hermanos que experimentaron una reacción adversa a la vacuna, aunque reconoce que no hay estudios que demuestren que es útil hacerlo.

Para las familias que buscan exenciones sin una razón de salud, tal vez porque están mal informadas o filosóficamente opuestas a las vacunas, Zandvliet aprovecha la oportunidad para educarlos. A veces, logra que padres renuentes vacunen parcialmente a sus hijos o que se extiendan las vacunas sobre un período más largo de lo recomendado por los Centros para el Control y Prevención de Enfermedades (CDC).

“Si, como médicos, dejamos de escuchar, vamos a desalentar a la gente”, dijo Zandvliet. “Los médicos están diciendo: ‘Si no va por el calendario de los CDC para las vacunas, salga de mi oficina.’ Así que no lograron que ese niño se vacunara, y no lo protegieron’’.

Pamela Kahn, presidenta electa de la Organización de Enfermeras Escolares de California, quien trabaja en el condado de Orange, dijo que California tiene un fuerte historial de vacunación pero que las enfermeras escolares sólo pueden educar hasta cierto punto a los padres que se oponen a las vacunas.

“En general, las tasas de vacunas son realmente altas en California después de que esta ley entrara en vigor”, dijo Kahn. “Cuando se compara la cantidad de niños que estaban exentos entre ambos grupos, todavía estamos muy por delante en el juego”.

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