Category: Rehab News

The director of California’s mental health commission traveled to London this summer courtesy of a state vendor while he was helping to prevent a $360 million budget cut that would have defunded the company’s contract.

Emails and calendars reviewed by California Healthline show Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, made efforts to protect funding for Kooth, a London-based digital mental health company the state hired to develop a virtual tool to help tackle its youth mental health crisis. Ewing pressed key legislative staffers to maintain its contract, even as Democratic Gov. Gavin Newsom and lawmakers proposed cuts in the face of California’s $45 billion deficit.

When Ewing and three commissioners — Mara Madrigal-Weiss, the commission chair; Bill Brown; and Steve Carnevale — left for London in June, Ewing wasn’t sure whether he had saved Kooth’s funding. On the second day of their trip, staff informed him that lawmakers had restored the money.

A few days later, he emailed Kooth Chief Operating Officer Kate Newhouse suggestions he had shared with Assembly and Senate staff to improve Kooth’s youth teletherapy app. “We expect you to be involved in whatever we dream up,” Ewing wrote to Newhouse in another email.

It’s unclear why Kooth picked up a $15,000 tab for state officials to travel to London. It’s also unclear why Ewing pushed to protect its app from a spending cut. The commission is a 16-member independent body appointed by various elected officials to help ensure funds from a millionaires tax are used appropriately and effectively by counties for mental health services. Kooth’s contract is with the Department of Health Care Services, which is separate from the commission.

Kooth last year signed a four-year $271 million contract to create Soluna, a free mental health app for California users ages 13 to 25. The app, along with another, by the company Brightline, for younger users, launched in January to fill a need for young Californians and their families to access professional telehealth for free. It’s one component of Newsom’s $4.7 billion youth mental health plan.

Ewing, who reports to the commission, started in 2015 and earned $175,026 in 2023, according to The Sacramento Bee. He was placed on paid administrative leave in September pending an investigation. Commission chief counsel Sandra Gallardo said the commission does not comment on personnel matters. Ewing did not respond to requests for comment.

Three commission employees filed whistleblower complaints against Ewing in September with the California State Auditor. They spoke with California Healthline on the condition that their names not be used due to fears of workplace retaliation. They say Ewing’s conduct advancing a private company’s agenda as a public official crossed a line.

The agenda for Thursday’s commission meeting listed a personnel matter to be discussed in closed session. The whistleblowers said Ewing is the subject of the discussion.

Madrigal-Weiss said she couldn’t comment on Ewing’s actions. However, she said the commission supports virtual mental health resources for youth.

“These resources are less expensive and have proven valuable for youth, especially those who struggle to access services in typical brick-and-mortar spaces,” said Madrigal-Weiss, who is also executive director of student wellness and school culture for the San Diego County Office of Education.

Brown and Carnevale didn’t respond to requests for comment.

Kooth is committed to advancing youth access to behavioral health services, said Caroline Curran, of Metis Communications, a public relations firm representing Kooth.

“As a leader in youth behavioral health services with over 20 years of experience in the United Kingdom and the United States, we regularly convene sector-leading organizations to facilitate learning through sharing expertise and diverse perspectives on youth behavioral health,” Curran said.

As California Healthline reported in April, the Kooth and Brightline app rollouts have been slow, with few children using them. In May, Newsom proposed a $140 million budget cut. DHCS Director Michelle Baass said in a hearing that it was due to low use, but the state expects more users to come on board over time.

She told lawmakers on May 16 that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps, and they had been used for only about 2,800 coaching sessions.

State Sen. Caroline Menjivar (D-Van Nuys) asked Baass at the hearing whether “there’s room to get out” of the contract altogether. Senators later voted unanimously to cut the entire platform budget to save the state $360 million.

Ewing texted a colleague on June 3: “Kooth is freaking out.  Is the cut coming from the Admin or the Leg.? Do we know if it’s a done deal?”

State lobbying records show Kooth has paid around $100,000 this year to the firm Capital Advocacy. At the same time, Ewing’s emails and calendars show that he pushed for Kooth’s funding to be retained. For instance, his June 4 calendar shows he was scheduled to meet with Laura Tully, an executive from Kooth USA, at a coffee shop near the Capitol.

The next day, a whistleblower said, Ewing met with key Senate staff members: Scott Ogus, deputy staff director of the Senate Budget and Fiscal Review Committee, and Marjorie Swartz, a consultant for Senate President Pro Tempore Mike McGuire. They said Ewing also discussed Kooth’s contract that week with Rosielyn Pulmano, a health policy consultant for Assembly Speaker Robert Rivas.

“Toby kept saying that ‘California has to have a digital strategy,’” recalled the whistleblower, who attended both meetings. “He kept pushing Marjorie and Scott, saying that he would give them ideas to make the platform better.”

Ewing emailed ideas to the legislative aides on June 10 and 12.

About two weeks later, he and the commissioners left for the seven-day trip to the U.K. According to documents filed with the state Fair Political Practices Commission, receipts, and emails reviewed by California Healthline, Kooth covered the costs of four-star hotels, meals, train tickets, and international flights.

Public disclosure forms show Kooth paid expenses for Ewing, Madrigal-Weiss, and Brown. The forms do not show the company paid for Carnevale’s travel.

Under California law, state officials generally must report travel payments to the FPPC, which Ewing and his fellow commissioners did.

Kooth postponed a mental health investment conference in London in June, emails and documents show, but then organized new events for the California commissioners to attend instead.

On May 23, Newhouse informed Carnevale and Ewing in an email that Kooth needed to postpone the planned June event. Carnevale, a venture capitalist, described the news as “disappointing for all,” especially “because we have already booked trips, including family members of Commissioners who were planning to turn this into a holiday.”

Acknowledging the disruption, Newhouse told Carnevale that she “would like to think creatively as to whether we could try to arrange a meeting where you can talk about the CYBHI,” referring to Newsom’s Children and Youth Behavioral Health Initiative.

“I know though from our conversation that we need to cover the ‘purpose’ of your trip and not sure what is possible or not,” she wrote.

Curran, the Kooth spokesperson, said the company “adapted by holding a knowledge exchange between representatives from international policy institutes, research foundations, and non-profit organizations.”

Madrigal-Weiss defended the trip, which she said included meetings with “members of the government, service providers, education, and finance” who shared ideas on how “to enhance funds for public mental health needs” through private and philanthropic partnerships.

One of the whistleblowers said many of the commissioners back in California were not aware of the trip until their colleagues were halfway across the world. Sami Gallegos, a spokesperson for the California Health and Human Services Agency, said the Department of Health Care Services did not participate in the travel.

Ewing was put on leave before Kooth’s rescheduled conference this month in London.

Although it’s not unusual for state officials to travel overseas — often on the dime of private entities — it doesn’t look good, said Sean McMorris, a government ethics expert with California Common Cause, a nonprofit government watchdog group.

“It looks like undue influence,” McMorris said. “I think a lot of people would view something like this as a way to curry favor. You can connect the dots.”

Kooth has similarly gifted travel to state officials in Pennsylvania, where it had a $3 million contract with 30 school districts. In each case, Kooth invited the officials to speak to highlight their work. Pennsylvania has informed Kooth it intends to terminate the contract.

Jackie Fortiér reported the audio story.

When people check in for their annual mammogram these days, some may face a surprising question: In addition to reviewing the mammogram for breast cancer, would the patient like the radiologist to examine the images for heart disease risk?

That’s what happened recently when a colleague visited Washington Radiology, a practice with more than a dozen locations in Washington, D.C., Maryland, and Virginia.

For $119, she was told, the practice would use artificial intelligence software to analyze her mammogram for calcification in the arteries of her breasts, which could indicate she’s at risk for cardiovascular disease.

Washington Radiology is one of a number of practices nationwide offering this type of screening. Here’s what to know about the screening and whether research supports it.

Although breast X-rays are typically used to detect and diagnose breast cancer, the pictures also indicate whether the arteries in the breast have calcifications, which show up as parallel white lines on the film. Calcifications, which are considered “incidental” findings unrelated to breast cancer, may be associated with someone’s heart disease risk. They’ve been visible on images for decades, and some radiologists have routinely noted them in their reports. But the information hasn’t typically been passed on to patients.

Now some practices make the results available to patients — sometimes for a fee.

Washington Radiology didn’t respond to interview requests, but in a video on its website describing the practice’s “Mammo+Heart” AI screening, Islamiat Ego-Osuala, a breast imaging radiologist there, said, “If the past few decades has taught us anything about the field of radiology, it is that the sky’s the limit. The possibilities are endless.”

Some imaging experts question that rosy assessment as it relates to screening for breast arterial calcification to gauge heart disease risk.

“What we’re seeing on the mammogram is calcification in the breast artery, but that’s not the same as the calcification in the coronary artery,” said Greg Sorensen, chief science officer at RadNet, which has nearly 400 imaging centers in eight states. RadNet doesn’t offer breast arterial calcification screening and has no plans to. “It doesn’t feel like it’s delivering value today,” Sorensen said.

(RadNet does offer patients an AI analysis of their mammograms to improve breast cancer detection. KFF Health News reported on that earlier this year.)

Coronary artery calcification is recognized as a strong marker of heart disease risk. But while studies have shown an association between breast arterial calcification and the risk of cardiovascular disease, questions remain.

For one thing, even women who don’t have breast arterial calcification might still be at risk of heart disease, heart attack, or stroke. In a study of postmenopausal women, 26% had breast arterial calcification, and over a 6½-year study period it was associated with a 23% increased risk of heart disease of any kind and a 51% increase in risk of heart attack or stroke. However, most cardiovascular events happened to women who did not have breast arterial calcification.

“I wouldn’t feel comfortable telling people they have a higher or lower risk of heart disease based on their breast arterial calcification,” said Sadiya Khan, a preventive cardiologist at Northwestern Medicine in Chicago who co-authored a medical journal editorial commenting on the study. “I think this is an exciting area, but we need to move cautiously.”

It’s understandable that women’s health clinicians would be eager to embrace the idea of using the annual breast cancer screening that millions of women get every year to screen for heart disease risk as well.

Heart disease is the No. 1 killer in the United States. It was responsible for more than 300,000 — or roughly 1 in 5 — women’s deaths in 2021.

Many women don’t recognize their heart disease risk or the many factors that increase it, such as high blood pressure, diabetes, high cholesterol, smoking, drinking too much alcohol, and being overweight.

Online calculators can help people assess their risk of cardiovascular disease. For those whose 10-year risk is 7.5% or higher, clinicians may recommend lifestyle changes and/or prescribe a statin to lower blood cholesterol. Laura Heacock, a radiologist who specializes in breast imaging at NYU Langone Health in New York City, pointed out that patients already can get much of the information resulting from breast arterial calcification scoring from their physicians and use of those risk calculators. The key is that breast arterial calcification screening provides another chance to talk about heart disease risk.

One study found that 57% of women who were informed that they had breast arterial calcification after a mammogram reported they had discussed their results with their primary care physician or a cardiologist.

Heacock said she’d like to see more studies showing that reporting breast arterial calcification leads to changes in patient care and fewer heart attacks and strokes.

Every woman who visits the Lynn Women’s Health and Wellness Institute in Boca Raton, Florida, for a mammogram is screened for breast arterial calcification. It’s been a standard service since 2020, said Heather Johnson, a preventive cardiologist at the center. If calcification is found, the woman is referred to a cardiologist or other health care practitioner at the center to discuss the findings and get more information about heart disease risk.

Johnson acknowledged that more studies are needed to understand the connection between calcification in breast arteries and heart disease. Still, she said, the screening “allows a communication pathway.”

Patients at the Boca Raton institute aren’t charged for the screening.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

On learning last year she was pregnant with her second child, Cailyn Morreale was overcome with fear and trepidation.

“I was so scared,” said Morreale, a resident of the small western North Carolina town of Mars Hill. In that moment, her joy about being pregnant was eclipsed by fear she would have to stop taking buprenorphine, a drug used to treat opioid withdrawal that had helped counter her addiction.

Morreale’s fear was compounded by the rigidity of the most common approach to treating babies born after being exposed in the womb to opioids or some medications used to treat opioid addiction.

For decades throughout the opioid crisis, most doctors have relied on medication-heavy regimens to treat babies who are born experiencing neonatal opioid withdrawal syndrome. Those protocols often meant separating newborns from their mothers, placing them in neonatal intensive care units, and giving them medications to treat their withdrawal.

But research has since indicated that in many, if not most, cases, those extreme measures are unnecessary. A newer, simpler approach that prioritizes keeping babies with their families called Eat, Sleep, Console is being increasingly embraced.

In recent years, doctors and researchers have found that keeping babies with their mothers and ensuring they’re comfortable often works better and gets them out of the hospital faster.

Despite her worst fears, Morreale was never separated from her son. She was able to begin breastfeeding immediately. In fact, she was told, the trace of buprenorphine in her breast milk would help her son withdraw from it.

Her experience was different because she had found her way to Project CARA, an Asheville, North Carolina-based program, administered through the Mountain Area Health Education Center, that supports pregnant people and parents with substance use disorders. Morreale’s care team assured her she did not need to discontinue buprenorphine and that her baby would be assessed and monitored using the Eat, Sleep, Console approach. The protocol deems babies OK to be sent home so long as they’re eating, sleeping, and consolable when upset.

“By the grace of God, he was awesome,” Morreale said of her son.

David Baltierra, former director of West Virginia University’s Rural Family Medicine Residency Program, chair of WVU’s Department of Family Medicine – Eastern Division, and a family physician, suggests this protocol could simply be called “parenting.”

The method is increasingly being used instead of the long-embraced approach to treating opioid-affected newborns called the Finnegan Neonatal Abstinence Scoring System. That tool includes a list of 21 questions (is the baby crying excessively, sweating, experiencing tremors, sneezing, etc.), the answers to which determine whether the newborn should get medication to counteract withdrawal symptoms, which would then require an extended stay in a neonatal ICU.

Baltierra, though, has issues with the Finnegan method. For example, it often results in a soundly sleeping baby being awakened to be scored. That didn’t make sense to Baltierra. If the baby is sleeping, she’s likely doing fine.

Instead, health professionals should look for the telltale signs of a baby experiencing opioid withdrawal syndrome, he said. “Their body is in tension, they have a high pitch, they don’t calm down.”

Baltierra and his colleagues have been training residents to use an Eat, Sleep, Console approach for a decade, progressively more so in the past six years. The results are persuading more health professionals to adopt the method.

A 2023 study found babies treated this way were discharged from the hospital in nearly half the time and less likely to receive medication than those receiving Finnegan-based care.

Matthew Grossman, an associate professor of pediatrics at the Yale School of Medicine, refers to the introduction of the model of treatment he has helped pioneer as “the least innovative” undertaking imaginable.

Research shows that optimal care for pregnant women who’ve experienced opioid use disorder includes treatment with buprenorphine or methadone, which carries the risk their newborn will have withdrawal symptoms. Grossman and colleagues found a non-pharmacological-first approach works best.

He said the Finnegan tool is useful but often too rigid. Under its scoring, one sneeze too many could send a baby to the NICU for weeks.

Grossman said he observed that some babies receiving medications did well for a few days but began to decline when their mothers were sent home without them. Those observations made him ask, “Did the kid need more medicine, or more mom?”

Research by Leila Elder and Madison Humerick, who each did their residency in WVU’s rural program, found that median stays for newborns in withdrawal dropped from 13 days in 2016 to three in 2020.

Elder said babies born at the 25-bed rural hospital where they performed deliveries received medications to treat their withdrawal symptoms only when unrelated issues sent them to other hospitals for NICU care.

The simpler treatment also means more babies born in rural communities can receive care closer to home and has reduced the likelihood a mother will be released before her baby is cleared to go home.

Grossman suggested that rural hospitals are better suited to employ the Eat, Sleep, Console approach than big-city institutions, given the latter’s generally easier access to a NICU and propensity to choose that option.

Sarah Peiffer recalls the first time, as a medical student, she witnessed a nurse administering the Finnegan protocol, discussing it in clinical terms at a new mother’s bedside.

“And I remember being kind of horrified,” she said. The process was clearly distressing to both mother and child. “I felt like there was almost a punitive feeling to it, like we were telling this mom, ‘Look what you did to your baby.’”

Peiffer is now a Project CARA practitioner and family health physician at Blue Ridge Health in western North Carolina and a vocal proponent of ESC and its approach to partnering with families. “You look at all the nonpharmacologic stuff you’re supposed to be doing — like keeping the lights low in the room, keeping the baby swaddled, doing as much skin-to-skin with mom as possible — and you really treat mom as medicine.”

Research suggests immediate postbirth skin‐to‐skin contact offers “vital advantages” to short‐ and long‐term health and bonding.

That contact, Elder said, “releases endorphins for mom,” which helps lower the risk of postpartum depression.

Grossman said developing the Eat, Sleep, Console protocol was simply a matter of pausing to reassess.

The original intent of the Finnegan tool wasn’t to render the process so rigid. But “everybody is excited to have a tool, and then this approach calcified around it,” he said.

Grossman said the objective of the simpler approach was to place the family at the core of care, and shorter hospital stays for babies was simply a fortuitous outcome. The shift in approach fits into a wider move toward judgment-free, family-centered care for those who’ve experienced addiction and for their children.

Now, he said, after five days, mothers often say “‘Can we go home? I think I got this,’” and they’re treated “with the same respect as any other mom.”

Peiffer said she has witnessed this mother-centric care counter “that sense of shame that people feel instead of families feeling empowered to care for their infant.” It represents “such a major shift in how we think about neonatal withdrawal both medically and culturally.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.