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Watch: Meet the Latest Fact-Checker — Your Doctor

Kaiser Health News - 8 hours 2 min ago

In a one-on-one conversation, KHN partnerships editor and senior correspondent Mary Agnes Carey talked with American Medical Association President Dr. Jack Resneck Jr. about how the current climate of misinformation affects doctors and their daily efforts to treat patients.

This interview, which took place Sept. 29 as part of PolitiFact’s United Facts of America: A Festival of Fact-Checking, covered a range of topics — from how the debate over the safety of covid-19 vaccines played out in exam rooms across the country, to what needs to be done to help rebuild the nation’s trust in the public health system, and the misinformation that swirls around the abortion issue.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Categories: Health Care

Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers

Kaiser Health News - 8 hours 2 min ago

After 11 days in a St. Paul, Minnesota, skilled nursing facility recuperating from a fall, Paula Christopherson, 97, was told by her insurer that she should return home.

But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.

“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother’s nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.

Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home.

Half of the nearly 65 million people with Medicare are enrolled in the private health plans called Medicare Advantage, an alternative to the traditional government program. The plans must cover — at a minimum — the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care every year.

But the private plans have leeway when deciding how much nursing home care a patient needs.

“In traditional Medicare, the medical professionals at the facility decide when someone is safe to go home,” said Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. “In Medicare Advantage, the plan decides.”

Mairead Painter, a vice president of the National Association of State Long-Term Care Ombudsman Programs who directs Connecticut’s office, said, “People are going to the nursing home, and then very quickly getting a denial, and then told to appeal, which adds to their stress when they’re already trying to recuperate.”

The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits,” according to an April analysis by the Department of Health and Human Services’ inspector general. Investigators found that nursing home coverage was among the most frequently denied services by the private plans and often would have been covered under traditional Medicare.

The federal Centers for Medicare & Medicaid Services recently signaled its interest in cracking down on unwarranted denials of members’ coverage. In August, it asked for public feedback on how to prevent Advantage plans from limiting “access to medically necessary care.”

The limits on nursing home coverage come after several decades of efforts by insurers to reduce hospitalizations, initiatives designed to help drive down costs and reduce the risk of infections.

Charlene Harrington, a professor emerita at the University of California-San Francisco’s School of Nursing and an expert on nursing home reimbursement and regulation, said nursing homes have an incentive to extend residents’ stays. “Length of stay and occupancy are the main predictor of profitability, so they want to keep people as long as possible,” she said. Many facilities still have empty beds, a lingering effect of the covid-19 pandemic.

When to leave a nursing home “is a complicated decision because you have two groups that have reverse incentives,” she said. “People are probably better off at home,” she said, if they are healthy enough and have family members or other sources of support and secure housing. “The resident ought to have some say about it.”

Jill Sumner, a vice president for the American Health Care Association, which represents nursing homes, said her group has “significant concerns” about large Advantage plans cutting off coverage. “The health plan can determine how long someone is in a nursing home typically without laying eyes on the person,” she said.

The problem has become “more widespread and more frequent,” said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “It’s not just one plan,” he said. “It’s pretty much all of them.”

As Medicare Advantage enrollment has spiked in recent years, Kumar said, disagreements between insurers and nursing home medical teams have increased. In addition, he said, insurers have hired companies, such as Tennessee-based naviHealth, that use data about other patients to help predict how much care an individual needs in a skilled nursing facility based on her health condition. Those calculations can conflict with what medical teams recommend, he said.

UnitedHealthcare, which is the largest provider of Medicare Advantage plans, bought naviHealth in 2020.

Sumner said nursing homes are feeling the impact. “Since the advent of these companies, we’ve seen shorter length of stays,” she said.

In a recent news release, naviHealth said its “predictive technology” helps patients “enjoy more days at home, and health care providers and health plans can significantly reduce costs.”

UnitedHealthcare spokesperson Heather Soule would not explain why the company limited coverage for the members mentioned in this article. But, in a statement, she said such decisions are based on Medicare’s criteria for medically necessary care and involve a review of members’ medical records and clinical conditions. If members disagree, she said, they can appeal.

When the patient no longer meets the criteria for coverage in a skilled nursing facility, “that does not mean the member no longer requires care,” Soule said. “That is why our care coordinators proactively engage with members, caregivers, and providers to help guide them through an individualized care plan focused on the member’s unique needs.”

She noted that many Advantage plan members prefer receiving care at home. But some members and their advocates say that option is not always practical or safe.

Patricia Maynard, 80, a retired Connecticut school cafeteria employee, was in a nursing home recovering from a hip replacement in December when her UnitedHealthcare Medicare Advantage plan notified her it was ending coverage. Her doctors disagreed with the decision.

“If I stayed, I would have to pay,” Maynard said. “Or I could go home and not worry about a bill.” Without insurance, the average daily cost of a semiprivate room at her nursing home was $415, according to a 2020 state survey of facility charges. But going home was also impractical: “I couldn’t walk because of the pain,” she said.

Maynard appealed, and the company reversed its decision. But a few days later, she received another notice saying the plan had decided to stop payment, again over the objections of her medical team.

The cycle continued 10 more times, Krupa said.

Maynard’s repeated appeals are part of the usual Medicare Advantage appeals process, said Beth Lynk, a CMS spokesperson, in a statement.

When a request to the Advantage plan is not successful, members can appeal to an independent “quality improvement organization,” or QIO, that handles Medicare complaints, Lynk said. “If an enrollee receives a favorable decision from the QIO, the plan is required to continue to pay for the nursing home stay until the plan or facility decides the member or patient no longer needs it,” she explained. Residents who disagree can file another appeal.

CMS could not provide data on how many beneficiaries had their nursing home care cut off by their Advantage plans or on how many succeeded in getting the decision reversed.

To make fighting the denials easier, the Center for Medicare Advocacy created a form to help Medicare Advantage members file a grievance with their plan.

When UnitedHealthcare decided it wouldn’t pay for an additional five days in the nursing home for Christopherson, she stayed at the facility and appealed. When she returned to her apartment, the facility billed her nearly $2,500 for that period.

After Christopherson made repeated appeals, UnitedHealthcare reversed its decision and paid for her entire stay.

Loomis said her family remains “mystified” by her mother’s ordeal.

“How can the insurance company deny coverage recommended by her medical care team?” Loomis asked. “They’re the experts, and they deal with people like my mother every day.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Categories: Health Care

Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution

Kaiser Health News - Mon, 10/03/2022 - 5:00am

I woke up in a strange bedroom with 24 electrodes glued all over my body and a plastic mask attached to a hose covering my face.

The lab technician who watched me all night via video feed told me that I had “wicked sleep apnea” and that it was “central sleep apnea” — a type that originates in the brain and fails to tell the muscles to inhale.

As a journalist — and one terrified by the diagnosis — I set out to do my own research. After a few weeks of sleuthing and interviewing experts, I reached two important conclusions.

First, I had moderate apnea, if that, and it could be treated without the elaborate machines, mouthpieces, or other devices that specialists who had consulted on my care were talking about.

Second, the American health care system has joined with commercial partners to define a medical condition — in this case, sleep apnea — in a way that allows both parties to generate revenue from a multitude of pricey diagnostic studies, equipment sales, and questionable treatments. I was on a conveyor belt.

It all began with a desire for answers: I had been feeling drowsy during the day, and my wife told me I snored. Both can mean obstructive sleep apnea. With obstructive sleep apnea, the mouth and throat relax when a person is unconscious, sometimes blocking or narrowing the airway. That interrupts breathing, as well as sleep. Without treatment, the resulting disruption in oxygen flow might increase the risk of developing certain cardiovascular diseases.

So I contacted a sleep-treatment center, and doctors gave me an at-home test ($365). Two weeks later, they told me I had “high-moderate” sleep apnea and needed to acquire a continuous positive airway pressure, or CPAP, machine, at a cost of about $600.

Though I had hoped to get the equipment and adjust the settings to see what worked best, my doctors said I had to come to the sleep lab for an overnight test ($1,900) to have them “titrate” the optimal CPAP air pressure.

“How do you treat central sleep apnea?” I worriedly asked the technician after that first overnight stay. She said something about an ASV (adaptive servo-ventilation) machine ($4,000). And one pricey lab sleepover wasn’t enough, she said. I needed to come back for another.

(Most procedures and devices mentioned in this article were covered or would have been covered by insurance — in my case, Medicare, plus a supplemental plan. Unnecessary care is a big reason Americans’ insurance costs — premiums, copays, and deductibles — tend to rise year after year.)

As a journalist who spent years covering the business of health care, I found there was more motivating my expensive testing cascade than concerns about my health.

The American Academy of Sleep Medicine, or AASM, a nonprofit based near Chicago, decides what is sleep apnea and how to treat it. Working with sleep societies around the world, it publishes the International Classification of Sleep Disorders, relied on by doctors everywhere to diagnose and categorize disease.

But behind that effort lie considerable conflicts of interest. Like so much of U.S. health care, sleep medicine turns out to be a thriving industry. AASM finances its operations in part with payments from CPAP machine manufacturers and other companies that stand to profit from expensive treatments and expansive definitions of apnea and other sleep disorders.

Zoll Itamar, which makes the at-home testing device I used, as well as implantable nerve-stimulation hardware for central sleep apnea, is a $60,000, “platinum” partner in AASM’s Industry Engagement Program. So is Avadel Pharmaceuticals, which is testing a drug to treat narcolepsy, characterized by intense daytime sleepiness.

Other sponsors include the maker of an anti-insomnia drug; another company with a narcolepsy drug; Fisher & Paykel Healthcare, which makes CPAP machines and masks; and Inspire Medical Systems, maker of a heavily advertised surgical implant, costing tens of thousands of dollars, to treat apnea.

Corporate sponsors for Sleep 2022, a convention AASM put on in Charlotte, North Carolina, with other professional societies, included many of those companies, plus Philips Respironics and ResMed, two of the biggest CPAP machine makers.

In a statement, AASM spokesperson Jennifer Gibson said a conflict-of-interest policy and a non-interference pledge from industry funders protect the integrity of the academy’s work. Industry donations account for about $170,000 of AASM’s annual revenue of about $15 million, she said. Other revenue comes from educational materials and membership and accreditation fees.

Here’s what else I found. Almost everybody breathes irregularly sometime at night, especially during REM sleep, characterized by rapid eye movement and dreams. Blood oxygen levels also fluctuate slightly.

But recent European studies have shown that standards under the International Classification of Sleep Disorders would doom huge portions of the general population to a sleep apnea diagnosis — whether or not people had complaints of daytime tiredness or other sleep problems.

A study in the Swiss city of Lausanne showed that 50% of local men and 23% of the women 40 or older were positive for sleep apnea under such criteria.

Such rates of disease are “extraordinarily high,” “astronomical,” and “implausible,” Dr. Dirk Pevernagie, a scientist at Belgium’s Ghent University Hospital, wrote with colleagues two years ago in a comprehensive study in the Journal of Sleep Research.

“Right now, there is no real evidence for the criteria that have been put forward to diagnose obstructive sleep apnea and rate its severity,” he said in an interview.

Likewise, 19% of middle-aged subjects in a 2016 Icelandic study appeared to have moderate to severe “apnea” under one definition in the International Classification of Sleep Disorders even though many reported no drowsiness.

“Most of them were really surprised,” said Erna Sif Arnardóttir, who led the study and is running a large European program to refine detection and treatment of apnea.

Nevertheless, the official AASM journal recommends extremely broad screening for sleep apnea, looking for patients who have what it defines as illness. Everybody 18 and older should be screened every year for apnea if they have diabetes, obesity, untreated high blood pressure, or heart disease — even if they have never complained about sleep problems, the group says.

AASM “continually evaluates the definitions, criteria and recommendations used in the identification of sleep apnea and other sleep disorders,” Gibson said in the statement. Meanwhile, routine screening by primary care doctors “is a simple way” of gauging whether a high-risk patient may have obstructive sleep apnea, the statement said.

The U.S. Preventive Services Task Force, an authoritative body that reviews the effectiveness of preventive care, takes a conservative view, more like that of the European researchers, concluding there is “insufficient” evidence to support widespread screening among patients with no symptoms.

Many insurers refuse to pay for CPAP machines and other treatments prescribed for people at the outer edges of the AASM’s apnea definition. But AASM is pressuring them to come around.

After all my reporting, I concluded that my apnea is real, though moderate. My alarming reading in the overnight lab — diagnosed quickly as central sleep apnea — was a byproduct of the testing machinery itself. That’s a well-described phenomenon that occurs in 5% to 15% of patients.

And when I looked closely at the results of my at-home diagnostic test, I had an epiphany: My overall score was 26 breathing interruptions and blood-oxygen level declines, on average, per hour — enough to put me in the “high-moderate” category for apnea. But when I looked at the data sorted according to sleeping positions, I saw that I scored much better when I slept on my side: only 10 interruptions in an hour.

So I did a little experiment: I bought a $25 pulse oximeter with a smartphone app that records oxygen dips and breathing interruptions. When I slept on my side, there were hardly any.

Now I sleep on my side. I snore less. I wake up refreshed. I’m not daytime drowsy.

None of my specialists mentioned turning on to my side — known in medical parlance as “positional therapy” — though the intervention is recognized as effective by many researchers. Sleeping on one’s back contributes to snoring and blockages, especially as people age and the muscles in the throat become looser.

“Positional patients … can sleep in the lateral position and sleep quite well,” said Arie Oksenberg, a sleep researcher formerly at Loewenstein Hospital in Israel.

But it’s not easy to find this in the official AASM treatment guidelines, which instead go right to the money-making options like CPAP machines, surgery, central apnea, and mouth appliances.

Dealing with apnea by shifting slightly in bed gets little more than a couple of paragraphs in AASM’s guideline on “other” treatments and a little box on a long and complex decision chart.

A third or more of patients wear CPAPs only a few hours a night or stop using them. It turns out people don’t like machines in their beds.

“Positional therapy is an effective treatment option for some patients,” said the AASM’s Gibson. But she said there are concerns about whether patients will sleep on their sides long term and whether trying to stay in one position might cause sleep interruptions itself.

It’s true that side-sleeping doesn’t help everybody. And it often takes practice. (Some people tape a tennis ball to their pajamas to keep them off their backs.) Even conservative sleep doctors say CPAP machines are the best solution for many patients.

But there is a largely overlooked alternative.

“Are we missing a simple treatment for most adult sleep apnea patients?” was the name of a 2013 paper that Oksenberg and a colleague wrote about positional therapy.

In my case, the answer was “yes.”

Jay Hancock is a former KHN senior correspondent.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Categories: Health Care

Mental Health Crisis Teams Aren’t Just for Cities Anymore

Kaiser Health News - Mon, 10/03/2022 - 5:00am

NEWTON, Iowa — Jeff White knows what can happen when 911 dispatchers receive a call about someone who feels despondent or agitated.

He experienced it repeatedly: The 911 operators dispatched police, who often took him to a hospital or jail. “They don’t know how to handle people like me,” said White, who struggles with depression and schizophrenia. “They just don’t. They’re just guessing.”

In most of those instances, he said, what he really needed was someone to help him calm down and find follow-up care.

That’s now an option, thanks to a crisis response team serving his area. Instead of calling 911, he can contact a state-run hotline and request a visit from mental health professionals.

The teams are dispatched by a program that serves 18 mostly rural counties in central and northern Iowa. White, 55, has received assistance from the crisis team several times in recent years, even after heart problems forced him to move into a nursing home. The service costs him nothing. The team’s goal is to stabilize people at home, instead of admitting them to a crowded psychiatric unit or jailing them for behaviors stemming from mental illness.

For years, many cities have sent social workers, medics, trained outreach workers, or mental health professionals to calls that previously were handled by police officers. And the approach gained traction amid concerns about police brutality cases. Proponents say such programs save money and lives.

But crisis response teams have been slower to catch on in rural areas even though mental illness is just as prevalent there. That’s partly because those areas are bigger and have fewer mental health professionals than cities do, said Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness.

“It certainly has been a harder hill to climb,” she said.

Melissa Reuland, a University of Chicago Health Lab researcher who studies the intersection of law enforcement and mental health, said that solid statistics are not available but that small police departments and sheriffs’ offices seem increasingly open to finding alternatives to a standard law enforcement response. Those can include training officers to handle crises better or seeking assistance from mental health professionals, she said.

The shortage of mental health services will continue to be a hurdle in rural areas, she said: “If it was easy, people would have fixed it.”

Still, the crisis response approach is making inroads, program by program.

White has lived most of his life in small Iowa cities surrounded by rural areas. He’s glad to see mental health care efforts strengthened beyond urban areas. “We out here get forgotten — and out here is where we need help the most,” he said.

Some crisis teams, like the one that helps White, can respond on their own, while others are paired with police officers or sheriffs’ deputies. For example, a South Dakota program, Virtual Crisis Care, equips law enforcement officers with iPads. The officers can use the tablets to set up video chats between people in crisis and counselors from a telehealth company. That isn’t ideal, Wesolowski said, but it’s better than having police officers or sheriffs’ deputies try to handle such situations on their own.

The counselors help people in mental health crises calm down and then discuss what they need. If it’s safe for them to remain at home, the counselor calls a mental health center, which later contacts the people to see whether they’re interested in treatment.

But sometimes the counselors determine people are a danger to themselves or others. If so, the counselors recommend that officers take them to an emergency room or jail for evaluation.

In the past, sheriffs’ deputies had to make that decision on their own. They tended to be cautious, temporarily removing people from their homes to ensure they were safe, said Zach Angerhofer, a deputy in South Dakota’s Roberts County, which has about 10,000 residents.

Detaining people can be traumatic for them and expensive for authorities.

Deputies often must spend hours filling out paperwork and shuttling people between the ER, jail, and psychiatric hospitals. That can be particularly burdensome during hours when a rural county has few deputies on duty.

The Virtual Crisis Care program helps avoid that situation. Nearly 80% of people who complete its video assessment wind up staying at home, according to a recent state study.

Angerhofer said no one has declined to use the telehealth program when he has offered it. Unless he sees an immediate safety concern, he offers people privacy by leaving them alone in their home or letting them sit by themselves in his squad car while they speak to a counselor. “From what I’ve seen, they are a totally different person after the tablet has been deployed,” he said, noting that participants appear relieved afterward.

The South Dakota Department of Social Services funds the Virtual Crisis Care program, which received startup money and design help from the Leona M. and Harry B. Helmsley Charitable Trust. (The Helmsley Charitable Trust also contributes to KHN.)

In Iowa, the program that helps White always has six pairs of mental health workers on call, said Monica Van Horn, who helps run the state-funded program through the Eyerly Ball mental health nonprofit. They are dispatched via the statewide crisis line or the new national 988 mental health crisis line.

In most cases, the Eyerly Ball crisis teams respond in their own cars, without police. The low-key approach can benefit clients, especially if they live in small towns where everyone seems to know each other, Van Horn said. “You don’t necessarily want everyone knowing your business — and if a police car shows up in front of your house, everybody and their dog is going to know about it within an hour,” she said.

Van Horn said the program averages between 90 and 100 calls per month. The callers’ problems often include anxiety or depression, and they are sometimes suicidal. Other people call because children or family members need help.

Alex Leffler is a mobile crisis responder in the Eyerly Ball program. She previously worked as a “behavior interventionist” in schools, went back to college, and is close to earning a master’s degree in mental health counseling. She said that as a crisis responder, she has met people in homes, workplaces, and even at a grocery store. “We respond to just about any place,” she said. “You just can make a better connection in person.”

Thomas Dee, a Stanford University economist and education professor, said such programs can garner support from across the political spectrum. “Whether someone is ‘defund the police’ or ‘back the blue,’ they can find something to like in these types of first-responder reforms,” he said.

Critics of police have called for more use of unarmed mental health experts to defuse tense situations before they turn deadly, while law enforcement leaders who support such programs say they can give officers more time to respond to serious crimes. And government officials say the programs can reduce costly hospitalizations and jail stays.

Dee studied the Denver Support Team Assisted Response program, which lets 911 dispatchers send medics and behavioral health experts instead of police to certain calls. He found the program saved money, reduced low-level crime, and did not lead to more serious crimes.

Dr. Margie Balfour is an associate professor of psychiatry at the University of Arizona and an administrator for Connections Health Solutions, an Arizona agency that provides crisis services. She said now is a good time for rural areas to start or improve such services. The federal government has been offering more money for the efforts, including through pandemic response funding, she said. It also recently launched the 988 crisis line, whose operators can help coordinate such services, she noted.

Balfour said the current national focus on the criminal justice system has brought more attention to how it responds to people with mental health needs. “There’s a lot of things to disagree on still with police reform,” she said. “But one thing that everybody agrees on is that law enforcement doesn’t need to be the default first responder for mental health.”

Arizona has crisis response teams available throughout the state, including in very rural regions, because settlement of a 1980s class-action lawsuit required better options for people with mental illnesses, Balfour said.

Such programs can be done outside cities with creativity and flexibility, she said. Crisis response teams should be considered just as vital as ambulance services, Balfour said, noting that no one expects police to respond in other medical emergencies, such as when someone has a heart attack or stroke.

“People with mental health concerns deserve a health response,” she said. “It’s worth it to try to figure out how to get that to the population.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Journalists Dig In on the Fiscal Health of the Nation and Hospital Closures in Rural Missouri

Kaiser Health News - Sat, 10/01/2022 - 5:00am

KHN chief Washington correspondent Julie Rovner discussed health care costs and the fiscal health of Medicare and Social Security on C-SPAN’s “Washington Journal” on Sept. 28. She also discussed President Joe Biden’s comments about the covid-19 pandemic being “over,” as well as health inflation, the government funding bill, and other domestic news on WAMU/NPR’s “1A” on Sept. 23.

KHN senior correspondent Sarah Jane Tribble discussed the collapse of two rural Missouri hospitals on The Eagle 93.9-KSSZ’s “Wake Up Mid-Missouri” on Sept. 26.

KHN senior correspondent Julie Appleby discussed the legal challenge to the Affordable Care Act provision that guarantees free preventive care benefits on Texas Public Radio’s “The Source” on Sept. 21.

KHN correspondent Brett Kelman discussed a recent Supreme Court ruling that may affect doctors charged with overprescribing opioids on Apple News’ “Apple News Today” on Sept. 30.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Listen: Grieving Families Face the Cruelest Bills

Kaiser Health News - Fri, 09/30/2022 - 12:00pm

NPR’s “Consider This” podcast tells the stories of the Markow, Shickel, and Raspe familes. All had very sick infants who died after needing highly technical, very expensive treatment in neonatal intensive care units. Medical bills lived on for each family even after their babies died. “All Things Considered” host Juana Summers spoke to KHN Midwest correspondent Lauren Weber about her reporting on The Cruelest Bills.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Watch: Their Baby Died. The Medical Bills Haunted Them.

Kaiser Health News - Fri, 09/30/2022 - 5:00am

Born with a congenital heart defect and other medical issues, Sterling Raspe lived just eight months. In that time, she needed dozens of medical procedures and often required round-the-clock care in the neonatal intensive care unit. At one point, her parents were told they owed $2.5 million for her care. “It’s an offensive amount of money,” said Sterling’s father, Kingsley Raspe, in this KHN video produced by Hannah Norman and reported by Lauren Weber.

More than 300,000 U.S. families have infants who require advanced medical attention in NICUs every year. The services are delivered and, in keeping with the U.S. health care system, billing follows. But for the smaller fraction of families whose children die, the burden can be too much to bear.

For more about the Raspe family and others in similar circumstances, read “The Cruelest Bills.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Sports Programs in States in Northern Climes Face a New Opponent: Scorching Septembers

Kaiser Health News - Fri, 09/30/2022 - 5:00am

BIGFORK, Mont. — On a recent afternoon, it was a crisp 70 degrees on the football field at the high school in this northwestern Montana community less than 200 miles south of the U.S.-Canada border.

Vikings head coach Jim Benn was running his team through drills in the pristine fall weather, without much interruption. Just a couple of weeks earlier, though, players needed frequent water breaks as they sweated through temperatures in the low to mid-90s, about 15 degrees higher than average for the time of year.

Although temperatures have started to drop now that autumn is underway, Montana and many other states in the northern U.S. are getting hotter — and staying hot for longer. August is when many high school sports ramp up, and this year’s was either the hottest on record or close to it for many communities across Montana, according to the National Weather Service and other meteorologists. The heat wave stretched into September, and at least six Montana cities broke the 100-degree mark during the first half of the month.

This August was the hottest on record for the nearby states of Idaho, Washington, and Oregon. Nationwide, this summer was the third-hottest on record, according to the National Oceanic and Atmospheric Association.

Health experts and researchers say states — especially the states in the northern U.S., such as Idaho, Maine, Montana, and North Dakota — aren’t adapting fast enough to keep high school athletes safe. Students and their families have sued schools, accusing them of not doing enough to protect athletes. Many states that have taken action did so only after an athlete died.

“Between high school and college, we’re losing roughly six athletes each year to exertional heatstroke, and the majority of those are high school athletes,” said Rebecca Stearns, chief operating officer at the University of Connecticut’s Korey Stringer Institute, which is named after a Minnesota Vikings player who died from heatstroke in 2001. The institute studies and tries to prevent the condition.

The true number of heat-related deaths could be higher, she said, because death certificates aren’t always accurately filled out. Exertional heat illness is the second-leading cause of death for high school and college athletes, behind cardiac arrest, she said.

In Bigfork, Benn said he hadn’t seen one of his athletes experience an exertional heat illness — such as heat exhaustion or heatstroke, which can cause fainting, vomiting, and even death — during his nearly 30-year coaching career in Montana until last year. An athlete became overheated at an early summer football camp during the record-shattering 2021 heat wave.

“We immediately got water on him, got him cooled down,” he said.

The player recovered after he was sprayed with a hose. Benn said he didn’t have an immersion tub filled with ice water on hand, which is what Stearns said is the recommended treatment.

“It is exactly why we need standard policies that have medical best practices incorporated,” Stearns said.

The Korey Stringer Institute ranks all 50 states and Washington, D.C., based on how well they follow best practices for preventing and responding to exertional heat illness among high school athletes, as well as other health risks such as cardiac arrest. Montana is 48th on the list, followed by Minnesota, Maine, and California.

California is last, according to the institute’s report, because it’s the only state that doesn’t regulate high school athletic trainers, which are generally responsible for the health and safety of athletes. Stearns said the institute is working with California sports officials who are pushing for laws that require licensing of athletic trainers.

States in the northern U.S. dominate the bottom third of the institute’s rankings. Stearns said many states the institute has approached about improving heat safety think it isn’t an issue or resist some policies because implementing them could come with a hefty price tag.

But some of the efforts don’t cost a penny, she said. At Bigfork High School, for example, Benn has implemented a three-day acclimatization period, without football pads, when his players return to the field in early August. “That’s really low-hanging fruit, in my perspective,” Stearns said.

Stearns added that most heat-related illnesses occur during the first days of practice, which are typically the hottest and when athletes are not accustomed to exerting themselves in the heat. But she said the state’s high school sports association should mandate acclimatization periods.

Montana and many other states also don’t have a system dictating when practices need to be modified — for example, by removing pads or reducing the length and the number of workouts — or canceled altogether, said Stearns. Policies that require an emergency plan for responding to an exertional heat illness are lacking in many northern states, as well.

Stearns and other researchers, such as Bud Cooper at the University of Georgia, said states should use what’s known as the “wet bulb globe temperature” — which accounts for air temperature, humidity, and radiant heat from surfaces such as turf that absorb sunlight — to make those determinations, rather than the heat index. The heat index doesn’t account for radiant heat, which increases the risk of developing heat illness. The foundation of the National Federation of State High School Associations said in February that it was sending 5,000 of the special thermometers to high schools across the country.

Stearns said that research suggests acclimatization periods reduce the number of exertional heat illnesses by as much as 55% and that states that have used the wet bulb globe temperature to mandate changes to practice have seen an 80% reduction.

In Georgia, Cooper’s work documenting heat-related deaths among high school athletes led to sweeping policy changes in 2012. Since the policy shift, Georgia has gone from being the state with the highest number of heat-related deaths among high school football players to having no deaths.

Researchers such as Cooper have begun to provide regional policy guidelines based on the local average wet bulb globe temperatures to help states understand the risks for high school athletes and give them a starting point for making policy changes.

New Jersey was among the early adopters of the wet bulb system among states in the northern U.S. when it approved a law in 2020 requiring school districts to buy the thermometers. The state also requires hundreds of schools to put cold immersion tubs on-site when temperatures reach a certain level. The state is now second in the institute’s rankings of sports safety policies, behind Florida and ahead of Georgia.

In the Pacific Northwest, Oregon and Washington have policies that mandate changes to school sports practices based on the heat index, not the wet bulb globe temperature. Heat and sports safety researchers say that’s better than nothing.

The Montana High School Association, which regulates high school athletics, has implemented heat guidance that allows referees to call for extra breaks during football or soccer games, said executive director Brian Michelotti. The association also asks other sports, such as cross-country running, to schedule meets early in the day.

While Montana health officials say the state has never documented a death related to heat illness among the state’s high school athletes, the historic heat waves over the past two summers have athletic officials considering additional precautions. “It really has triggered us to have more discussions about that and really come back and revisit with some sport science committees,” Michelotti said.

He said any policy changes would have to be approved by the association’s seven-member board and wouldn’t happen until at least next year.

Heat and sports safety experts such as Stearns at the Korey Stringer Institute said adding statewide policies and mandates saves lives by ensuring that all coaches and schools are following best practices before a death happens.

“One life is too much a price for all of the games in a season,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Pharma-Funded FDA Gets Drugs Out Faster, But Some Work Only ‘Marginally’ and Most Are Pricey

Kaiser Health News - Fri, 09/30/2022 - 5:00am

Dr. Steven-Huy Han, a UCLA liver specialist, has prescribed Ocaliva to a handful of patients, although he’s not sure it helps.

As advertised, the drug is lowering levels of an enzyme called alkaline phosphatase in their blood, and that should be a sign of healing for their autoimmune disease, called primary biliary cholangitis. But “no one knows for sure,” Han said, whether less enzyme means they won’t get liver cancer or cirrhosis in the long run.

“I have no idea if the drug will make them better,” he said. “It could take 10, 20, or 30 years to know.”

Ocaliva came to market through an FDA review process created 30 years ago called accelerated approval, which allows pharmaceutical companies to license promising treatments without proving they are effective. It has become a common path to market — accounting for 14 of the 50 approvals of novel drugs in 2021 compared with four among 59 in 2018, for example.

The FDA’s accelerated approval is usually based on a “surrogate marker” of effectiveness — evidence of lower viral loads for HIV, for example, or shrinking tumors for cancer. Debate rages over the validity of some of these stand-ins, and some of the drugs.

“If you’ve got a game-changing drug that truly is going to make a difference, you don’t need surrogate markers to prove that. If it’s effective, patients will survive longer,” said Dr. Aaron Mitchell, an oncologist at Memorial Sloan Kettering Cancer Center. The shortened approval process, he said, is one reason “we are getting a lot of marginally effective, not clinically meaningful, more expensive drugs on the market.”

Many of the estimated 100,000 U.S. patients with primary biliary cholangitis — most are women — had few other treatment options. And their testimony, at FDA meetings and in online forums, helped boost Ocaliva to FDA approval in 2016. Its list price is about $100,000 a year.

After Deborah Sobel’s sister Sarah Jane Kiley died of liver complications in 2006 at age 47, Sobel met with members of Congress and bankers to urge support for the drug and its maker, Intercept Pharmaceuticals. Although the trial required for accelerated approval was too short to show long-term improvement, the drug lowered alkaline phosphatase levels in many patients who could tolerate taking it. For some, the side effects proved too much.

Sobel, who also has the disease, began taking Ocaliva six years ago. Her last liver scan “looked like I had rolled back some of the damage,” said Sobel, 67, of Naperville, Illinois. “I can’t attribute that to the drug, but I’m religious about taking it.”

Ocaliva’s profile is typical for the FDA’s accelerated program. In 2019 the drug ranked seventh in Medicare spending — about $54 million — among products approved through the program, which launched in 1992. That same year, Congress passed the Prescription Drug User Fee Act, or PDUFA, a law committing the drug industry to pay so-called user fees to help fund the FDA’s drug approval process.

The fees have steadily swollen in importance, accounting for $2.9 billion of the agency’s $6.5 billion 2022 budget, including two-thirds of the drug regulation budget, and the work of at least 40% of the FDA’s 18,000 employees. Companies in recent years have paid between $2.5 million and $3 million to have each drug application reviewed.

In most cases, companies that win accelerated approval must submit additional data, after the drug goes to market, that proves it cures or successfully treats the disease.

It turns out that some surrogate markers are better than others. Critics lashed out at the agency in 2021 after it approved Aduhelm for Alzheimer’s disease based on the drug’s capacity to dissolve clumps of amyloid plaques in the brain. Despite that evidence, most patients, who were in the earliest stages of Alzheimer’s, didn’t get better, and over a third suffered brain swelling, a frightening and painful side effect.

When it approved Ocaliva, the FDA required Intercept to conduct another trial to produce evidence of its benefit. But the company in 2021 stopped the trial, saying it was unable to enroll enough patients. To that point, the trial had shown no clinical benefit for patients on the drug. Now, Intercept is asking the FDA to accept a combination of evidence, including studies that it says show patients taking the drug fared better than “external controls” — patients whose health records indicate they would have qualified for Ocaliva but did not receive it.

The FDA already uses such “real-world evidence” for post-market reviews of the safety of drugs, vaccines, and medical devices. But when it comes to drug approvals, records collected for routine health care are often erroneous and usually can’t replace the rigorous evidence of randomized controlled trials.

Policy Born of Impatience

Impatience — among drug companies, investors, patients, and politicians — created the user fee agreements and accelerated-approval pathway, and that impatience, for profits and cures, fuels both programs.

In the late 1980s and early 1990s, the FDA was under tremendous pressure. With AIDS cutting a deadly swath through the gay community, activists held symbolic die-ins at FDA headquarters, demanding approval of new drugs. Meanwhile, conservative groups, frustrated that approvals could take three years or more, debated changing the FDA’s charter to put drugs on the market after cursory reviews. Democrats generally were skeptical of industry user fees — and many still are. During a June debate, Sen. Bernie Sanders (I-Vt.) said drug companies might be “charging outrageous prices” because so much of FDA’s regulatory budget “comes not from taxpayers who want more access to prescription drugs but from the pharmaceutical industry itself.”

The user fees came about after then-FDA Commissioner David Kessler and industry leader Gerald Mossinghoff agreed that companies would pay sums earmarked for the agency to modernize practices, hire more staff, and set deadlines for its reviews.

The impact was immediate. AIDS drugs were the first notable success beginning in 1995, turning HIV from a death sentence into a chronic but manageable disease.

One way user fees have sped reviews is by expanding communications between industry members and the FDA. Before, “it was pretty challenging to get a meeting with FDA,” said Dr. John Jenkins, a senior agency official for 25 years and now an industry consultant. By 2019, the FDA was hosting over 3,000 drug industry meetings each year. This has dramatically changed how companies operate, he said, providing more certainty about whether they are collecting the data FDA needs for its reviews.

Although FDA-regulated products account for about a fifth of every dollar spent by U.S. consumers, Congress has never shown appetite for dramatically increasing its budget, so every five years the user fee renewals become must-pass legislation. This is their year. The user fee accords — one for each brand-name, generic, and over-the-counter drug, as well as for animal drugs, biologics, and medical devices — are packed with new programs, tweaks to old ones, regulatory deadlines, and other items negotiated by the FDA and industry, with Congress tacking its priorities onto the authorizing bill.

The fee agreements are negotiated behind closed doors — industry and FDA officials met more than 100 times to prepare the 2022 accords. At least two industry negotiators were former FDA officials, and the lead FDA negotiator, Dr. Peter Stein, was a Merck and Janssen veteran before arriving at the FDA in 2016. The FDA held six public hearings on the agreements, then announced it did not intend to incorporate a single change.

The bill stalled over the summer because of disagreements over riders affecting generic drugs, lab tests, dietary supplements — and accelerated approval. The final bill, part of a stopgap spending measure, stripped out language that would have made it harder for accelerated products to stay on the market if manufacturers failed to produce evidence of lasting value in a timely way. Stephen Ubl, president of the industry trade group Pharmaceutical Research and Manufacturers of America, or PhRMA, called the slimmed-down bill “a win for patients, biopharmaceutical innovation and regulatory predictability.”

‘I Feel Divided’

Ocaliva patients and doctors are generally grateful to have the drug, though some physicians interviewed for this article said they wouldn’t prescribe it. The drug can seriously harm patients who already have cirrhosis of the liver and produces side effects such as severe itching. But some patients can’t tolerate, or fail to benefit from, the less expensive drug ursodiol, the other main treatment for primary biliary cholangitis. And some doctors who’ve studied Ocaliva believe the drug may slow liver damage.

“I feel divided about this,” said Dr. Renumathy Dhanasekaran, an assistant professor of gastroenterology and hepatology at the Stanford University School of Medicine. “As a scientist, the accelerated approval process concerns me, but as a physician treating patients with a very challenging disease, translating some of these drugs to the clinic faster is attractive.”

While final approval of Ocaliva for primary biliary cholangitis is pending, Intercept is seeking a broader, lucrative market for the drug: as many as 13 million Americans who have non-alcoholic steatohepatitis, or NASH, a variant of fatty liver disease. The only current treatment is radical weight loss. The FDA is expected to rule on that application in 2023.

Ocaliva and Aduhelm are far from the only accelerated approval drugs whose long-term impact remains uncertain. Only a fifth of the cancer drugs approved through the platform kept people alive longer than other treatments against which they were tested, according to a 2019 study co-authored by Dr. Bishal Gyawali, an associate professor of medical oncology and public health at Queen’s University in Canada.

FDA’s cancer branch has tried to remove ineffective accelerated approval drugs from the market, and says it may begin demanding that drugmakers start confirmatory trials before receiving accelerated approval for their products. But for now, many drugs with uncertain survival benefits remain on the market. Ibrance, an oral breast cancer drug that brought Pfizer nearly $5 billion in annual revenue in recent years, falls into this category.

FDA approved Ibrance for breast cancer in 2015 after a study showed it slowed tumor progression for a full year longer than aromatase inhibitors, then the standard of care. Although Pfizer won final approval through a confirmatory trial, less tumor growth apparently did not translate into longer survival for patients on Ibrance, subsequent studies indicated.

Still, with new cancer drugs continually coming to market, it makes sense for the FDA to approve promising new medications even if their benefits are incremental, said Dr. Matthew Goetz, a breast cancer specialist at the Mayo Clinic.

“All of us were excited about Ibrance when it came out,” he said. “It was an oral drug, very well tolerated, and it pushed off the time before a patient needed chemotherapy.”

Gyawali, another breast cancer expert, said he has treated his patients with Ibrance. “Many oncologists would agree that it’s a good tool to have in their toolbox.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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KHN’s ‘What the Health?’: On Government Spending, Congress Decides Not to Decide

Kaiser Health News - Thu, 09/29/2022 - 3:00pm

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

Click here for a transcript of the episode.

Congress is supposed to complete its annual appropriations bills before the start of the fiscal year on Oct. 1. But it rarely does, and this year is no different, as lawmakers scramble to pass a short-term funding bill so they can put off final decisions until at least December.

Meanwhile, with an eye to the midterms, House Republicans put out a “Commitment to America,” which includes only the vaguest promises related to health care. It’s yet another demonstration that the only thing in health care that unifies Republicans is their opposition to Democrats’ health policies. It’s notable that this latest Republican plan does not suggest repealing the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Victoria Knight of Axios.

Among the takeaways from this week’s episode:

  • The short-term funding bill to keep the government open includes the five-year reauthorization of the FDA’s user fees, which are charged to drugmakers and help pay the salaries of many FDA employees. Democrats had hoped to add provisions to that measure that would create regulations on dietary supplements, cosmetics, and lab tests. The current authorization runs out Oct. 1, and Republicans insisted they would support only a clean bill that did not have new government directives.
  • That government funding bill also will not include President Joe Biden’s request for $20 billion to help pay for additional covid-19 and monkeypox vaccines and testing. Democrats said they wanted to extend those programs, but Republicans balked and said the administration still has not accounted for all the previous appropriations.
  • Biden’s comment on “60 Minutes” suggesting that the covid pandemic “is over” hurt administration efforts to persuade Congress to pass the extra covid funding.
  • Biden took a victory lap this week and touted successes on administration priorities for Medicare. Among them, he said, was a reduction in next year’s Part B premium, which generally covers beneficiaries’ outpatient expenses. But that premium went down, primarily because Medicare charged too much in 2022.
  • Medicare premiums this year saw a dramatic increase because officials anticipated that the federal health program would see higher costs associated with the use of Aduhelm, an expensive medication for some Alzheimer’s patients that received tentative approval in 2021 by the FDA. Medicare officials later said they would cover the drug only for patients who also enrolled in a clinical trial, and the expectations for use of the drug plummeted.
  • Republican House members’ proposed agenda pledged to reverse the Democrats’ decision this year to allow Medicare to negotiate some drug prices. Although Democrats said the provision would help drive down costs, Republicans said they don’t like the government interfering in the private market and fear that the measure would hamper innovation.

Also this week, Rovner interviews filmmaker Cynthia Lowen, whose new documentary, “Battleground,” explores how anti-abortion forces played the long game to overturn Roe.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “Britain’s Hard Lessons From Handing Elder Care Over to Private Equity,” by Christine Spolar

Alice Miranda Ollstein: KHN’s “Embedded Bias: How Medical Records Sow Discrimination,” by Darius Tahir

Rachel Cohrs: The New York Times’ “Arbitration Has Come to Senior Living. You Don’t Have to Sign Up,” by Paula Span

Victoria Knight: Forbes’ “Mark Cuban Considering Leaving Shark Tank as He Bets His Legacy on Low-Cost Drugs,” by Jemima McEvoy 

Also mentioned in this week’s episode:

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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Environmental Justice Leader Says Proposition 30 Would Help Struggling Areas Clear the Air

Kaiser Health News - Thu, 09/29/2022 - 5:00am

RIALTO, Calif. — Ana Gonzalez grew up watching the Inland Empire transform from citrus groves and grapevines into warehouses and retail distribution centers. The booming region east of Los Angeles now comprises 4.65 million people — and 1 billion square feet of warehouse space.

In 2015, one of those warehouses was built right in front of her old house, blocking her view of her suburban neighborhood. Soon thereafter, her son battled bronchitis and pneumonia. “It got so bad that I ended up taking him to the ER about three to four times a year,” she said. Her son, now 16, like so many others in the region developed asthma due to air pollution. She grew concerned that state policies were overlooking predominantly Hispanic and low-income residents in her community.

Gonzalez, 35, has evolved from a concerned parent into an environmental advocate. Her years as an educator specializing in bilingual and special education, along with a bout of homelessness, fuel her passion for advocating for marginalized communities. Today, she serves as executive director of the Center for Community Action and Environmental Justice, which works on air quality and environmental justice issues on behalf of the region.

Gonzalez and the organization have endorsed Proposition 30 on the November ballot. Funded primarily by the ride-hailing company Lyft, it would impose an additional 1.75% tax on what Californians earn above $2 million per year to fund zero-emission vehicle purchases, electric charging stations, and wildfire prevention programs.

While the initiative would provide subsidies for low-income consumers, it would also subsidize businesses, such as Lyft and other ride-hailing companies, by helping them add clean cars to their fleet. Lyft and other ride-hailing companies are under a mandate to make at least 90% of their vehicle fleets electric by 2030.

The once-popular measure has slipped into toss-up territory. A September poll by the Public Policy Institute of California found 55% of likely voters back the measure, down from 63% in April. And it has divided environmentalists and Democrats.

The measure would generate an estimated $3.5 billion to $5 billion a year, growing over time, according to the nonpartisan Legislative Analyst’s Office. Of that, 45% would primarily subsidize zero-emission vehicles and 35% would boost construction of residential and public charging stations, with at least half of each category directed to low-income households and communities. The remaining 20% would fund wildfire suppression and prevention.

The state Democratic Party and the American Lung Association endorsed Proposition 30, calling it an innovative measure that will expand access to electric vehicle chargers for every Californian, regardless of where they live or work.

But opponents include the California Teachers Association and Democratic Gov. Gavin Newsom, who recently called the measure “a Trojan horse that puts corporate welfare above the fiscal welfare of our entire state.”

California is a leader in pushing — and paying for — clean energy, but the state has been criticized for failing to distribute California’s clean-car subsidies equitably. For example, a 2020 study found wealthier communities in Los Angeles County had more electric and plug-in hybrid vehicles than its disadvantaged communities. And state Assembly member Jim Cooper, a Black Democrat from Elk Grove who will become Sacramento County sheriff next year, has said the state’s push for electric vehicles fuels “environmental racism.”

Gonzalez points to studies, such as a report by Earthjustice, showing how people who live close to warehouses are more likely to be low-income and at higher risk of asthma due to the air pollution generated by diesel trucks.

KHN reporter Heidi de Marco met with Gonzalez at her new home, where a development is proposed behind her property, to discuss why she and her organization endorsed Proposition 30. Gonzalez said she has not been paid by Lyft. The interview has been edited for length and clarity.

Q: Why is Proposition 30 important for your community?

Our families are dying, and nobody is doing anything about it. We’re seeing all the illnesses that are connected to pollution, such as asthma, pneumonia, lung cancer, COPD [chronic obstructive pulmonary disease], and even diabetes.

We just decided to support it because we felt, as a team, that it was the right thing to do given how impacted we are by car and truck pollution. There are layers upon layers of pollution.

Along with the influx of warehouses bringing tons of trucks and their diesel exhaust emissions, the Inland Empire is unique when it comes to pollution. We have all the polluting industries that you can think of, from rail yards bringing more diesel emissions, from the trains to gas plants, which are emitting a lot of pollution. We have toxic landfills, airports, and all the car traffic from the intersections of the 10, 60, 215, and the 15 freeways.

Q: Proposition 30 is funded by Lyft, and Newsom opposes it, calling it a “cynical scheme” by the company to get more clean cars for its fleet. Lyft has been criticized by labor groups for lowering compensation through gig work instead of paying fair wages and benefits. Why are you siding with Lyft?

I see it two ways. One, yes, we need to hold Lyft accountable for the way they treat their drivers and making sure they’re paying them fair wages. I do believe Lyft should do better. But the way that I see it, the fact that they’re transitioning into clean-energy vehicles is where I have to give them props.

Even the developers in our communities have the money to transition their diesel trucks to clean energy, but they’re not investing in that. We have a climate change crisis, and I don’t necessarily see them as the enemy. I see them as folks trying to be part of the solution and transitioning to clean energy.

Q: Will the initiative make a difference when so much of the Inland Empire’s pollution is from Los Angeles and the warehouse industry?

It will make electric vehicles and clean energy vehicles more affordable. And it would create those incentives that our low-income community needs, especially our small-business owners like our self-employed truck drivers that cannot afford to transition to a clean-energy vehicle or a truck. This program would give them those subsidies that they need so they can afford to transition.

This proposition will also give money to expand the clean-vehicle infrastructure that we need. Because here we are telling everybody to change to clean-energy vehicles, but we don’t have the infrastructure. Where are they going to charge their cars when they go to work? Or when they go to school? Or even in their own homes?

So, this campaign would put us in the right direction because I don’t see any other efforts being done, including with the state. I feel like sometimes the governor is a little hypocritical because here he is trying to be a champion for climate change, but he’s not showing a real plan to transition compared to this proposition, where they at least have a plan in place to tackle that transition.

Q: The state and federal governments have already invested billions in clean-car programs. Why is Proposition 30 needed?

It’s going to take a while before the money gets to the appropriate agencies. Another thing that I see that the government fails at is that they always leave out the most affected, marginalized, disenfranchised communities such as the Inland Empire. We have been overseen for so long, and every time the government creates these programs, all this investment and infrastructure, local agencies sometimes don’t know about it — or they don’t do the work to ask for the money.

And what this program does through Prop. 30 is that it’s taxing the rich, the people that make over $2 million. We always give the tax breaks to the rich and it’s about time that the rich pay their fair share.

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Turned Away From Urgent Care — And Toward a Big ER Bill

Kaiser Health News - Thu, 09/29/2022 - 5:00am

Frankie Cook remembers last year’s car crash only in flashes.

She was driving a friend home from high school on a winding road outside Rome, Georgia. She saw standing water from a recent rain. She tried to slow down but lost control of her car on a big curve. “The car flipped about three times,” Frankie said. “We spun around and went off the side of this hill. My car was on its side, and the back end was crushed up into a tree.”

Frankie said the air bags deployed and both passengers were wearing seat belts, so she was left with just a headache when her father, Russell Cook, came to pick her up from the crash site.

Frankie, then a high school junior, worried she might have a concussion that could affect her performance on an upcoming Advanced Placement exam, so she and her father decided to stop by an urgent care center near their house to get her checked out. They didn’t make it past the front desk.

“‘We don’t take third-party insurance,’” Russell said the receptionist at Atrium Health Floyd Urgent Care Rome told him, though he wasn’t sure what she meant. “She told me, like, three times.”

The problem didn’t seem to be that the clinic lacked the medical expertise to evaluate Frankie. Rather, the Cooks seemed to be confronting a reimbursement policy that is often used by urgent care centers to avoid waiting for payments from car insurance settlements.

Russell was told to take Frankie to an emergency room, which by law must see all patients regardless of such issues. The nearest one, at Atrium Health Floyd Medical Center, was about a mile down the road and was owned by the same hospital system as the urgent care center.

There, Russell said, a doctor looked Frankie over “for just a few minutes,” did precautionary CT scans of her head and body, and sent her home with advice to “take some Tylenol” and rest. She did not have a concussion or serious head injury and was able to take her AP exam on time.

Then the bill came.

The Patient: Frankie Cook, 18, now a first-year college student from Rome, Georgia.

Medical Services: A medical evaluation and two CT scans.

Service Provider: Atrium Health Floyd, a hospital system with urgent care centers in northwestern Georgia and northeastern Alabama.

Total Bill: $17,005 for an emergency room visit; it was later adjusted to $11,805 after a duplicate charge was removed.

What Gives: The Cooks hit a hazard in the health care system after Frankie’s car struck that tree: More and more hospital systems own urgent care centers, which have limits on who they treat — for both financial and medical reasons.

Russell was pretty upset after he received such a large bill, especially when he had tried to make a quick, inexpensive trip to the clinic. He said Frankie’s grandmother was seen at an urgent care center after a car wreck and walked out with a bill for just a few hundred dollars.

“That’s kind of what I was expecting,” he said. “She just really needed to be looked over.”

So why was Frankie turned away from an urgent care center?

Lou Ellen Horwitz, CEO of the Urgent Care Association, said it’s a pretty standard policy for urgent care centers not to treat injuries that result from car crashes, even minor ones. “Generally, as a rule, they do not take care of car accident victims regardless of the extent of their injuries, because it is going to go through that auto insurance claims process before the provider gets paid,” she said.

Horwitz said urgent care centers — even ones owned by big health systems — often operate on thin margins and can’t wait months and months for an auto insurance company to pay out a claim. She said “unfortunately” people tend to learn about such policies when they show up expecting care.

Fold in the complicated relationship between health and auto insurance companies and you have what Barak Richman, a health care policy professor at Duke University’s law school, called “the wildly complex world that we live in.”

“Each product has its own specifications about where to go and what it covers. Each one is incredibly difficult and complex to administer,” he said. “And each one imposes mistakes on the system.”

Atrium Health did not respond to repeated requests for comment on Frankie’s case.

Horwitz dismissed the idea that a health system might push people in car wrecks from urgent care centers to emergency rooms to make more money off them. Still, auto insurance generally pays more than health insurance for the same services.

Richman remained skeptical.

“At the risk of sounding a little too cynical, there are always dollar signs when a health care provider sees a patient come through the door,” Richman said.

Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School, said it was likely strategic for the urgent care center to be right down the street from the ER. Part of the strategy makes sense medically, he said, “because if a bad thing happens, you want to get them to some place with more skill really quickly.”

But he also said urgent care centers are “one of the most effective ways” for a health system to generate new revenue, creating a pipeline of new patients to visit its hospitals and later see doctors for testing and follow-up.

Mehrotra also said urgent care centers are not bound by the Emergency Medical Treatment and Labor Act, a federal law known as EMTALA that requires hospitals to stabilize patients regardless of their ability to pay.

At the time of Frankie’s visit, both the urgent care center and emergency room were owned by Floyd health system, which operated a handful of hospitals and clinics in northwestern Georgia and northeastern Alabama. Since then, Floyd has merged with Atrium Health — a larger, North Carolina-based company that operates dozens of hospitals across the Southeast.

Frankie got a CT scan of her head and body in the emergency room, tests KHN confirmed she couldn’t have gotten at the urgent care center regardless of whether the test was medically necessary or just part of a protocol for people in car wrecks who complain of a headache.

Resolution: Sixteen months have passed since Frankie Cook’s hospital visit, and Russell has delayed paying any of the bill on advice he got from a family friend who’s an attorney. After insurance covered its share, the Cooks’ portion came to $1,042.

Getting to that number has been a frustrating process, Russell said. He heard about the initial $17,005 bill in a letter from a lawyer representing the hospital — another unnerving wrinkle of Frankie’s care resulting from the car wreck. The Cooks then had to pursue a lengthy appeal process to get a $5,200 duplicate charge removed from the bill.

Anthem Blue Cross Blue Shield, the Cooks’ insurer, paid $4,006 of the claim. It said in a statement that it’s “committed to providing access to high-quality medical care for our members. This matter was reviewed in accordance with our clinical guidelines, and the billed claims were processed accordingly.”

“It’s not going to put us out on the street,” Russell said of the $1,042 balance, “but we’ve got expenses like everybody else.”

He added, “I would have loved a $200 urgent care visit, but that ship has sailed.”

Related Links

The Takeaway: It’s important to remember that urgent care centers aren’t governed by the same laws as emergency rooms and that they can be more selective about who they treat. Sometimes their reasons are financial, not clinical.

It’s not uncommon for urgent care centers — even ones in large health systems — to turn away people who have been in car wrecks because of the complications that car insurance settlements create.

Although urgent care visits are less expensive than going to an emergency room, the clinics often can’t offer the same level of care. And you might have to pay the cost of an urgent care visit just to find out you need follow-up care in the emergency room. Then you could be stuck with two bills.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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‘American Diagnosis’: When Indigenous People Move to Cities, Health Care Funding Doesn’t Follow

Kaiser Health News - Wed, 09/28/2022 - 5:00am

Can’t see the audio player? Click here to listen.

The transcript for this segment is being processed. We’re working to post it four to five days after the episode airs.

Episode 12: Indigenous and Invisible in the Big City

Over 70% of Indigenous people in the United States live in urban areas. But urban Indian health makes up less than 2% of the Indian Health Service’s annual budget.

While enrolled members of federally recognized tribes can access the Indian Health Service or tribally run health care on their reservations, Indigenous people who live in cities can find themselves without access to the care they’re entitled to.

“Even though we’re living in urban areas now, that doesn’t mean that our benefits should leave us,” said Esther Lucero, president and CEO of the Seattle Indian Health Board.

The Seattle Indian Health Board is one of many urban clinics across the United States that opened to address the discrimination and lack of services Indigenous people face in cities. These clinics work to meet the cultural and ceremonial needs of the populations they serve.

“We are much more than a community health center or place that provides direct service. We are a home away from home,” Lucero said.

Episode 12 explores the barriers Indigenous people face to accessing quality health care in cities and the efforts of urban Indian clinics to meet the needs of this population.

Voices from the episode:

  • Esther Lucero, president and CEO of the Seattle Indian Health Board
  • Dr. Patrick Rock, CEO of the Indian Health Board of Minneapolis
  • Douglas Miller, an associate professor of Native American History at Oklahoma State University
  • Richard Wright, a spiritual health adviser with the Indian Health Board of Minneapolis

Season 4 of “American Diagnosis” is a co-production of KHN and Just Human Productions.

Our Editorial Advisory Board includes Jourdan Bennett-BegayeAlastair Bitsóí, and Bryan Pollard.

To hear all KHN podcasts, click here.

Listen and follow “American Diagnosis” on Apple Podcasts, Spotify, Google, or Stitcher.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Montana Health Officials Aim to Boost Oversight of Nonprofit Hospitals’ Giving

Kaiser Health News - Wed, 09/28/2022 - 5:00am

Montana health officials are proposing to oversee and set standards for the charitable contributions that nonprofit hospitals make in their communities each year to justify their access to millions of dollars in tax exemptions.

The proposal is part of a package of legislation that the state Department of Public Health and Human Services will ask lawmakers to approve when they convene in January. It comes two years after a state audit called on the department to play more of a watchdog role and nine months after a KHN investigation found some of Montana’s wealthiest hospitals lag behind state and national averages in community giving.

Montana state Sen. Bob Keenan, a Republican who has questioned whether nonprofit hospitals deserve their charity status, said the proposal is a start that could be expanded on later.

“Transparency is the name of the game here,” Keenan said.

The IRS requires nonprofit hospitals to tally what they spend to “promote health” to benefit “the community as a whole.” How hospitals count such contributions to justify their tax exemptions is opaque and varies widely. National researchers who study community benefits have called for tightening standards for what counts toward the requirement.

Montana is one of the most recent states to consider imposing new rules or increasing oversight of nonprofit hospitals amid questions about whether they pay their fair share. Dr. Vikas Saini, president of the national health care think tank Lown Institute, said that both at a state and local level, people in California are exploring whether to monitor hospital community benefits and enforce new standards. Last year, Oregon initiated a minimum amount that nonprofit hospitals must spend on community benefits. And Massachusetts updated its community benefits guidelines in recent years, pushing hospitals to give more detailed assessments of how the spending lines up with identified health needs.

Montana hospital industry officials said they want to work with the state to shape the proposed legislation, which they said the industry would support if it doesn’t conflict with federal rules. Saini said that to have an impact, any legislation would have to go beyond federal requirements.

In recent years, more people, like Keenan and Saini, have questioned whether nonprofit hospitals are contributing enough to their communities to deserve the major tax breaks they get while becoming some of the largest businesses in town.

“The hospitals are sort of the pillars of communities, but people are starting to ask these questions,” Saini said.

Saini’s institute reviews hospitals’ giving each year and has found that the majority of nonprofit systems nationwide spend less on what the institute calls “meaningful” benefits than the estimated value of their tax breaks. Actions the institute counts include patient financial aid and community investments such as food assistance, health education, or services offered at a loss, including addiction treatment.

The 2020 Montana audit found that hospitals in the state report benefits vaguely and inconsistently, making it difficult to determine whether their charity status is justified. However, state lawmakers didn’t address the issue in their 2021 biennial legislative session, and a Legislative Audit Division memorandum issued in June found the state health department had “made no meaningful progress” toward developing oversight of nonprofit hospitals’ charitable giving since then.

KHN found that Montana’s nearly 50 nonprofit hospitals directed roughly 8% of their total annual expenses, on average, toward community benefits in the tax year that ended in 2019. The national average was 10%.

In some cases, hospitals’ giving percentages have declined since then. For example, in the tax year that ended in 2019, Logan Health-Whitefish — a small hospital that’s part of the larger Flathead Valley health system — reported that less than 2% of its overall spending went toward community benefits. In its latest available documents, for the period ending in 2021, the hospital reported spending less than 1% of its expenses on community benefits while it made $15 million more than it spent.

Logan Health spokesperson Mellody Sharpton said the medical system’s overall community benefit is equal to nearly 9% of its spending, reaching across its six hospitals. It also has clinics throughout the valley. “It’s important to consider our organization’s community benefit as a whole as our facilities collaborate to ensure the appropriate care is provided at the appropriate facility to meet our patients’ health needs,” Sharpton said.

State health officials asked lawmakers to allow the agency to draft a bill that would give the health department clear authority to require hospitals to submit annual reports that include community benefit and charity care data. The measure also would allow the department to develop standards for that community benefit spending, according to the department’s description of its proposal.

“We see a great need here to move the ball forward,” state health department leader Charlie Brereton told lawmakers in August.

Montana Hospital Association President Rich Rasmussen said his organization wants to work with the health department in honing the legislation but said the definition of what counts as benefits should remain broad so hospitals can respond to their area’s most pressing needs.

Furthermore, he said, hospitals are already working on their own reporting standards. This year, the association created a handbook for members and set a 2023 goal for hospitals to uniformly report their community benefits, Rasmussen said. The association declined to provide a copy of the handbook, saying it would be available to the public once hospitals are trained on how to use it later this fall.

The association also plans to create a website that will serve as a one-stop shop for people who want to know how hospitals are reporting community benefits and addressing local health concerns, among other things.

Republican state Rep. Jane Gillette said she supports increased health department oversight and the idea behind the association’s website but doesn’t think the hospital industry should produce that public resource alone. Gillette said she plans to introduce legislation to require hospitals to report community benefits data to a group outside the industry — such as the state — which would then post the information online.

In the past, hospitals have resisted attempts to impose new rules on community benefit spending. In an interview with KHN last year, Jason Smith, then Bozeman Health’s chief advancement officer, said the system supported efforts to improve reporting contributions “outside of new legislation,” adding that hospitals can do better work without “state oversight bodies being placed in the arena with us.”

Asked whether the health system still stands by that statement, Denise Juneau, Bozeman Health’s chief government and community affairs officer, said hospital officials hope any new legislation will align with existing federal guidelines. She said Bozeman Health will continue to work with the Montana Hospital Association to define and provide better community benefit information, with or without new legislation.

A lawmaker would have to back the state’s proposal by mid-December to keep it alive.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Few Places Have More Medical Debt Than Dallas-Fort Worth, but Hospitals There Are Thriving

Kaiser Health News - Wed, 09/28/2022 - 5:00am

PROSPER, Texas — Almost everything about the opening of the 2019 Prosper High School Eagles’ football season was big.

The game in this Dallas-Fort Worth suburb began with fireworks and a four-airplane flyover. A trained eagle soared over the field. And some 12,000 fans filled the team’s new stadium, a $53 million colossus with the largest video screen of any high school venue in Texas. Atop the stadium was also a big name: Children’s Health.

Business has been good for the billion-dollar pediatric hospital system, which agreed to pay $2.5 million to put its name on the Prosper stadium. Other Dallas-Fort Worth medical systems have also thrived. Though exempt from taxes as nonprofit institutions, several, including Children’s, notched double-digit margins in recent years, outperforming many of the area’s Fortune 500 companies.

But patients aren’t sharing in the good times. Of the nation’s 20 most populous counties, none has a higher concentration of medical debt than Tarrant County, home to Fort Worth. Second is Dallas County, credit bureau data shows.

The mismatched fortunes of hospitals and their patients reach well beyond this corner of Texas. Nationwide, many hospitals have grown wealthy, spending lavishly on advertising, team sponsorships, and even spas, while patients are squeezed by skyrocketing medical prices and rising deductibles.

A KHN review of hospital finances in the country’s 306 hospital markets found that several of the most profitable markets also have some of the highest levels of patient debt.

Overall, about a third of the 100 million adults in the U.S. with health care debt owe money for a hospitalization, according to a poll conducted by KFF for this project. Close to half of those owe at least $5,000. About a quarter owe $10,000 or more.

Many are pursued by collectors when they can’t pay their bills or hospitals sell the debt.

“The fact is, if you walk into a hospital today, chances are you are going to walk out with debt, even if you have insurance,” said Allison Sesso, chief executive of RIP Medical Debt, a nonprofit that buys debt from hospitals and debt collectors so patients won’t have to pay it.

Community Shadowed by Debt

Across the Dallas-Fort Worth metro area — the nation’s fourth-largest — the impact has been devastating. 

“Medical debt is forcing people here to make incredibly agonizing choices,” said Toby Savitz, programs director at Pathfinders, a Fort Worth nonprofit that assists people with credit problems. Savitz estimated that at least half their clients have medical debt. Many are scrimping on food, neglecting rent, even ending up homeless, she said, “and this is not just low-income people.” 

David Zipprich, a Fort Worth businessman and grandfather, was forced out of retirement after hospitalizations left him owing more than $200,000.

Zipprich, 64, had spent a career in financial consulting. He owned a small bungalow in a historical neighborhood near the Fort Worth rail yards. His daughters, both teachers, and his four grandchildren lived nearby. He had health insurance and some savings, and he’d paid off his mortgage.

Then in early 2020, Zipprich landed in the hospital. While driving, his blood sugar dropped precipitously, causing him to black out and crash his car.

Three months later, after he was diagnosed with diabetes, another complication led to another hospitalization. In December 2020, covid-19 put him there yet again. “I look back at that year and feel lucky I even survived,” Zipprich said.

But even with insurance, Zipprich was inundated with debt notices and calls from collectors. His credit score plummeted below 600, and he had to refinance his home. “My stress was off the charts,” he said, sitting in his neatly kept living room with his Shih Tzu, Murphy.

Overall in Tarrant County, 27% of residents with credit reports have medical debt on their records, credit bureau data analyzed by KHN and the nonprofit Urban Institute shows. In Dallas County, it’s 22%.

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That’s more than five times the rate in the largest counties in New York, data shows. The Texans also owe a lot more — the median amount of medical debt on credit records in Tarrant and Dallas counties is nearly $1,000, compared with $400 or less in New York.

Last year, Zipprich returned to work, taking a job in New Jersey that required he commute back and forth to Texas. He recently quit, citing the strain of so much travel. He’s now job hunting again. “I never thought this would happen to me,” he said.

Who Is Responsible?

Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.

Johnson said the center, where she’d gone after a knee injury, initially said her visits would cost $60. “Then they billed me hundreds,” she said. “I don’t go to the doctor unless I absolutely have to because it’s so expensive.”

Hospital industry leaders blame the patient debt on health insurers, citing the rise of high-deductible plans and other efforts that limit coverage. “The last thing that hospitals want is for their patients to face financial barriers,” said Molly Smith who leads public policy at the American Hospital Association. “Hospitals are in there trying to work on behalf of patients.”

Despite repeated requests from KHN, none of the medical systems around Dallas-Fort Worth would discuss their finances or the debt carried by patients.

But Smith and other hospital leaders point to billions of dollars of free or discounted care that hospitals nationwide provide every year. “Hospitals have been pretty darn generous,” said Stephen Love, president of the Dallas-Fort Worth Hospital Council. “If other parts of the community did as much as hospitals, we wouldn’t be in this problem.”

Unlike drug companies, device makers, and many physician practices, most U.S. hospitals are nonprofit and must provide charity care as a condition of their tax-exempt status.

Regardless of tax status, medical centers in markets with high medical debt do provide more charity care, according to an analysis by KHN and the Urban Institute, a Washington think tank. That’s important, said Dr. Vikas Saini, president of the Lown Institute, a nonprofit that grades hospitals on their quality and community benefits. But he asked: “Is a hospital truly serving its community if it’s pushing so many into debt?”

Around Dallas-Fort Worth, major medical systems frequently tout their commitment to the region and its patients.

When Texas Health Resources, a Dallas-based nonprofit system with more than $5 billion in annual revenue, opened a new hospital tower in Fort Worth earlier this year, Barclay Berdan, the system’s chief executive, said the building “reinforces Texas Health’s long-standing commitment to the Fort Worth community.” The nine-story, $300 million tower is one of more than a half-dozen new hospitals and major expansions around the Dallas-Fort Worth area since 2018.

The big building spree has been accompanied by big bottom lines.

From 2018 to 2021, Texas Health, which owns hospitals in North Texas, had an average operating margin of almost 6%, according to a KHN analysis of publicly available financial reports.

Other major systems in the area, including Baylor, Children’s Health, and HCA, the nation’s largest for-profit hospital company, did even better, KHN found. Cook Children’s, the region’s second major pediatric system, had an average operating margin of nearly 12%.

By comparison, profits at most of the 25 Fortune 500 companies based around Dallas-Fort Worth, such as ExxonMobil, were less than 6% in 2019, according to Fortune data.

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Approaching a Tipping Point

Hospitals have thrived in other markets with high patient debt, KHN found.

In Charlotte, North Carolina, where a quarter of residents have medical debt on their credit reports, hospitals recorded an average operating margin of 13.6% from 2017 to 2019.

The average margin at hospitals in and around Gainesville and Lakeland, two central Florida markets where a quarter of residents also carry medical debt, topped 9%. In Tulsa, Oklahoma, which has the same level of debt, margins have averaged 8.5%.

Overall, U.S. hospitals recorded their most profitable year on record in 2019, with an aggregate operating margin of 6.5%, according to the federal Medicare Payment Advisory Commission. Total margins, which include income from investments, were even higher.

“You might think that hospitals in communities where patients have a lot of debt would be less profitable, but that doesn’t seem to be the case,” said Anuj Gangopadhyaya, a senior Urban Institute researcher who worked with KHN on an analysis of hospital finance and consumer debt data in U.S. hospital markets.

In fact, the analysis found, there is no apparent relationship between the profits of hospitals in a market and how much medical debt residents have. So while hospitals in places like Charlotte and Tulsa may be comfortably in the black, in other places with high patient debt such as Amarillo, Texas, and Columbia, South Carolina, hospitals are struggling, data shows.

Industry experts say the most profitable medical centers — like those around Dallas-Fort Worth — have developed business models that allow them to prosper even if their patients can’t pay.

One key is prices. These hospitals maximize what they charge for everything from a complex surgery to a dose of aspirin. Most of those charges are picked up by health insurers, which still pay a much larger share of hospital bills than patients do, even those with the highest deductibles.

Across the country, many medical systems have strengthened their market power in recent years by consolidating, buying up smaller hospitals and physician practices, which enable the hospital systems to charge even more.

Dallas-Fort Worth has the highest medical prices in Texas, according to the Health Care Cost Institute, a nonprofit that tracks costs nationwide. And in a state where most markets have relatively low medical prices, in-patient care at Dallas-Fort Worth hospitals was 13% more expensive than the national median in 2020.

In addition to charging more, the most profitable hospitals frequently squeeze more savings from their operations, holding down what they pay workers, for example, and securing better contracts from suppliers. “Hospitals have had to get leaner and meaner,” said Kevin Holloran, a senior director at Fitch Ratings who tracks nonprofit health systems for the bond rating firm.

It’s unclear how much longer this business model can endure.

Across the country, many small and rural hospitals have closed in recent years. Even some larger systems are now losing money, as inflation and rising labor costs put new pressure on bottom lines.

As bills rise, hospitals are having a harder time collecting. Last year, nearly 1 in 5 patient bills generated by hospitals for people with insurance topped $7,500, according to an analysis of hospital billing records by Crowe LLP, a Chicago-based accounting and consulting firm. That was more than triple the rate in 2018.

“These are bills that fewer and fewer patients out there can afford,” said Brian Sanderson, a senior Crowe health care consultant and former hospital executive. Indeed, hospitals manage to collect less than 17% of patient balances that exceed $7,500, according to Crowe’s analysis.

“The rates at which patient balances are growing is just unsustainable for our health systems,” Sanderson said, predicting that most will never be able to collect bills of this size. “It’s trending to the ridiculous.”

Robert Earley, a former Texas state legislator who used to head Fort Worth’s public health system, compared today’s hospitals to shrimpers in the Gulf Coast district he once represented.  

“They wanted to pull so much shrimp out of the bay that they didn’t think about whether there’d be any there long term,” Earley said, recalling his constituents’ struggles. “I worry that those of us in health care aren’t asking ourselves enough if this system is sustainable.”

How the Research Was Done

To explore connections between hospital profits and patient debt, KHN and the Urban Institute examined data from each of the nation’s 306 hospital markets, also known as hospital referral regions.

Researchers calculated medical debt in each hospital referral region using 2019 credit bureau data maintained by the Urban Institute. They then compared the debt load in each market to the average operating margin for hospitals in that market over three years from 2017 to 2019, weighting each hospital’s margin by the number of adjusted admissions.

The margins data comes from hospital cost reports that hospitals file annually with the federal Centers for Medicare & Medicaid Services. These reports are aggregated by the nonprofit Rand Corp., which supplied the data to KHN and the Urban Institute.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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$2,700 Ambulance Bill Pulled Back From Collections

Kaiser Health News - Wed, 09/28/2022 - 5:00am

Peggy Dula is as surprised as she is relieved. The 55-year-old resident of St. Charles, Illinois, had been fighting a $2,700 ambulance bill for nearly a year. Now, the amount she owes from her September 2021 car wreck appears to be zero.

This summer, KHN, NPR, and CBS News spotlighted Dula in the Bill of the Month series. The initial $3,600 charge for Dula’s ambulance ride was significantly higher than the charges received by her two siblings, who were riding in her car at the time and were transported to the same hospital. The siblings rode in separate ambulances, each from a different nearby fire protection district. All three were billed different amounts for the same services. Dula’s injuries were the least serious, but her bill was the most expensive.

Even after Dula’s insurer paid $900, her bill from Pingree Grove and Countryside Fire Protection District was still roughly twice what each of her siblings had been charged.

Dula’s attempts to resolve the bill were unsuccessful.

Paramedic Billing Services, the company that handles billing for Pingree Grove, said she’d have to dispute charges directly with the fire protection district. But Dula said she couldn’t get a fire district representative on the phone. Then, in June, she received a letter from collections agency Wakefield & Associates seeking payment for her ambulance bill.

Dula remained resolute about not paying until the price was lowered to be more in line with what her siblings had been charged. But the collections agency was equally firm. And that’s where the bill stood for months, in a stalemate.

Last week, Dula called the hospital where she was transported after the crash. She had recently received a bill from the hospital saying she owed nearly $1,500, but when she called she was told her balance was zero. The surprise resolution of her hospital bill prompted her to call Wakefield & Associates to check on her ambulance bill. She said she was told the bill had been pulled back from collections and her balance was zero.

The apparent resolution came approximately a month after “CBS Mornings” covered Dula’s Bill of the Month saga. Wakefield & Associates confirmed to KHN that the bill had been pulled back and that her balance with the agency is zero. Pingree Grove Fire Chief Kieran Stout did not return multiple requests for comment.

“It feels great,” Dula said. “It was a real monkey on my back.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Health Plan Shake-Up Could Disrupt Coverage for Low-Income Californians

Kaiser Health News - Tue, 09/27/2022 - 5:00am

Almost 2 million of California’s poorest and most medically fragile residents may have to switch health insurers as a result of a new strategy by the state to improve care in its Medicaid program.

A first-ever statewide contracting competition to participate in the program, known as Medi-Cal, required commercial managed-care plans to rebid for their contracts and compete against others hoping to take those contracts away. The contracts will be revamped to require insurers to offer new benefits and meet stiffer benchmarks for care.

The long-planned reshuffle of insurers is likely to come with short-term pain. Four of the managed-care insurers, including Health Net and Blue Shield of California, stand to lose Medi-Cal contracts in a little over a year, according to the preliminary results of the bidding, announced in late August. If the results stand, some enrollees in rural Alpine and El Dorado counties, as well as in populous Los Angeles, San Diego, Sacramento, and Kern counties, will have to change health plans — and possibly doctors.

“I’m still shocked and I’m still reeling from it,” said John Sturm, one of about 325,000 members of Community Health Group, the largest Medi-Cal plan in San Diego County, which could lose its contract. “Which doctors can I keep? How long is it going to take me to switch plans? Are there contingency plans when, inevitably, folks slip through the cracks?” Sturm wondered.

Sturm, 54, who has three mental health conditions, largely because of childhood sexual abuse, said finding a psychologist and psychiatrist he could trust took a lot of time and effort. He pointed to the disruption caused by the rollout of Medi-Cal’s new prescription drug program this year, despite assurances it would go smoothly.

“I have concerns, and I know other people in the community have concerns about what we’re being told versus what the reality is going to be,” Sturm said.

Arguably, the biggest loser in the bidding is Health Net, the largest commercial insurer in Medi-Cal, which stands to lose half its enrollees — including more than 1 million in Los Angeles County alone. St. Louis-based Centene Corp., which California is investigating over allegations it overcharged the state for prescription drugs, bought Health Net in 2016, in part for its Medicaid business, of which L.A. is the crown jewel.

But the state’s health plan selections are not set in stone. The losing insurers are fiercely contesting the results in formal appeals that read like declarations of war on their competitors and on the state. Some of the losers essentially call their winning rivals liars.

The stakes are high, with contracts in play worth billions of dollars annually. Insurers that lose their appeals with the state Department of Health Care Services, which runs Medi-Cal, are likely to take their complaints to court. That could delay final decisions by months or years, causing a headache for the department, which wants coverage under the new contracts to start Jan. 1, 2024.

State officials hope to spend the rest of this year and all of 2023 ensuring the chosen health plans are up to the task, which includes having enough participating providers to minimize disruptions in care.

“Member access and continuity are really our top priorities as part of this transition, and we have dedicated teams that will be working with the health plans on the transition planning and the continuity planning,” Michelle Baass, director of the department, told KHN.

Baass also noted that enrollees have continuity of care rights. “For example, if a member is currently under the care of a doctor during the prior 12 months, the member has the right to continue seeing that doctor for up to 12 months, if certain conditions are met,” she said.

The competitive bidding process is an effort by the department to address persistent complaints that it has not effectively monitored subpar health plans.

Eight commercial insurers bid for Medi-Cal business in 21 counties. They were required to submit voluminous documents detailing every aspect of their operations, including past performance, the scope of their provider networks, and their capacity to meet the terms of the new, stricter contracts.

The new contracts contain numerous provisions intended to bolster quality, health care equity, and transparency — and to boost accountability of the subcontractors to whom health plans often outsource patient care. For example, the plans and their subcontractors will be required to reach or exceed the 50th percentile among Medicaid plans nationally on a host of pediatric and maternal care measures — or face financial penalties.

They will also be on the hook for providing nonmedical social services that address socioeconomic factors, such as homelessness and food insecurity, in an ambitious $8.7 billion, five-year Medi-Cal initiative known as CalAIM, that is already underway.

Local, publicly governed Medi-Cal plans, which cover about 70% of the 12.4 million Medi-Cal members who are in managed care, did not participate in the bidding, though their performance has not always been top-notch. Kaiser Permanente, which this year negotiated a controversial deal with the state for an exclusive Medi-Cal contract in 32 counties, was also exempt from the bidding. (KHN is not affiliated with Kaiser Permanente.)

But all Medi-Cal health insurers, including KP and the local plans, will have to commit to the same goals and requirements.

In addition to Health Net, Blue Shield of California, and Community Health Group — which have contracts with Medi-Cal only in San Diego County — are also big losers, as is Aetna, which lost bids in 10 counties.

Blue Shield, which lost in all 13 counties where it submitted bids, filed a fiercely worded appeal that accuses its rivals Anthem Blue Cross, Molina, and Health Net of failing to disclose hundreds of millions of dollars in penalties against them. It accused those three plans of poor performance “and even mendacity” and said they filled their bids with “puffery,” which the state “bought, hook, line and sinker,” without “an iota of independent analysis.”

Health Net’s appeal slammed Molina, which beat it out in L.A., Sacramento, Riverside, and San Bernardino counties. Molina’s bid, Health Net said, “contains false, inaccurate and misleading information.” The whole bidding process, it said, was “highly flawed,” resulting in “erroneous contract awards that jeopardize the stability of Medi-Cal.”

In particular, Health Net said, the Department of Health Care Services “improperly reopened the procurement” after the deadline, which allowed Molina to make “comprehensive changes” that raised its score.

The protesting health plans are requesting that they be awarded contracts or that the bidding process start over from scratch.

Joseph Garcia, chief operating officer for Community Health Group, said, “It would be easiest for all concerned if they just added us. They don’t have to remove anybody.”

Community Health Group has garnered an outpouring of support from hospital executives, physician groups, community clinics, and the heads of multiple publicly governed Medi-Cal plans who sent a letter to Baass saying they were “shocked, concerned, and very disappointed” by the state’s decision. They called Community Health Group “our strongest partner of 40 years,” for whom “equity is not a buzzword or a new priority,” noting that more than 85% of its staff is bilingual and multicultural.

Community Health Group noted in its appeal that it had lost by less than a point to Health Net, which won a San Diego contract — “a miniscule difference that in itself resulted from deeply flawed scoring.”

Garcia said that if Community Health Group loses its appeal, it will “absolutely” sue in state court. A hearing officer appointed by Baass to consider the appeals has set deadlines to receive written responses and rebuttals by Oct. 7.

There is ample precedent for protracted legal battles in bidding for Medicaid contracts. In Louisiana, Centene and Aetna protested the results of a 2019 rebidding process, which led the state to nullify its awards and restart the bidding. The new results were announced this year, with Centene and Aetna among the winners. In Kentucky, the state court of appeals issued a ruling this month in a contested Medicaid procurement that had been held two years earlier.

Another factor could delay the new contract: California is juggling several massive Medi-Cal changes at the same time. Among them are the implementation of CalAIM and the anticipated enrollment of nearly 700,000 unauthorized immigrants ages 26-49 by January 2024, on top of nearly a quarter-million unauthorized immigrants 50 and older who became eligible this year. And then there’s the recalculation of enrollees’ eligibility, which will take place whenever the federal covid-19-related public health emergency ends. That could push 2 million to 3 million Californians out of Medi-Cal.

“Just hearing you list all those things gave me a minor panic attack,” said Abigail Coursolle, a senior attorney at the National Health Law Program. “They are making a lot of work for themselves in a short amount of time.”

But, Coursolle added, the state has “a very positive vision for improving access and improving the quality of services that people in Medi-Cal receive, and that’s very important.”

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Britain’s Hard Lessons From Handing Elder Care Over to Private Equity

Kaiser Health News - Tue, 09/27/2022 - 5:00am

LONDON — A little over a decade ago, Four Seasons Health Care was among the largest long-term care home companies in Britain, operating 500 sites with 20,000 residents and more than 60 specialist centers. Domestic and global private equity investors had supercharged the company’s growth, betting that the rising needs of aging Britons would yield big returns.

Within weeks, the Four Seasons brand may be finished.

Christie & Co., a commercial real estate broker, splashed a summer sale across its website that signaled the demise: The last 111 Four Seasons facilities in England, Scotland, and Jersey were on the market. Already sold were its 29 homes in Northern Ireland.

Four Seasons collapsed after years of private equity investors rolling in one after another to buy its business, sell its real estate, and at times wrest multimillion-dollar profits through complex debt schemes — until the last big equity fund, Terra Firma, which in 2012 paid about $1.3 billion for the company, was caught short.

In a country where government health care is a right, the Four Seasons story exemplifies the high-stakes rise — and, ultimately, fall — of private equity investment in health and social services. Hanging over society’s most vulnerable patients, these heavily leveraged deals failed to account for the cost of their care. Private equity firms are known for making a profit on quick-turnaround investments.

“People often say, ‘Why have American investors, as well as professional investors here and in other countries, poured so much into this sector?’ I think they were dazzled by the potential of the demographics,” said Nick Hood, an analyst at Opus Restructuring & Insolvency in London, which advises care homes — the British equivalent of U.S. nursing homes or assisted living facilities. They “saw the baby boomers aging and thought there would be infinite demands.”

What they missed, Hood said, “was that about half of all the residents in U.K. homes are funded by the government in one way or another. They aren’t private-pay — and they’ve got no money.”

Residents as ‘Revenue Streams’

As in the United States, long-term care homes in Britain serve a mixed market of public- and private-pay residents, and those whose balance sheets rest heavily on government payments are stressed even in better economic times. Andrew Dobbie, a community officer for Unison, a union that represents care home workers, said private equity investors often see homes like Four Seasons as having “two revenue streams, the properties themselves and the residents,” with efficiencies to exploit.

But investors don’t always understand what caregivers do, he said, or that older residents require more time than spreadsheets have calculated. “That’s a problem when you are looking at operating care homes,” Dobbie said. “Care workers need to have soft skills to work with a vulnerable group of people. It’s not the same skills as stocking shelves in a supermarket.”

A recent study, funded in part by Unison and conducted by University of Surrey researchers, found big changes in the quality of care after private equity investments. More than a dozen staff members, who weren’t identified by name or facility, said companies were “cutting corners” to curb costs because their priority was profit. Staffers said “these changes meant residents sometimes went without the appropriate care, timely medication or sufficient sanitary supplies.”

In August, the House of Commons received a sobering account: The number of adults 65 and older who will need care is speedily rising, estimated to go from 3.5 million in 2018 to 5.2 million in 2038. Yet workers at care homes are among the lowest paid in health care.

“The covid-19 pandemic shone a light on the adult social care sector,” according to the parliamentary report, which noted that “many frustrated and burnt out care workers left” for better-paying jobs. The report’s advice in a year of soaring inflation and energy costs? The government should add “at least £7 billion a year” — more than $8 billion — or risk deterioration of care.

Britain’s care homes are separate from the much-lauded National Health Service, funded by the government. Care homes rely on support from local authorities, akin to counties in the United States. But they have seen a sharp drop in funding from the British government, which cut a third of its payments in the past decade. When the pandemic hit, the differences were apparent: Care home workers were not afforded masks, gloves, or gowns to shield them from the deadly virus.

Years ago, care homes were largely run by families or local entities. In the 1990s, the government promoted privatization, triggering investments and consolidations. Today, private equity firms own three of the country’s five biggest care home providers.

Chris Thomas, a research fellow at the Institute for Public Policy Research, said investors benefited from scant financial oversight. “The accounting practices are horrendously complicated and meant to be complicated,” he said. Local authorities try “to regulate more, but they don’t have the expertise.”

The Financial Shuffle

At Four Seasons, the speed of change was dizzying. From 2004 to 2017, big money came and went, with revenue at times threaded through multiple offshore vehicles. Among the groups that owned Four Seasons, in part or in its entirety: British private equity firm Alchemy Partners; Allianz Capital Partners, a German private equity firm; Three Delta LLP, an investment fund backed by Qatar; the American hedge fund Monarch Alternative Capital; and Terra Firma, the British private equity group that wallowed in debt demands. H/2 Capital Partners, a hedge fund in Connecticut, was Four Seasons’ main creditor and took over. By 2019, Four Seasons was managed by insolvency experts.

Pressed on whether Four Seasons would exist in any form after the current sale of its property and businesses, MHP Communications, representing the company, said in an email: “It is too early in the process to speculate about the future of the brand.”

Vivek Kotecha, an accountant who has examined the Four Seasons financial shuffle and co-authored the Unison report, said private equity investment — in homes for older residents and, increasingly, in facilities for troubled children — is now part of the financial mainstream. The consulting firm McKinsey this year estimated that private markets manage nearly $10 trillion in assets, making them a dominant force in global markets.

“What you find in America with private equity is much the same here,” said Kotecha, the founder of Trinava Consulting in London. “They are often the same firms, doing the same things.” What was remarkable about Four Seasons was the enormous liability from high-yield bonds that underpinned the deal — one equaling $514 million at 8.75% interest and another for $277 million at 12.75% interest.

Guy Hands, the high-flying British founder of Terra Firma, bought Four Seasons in 2012, soon after losing an epic court battle with Citigroup over the purchase price of the music company EMI Group. Terra Firma acquired the care homes and then a gardening business with more than 100 stores. Neither proved easy, or good, bets. Hands, a Londoner who moved offshore to Guernsey, declined through a representative to discuss Four Seasons.

Kotecha, however, helped the BBC try to make sense of Four Seasons’ holdings by tracking financial filings. It was “the most complicated spreadsheet I’ve ever seen,” Kotecha said. “I think there were more subsidiaries involved in Four Seasons’ care homes than there were with General Motors in Europe.”

As Britain’s small homes were swept up in consolidations, some financial practices were dubious. At times, businesses sold the buildings as lease-back deals — not a problem at first — that, after multiple purchases, left operators paying rent with heavy interest that sapped operating budgets. By 2020, some care homes were estimated to be spending as much as 16% of their bed fees on debt payments, according to parliamentary testimony this year.

How could that happen? In part, for-profit providers — backed by private equity groups and other corporations — had subsidiaries of their parent companies act as lender, setting the rates.

Britain’s elder care was unrecognizable within a generation. By 2022, private equity companies alone accounted for 55,000 beds, or about 12.6% of the total for-profit care beds for older people in the United Kingdom, according to LaingBuisson, a health care consultancy. LaingBuisson calculated that the average residential care home fee as of February 2022 was about $44,700 a year; the average nursing home fee was $62,275 a year.

From 1980 to 2018, the number of residential care beds provided by local authorities fell 88% — from 141,719 to 17,100, according to the nonprofit Centre for Health and the Public Interest. Independent operators — nonprofits and for-profits — moved in, it said, controlling 243,000 beds by 2018. Nursing homes saw a similar shift: Private providers accounted for 194,100 beds in 2018, compared with 25,500 decades earlier.

Beyond Government Control

British lawmakers last winter tried — and failed — to bolster financial reporting rules for care homes, including banning the use of government funds to pay off debt.

“I don’t have a problem with offshore companies that make profits if they offer good services. I don’t have a problem with private equity and hedge funds who deliver good returns to their shareholders,” Ros Altmann, a Conservative Party member in the House of Lords and a pension expert, said in a February debate. “I do have a problem if those companies are taking advantage of some of the most vulnerable people in our society without oversight, without controls.”

She cited Four Seasons as an example of how regulators “have no control over the financial models that are used.” Altmann warned that economic headwinds could worsen matters: “We now have very heavily debt-laden [homes] in an environment where interest rates are heading upward.”

In August, the Bank of England raised borrowing rates. It now forecasts double-digit inflation — as much as 11% — through 2023.

And that leaves care home owner Robert Kilgour pensive about whether government grasps the risks and possibilities that the sector is facing. “It’s a struggle, and it’s becoming more of a struggle,” he said. A global energy crisis is the latest unexpected emergency. Kilgour said he recently signed electricity contracts, for April 2023, at rates that will rise by 200%. That means an extra $2,400 a day in utility costs for his homes.

Kilgour founded Four Seasons, opening its first home, in Fife, Scotland, in 1989. His ambition for its growth was modest: “Ten by 2000.” That changed in 1999 when Alchemy swooped in to expand nationally. Kilgour had left Four Seasons by 2004, turning to other ventures.

Still, he saw opportunity in elder care and opened Renaissance Care, which now operates 16 homes with 750 beds in Scotland. “I missed it,” he said in an interview in London. “It’s people and it’s property, and I like that.”

“People asked me if I had any regrets about selling to private equity. Well, no, the people I dealt with were very fair, very straight. There were no shenanigans,” Kilgour said, noting that Alchemy made money but invested as well.

Kilgour said the pandemic motivated him to improve his business. He is spending millions on new LED lighting and boilers, as well as training staffers on digital record-keeping, all to winnow costs. He increased hourly wages by 5%, but employees have suggested other ways to retain staff: shorter shifts and workdays that fit school schedules or allow them to care for their own older relatives.

Debates over whether the government should move back into elder care make little sense to Kilgour. Britain has had private care for decades, and he doesn’t see that changing. Instead, operators need help balancing private and publicly funded beds “so you have a blended rate for care and some certainty in the business.”

Consolidations are slowing, he said, which might be part of a long-overdue reckoning. “The idea of 200, 300, 400 care homes — that big is good and big is best — those days are gone,” Kilgour said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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At This Recovery Center, Police Cope With the Mental Health Costs of the Job

Kaiser Health News - Tue, 09/27/2022 - 5:00am

HAVRE DE GRACE, Md. — Ken Beyer can’t think of a day in the past few months when his phone didn’t flutter with calls, text messages, and emails from a police department, a sheriff’s office, or a fire station seeking help for an employee. A patrol officer threatening to kill himself with his service weapon before roll call. A veteran firefighter drowning in vodka until he collapses. A deputy overdosing on fentanyl in his squad car.

“It’s the worst that I’ve seen in my career,” said Beyer, co-founder and CEO of Harbor of Grace Enhanced Recovery Center, a private mental health and substance use recovery and treatment center for first responders in the waterfront Maryland town of Havre de Grace. Established in 2015, Harbor of Grace is one of only six treatment centers in the U.S. approved by the Fraternal Order of Police, the world’s largest organization of law enforcement officers.

Public safety is a profession plagued by high rates of mental health and addiction problems. Considering the unrelenting pressures on first responders, Beyer said, the treatment centers can’t keep up with the demand.

Specialized recovery facilities like Harbor of Grace focus on treating law enforcement officers, firefighters, emergency medical technicians, and dispatchers — people who regularly encounter violence and death at work. In the past two years, Beyer said, the number of police officers admitted for treatment at his facility alone has more than tripled. “And we always have up to 20 cops in the queue,” he said. Other treatment centers for first responders reported a similar spike in patients.

Anger at police and policing practices soared after a Minneapolis officer murdered George Floyd in 2020, and it put additional strain on officers’ mental health, said Dr. Brian Lerner, a psychiatrist and the medical director at Harbor of Grace. “Officers feel disparaged by the public and often, they also feel unsupported by their agencies,” he said.

That’s part of the reason “we’re looking at a significant rate of burnout among police officers,” said Jennifer Prohaska, a clinical psychologist in Kansas City, Kansas, who focuses on helping law enforcement personnel.

The poor state of many officers’ mental health, combined with low morale, has contributed to an exodus of police across the country that has left departments understaffed and the remaining officers overworked and exhausted. Atlanta, Seattle, Phoenix, and Dallas are hit particularly hard by officer shortages. “That’s creating enormous stress on the system,” Prohaska said. “It’s a perfect storm.”

Even before the most recent stressors, rates of burnout and depression were up among first responders. Rates of post-traumatic stress disorder are five times as high in police officers as in the civilian population. Some studies estimate that as many as 30% of police officers have a substance use problem. Alcohol dependence is at the top of the list.

Last year alone, 138 law enforcement officers died by suicide — more than the number killed — 129 — in the line of duty, according to the FBI. A recent report from the Ruderman Family Foundation suggests that police suicides are often undercounted because of stigma.

Harbor of Grace has a small campus of eight single-story brick buildings with light blue and yellow accents and looks more like a seaside inn than a clinical setting. The center can treat 47 patients at a time. It has seven acute care beds, mostly for detox.

It offers help for a wide range of mental health conditions, including addiction, sleep disorders, anxiety, depression, suicidal ideation, and PTSD.

To date, more than 500 law enforcement agencies — federal, state, and local — have sent employees to Harbor of Grace. The center has 45 full-time clinical staffers, including an emergency physician and several psychiatrists, nurses, and counselors. Many have previously worked as first responders — from Army medics and firefighters to police officers.

On a recent morning at Harbor of Grace, the sun burned hot over the Chesapeake Bay. A group of patients, mostly men and a few women in their 30s, gathered on the small patio. Some sat alone, while others stood in small groups chatting.

“We get all types, from all backgrounds, and at all stages of brokenness,” said Beyer, 66, a former firefighter and EMT who overcame a problem with alcohol several decades ago. “All our patients and most of our staff know what it’s like to hold a dead or a dying child,” he said.

Sgt. Ryan Close has held several dead children. The 37-year-old police officer works as a patrol supervisor for a small law enforcement agency in New England that he did not want to identify to protect the identities of his colleagues. He has been a police officer for 15 years and has worked for several departments. When he started, he said, officers did not receive psychological training or have access to designated peer support programs.

He said that almost every time he was involved in a critical incident — like a shooting or an accident with burnt and disfigured bodies — “my supervisor ordered me to the bar afterwards.” One incident in particular has stuck in his memory — when a young boy shot himself in the head with a rifle. Washing down the horror with alcohol “was the culture back then,” he said.

But Close didn’t drink much at the time and was mocked by his peers for ordering only small beers. It wasn’t until years later, when memories of his experiences at work reemerged and he had trouble sleeping, that he started to self-medicate with alcohol. He developed social anxiety, and his marriage suffered.

His department pushed him to get help, and he entered Harbor of Grace in April 2021 for a 28-day treatment cycle. There, he learned to let go of his hardened veneer and his impulse to always be in control. He saw many other cops struggle with that too when they got to the center. “I witnessed grown men have a fit like a 6-year-old because a staff member wouldn’t let them use their cellphone.”

Many first responders develop heavy defense mechanisms and are “insecure, non-trusting, controlling,” Beyer said. They often wait way too long before they seek help, he added.

Police officers tend to be “very closed, very unwilling to be vulnerable,” Lerner said. But he finds that most first responders make model patients after they take the first steps. “At that point, they’re all in,” he said. “They don’t do anything halfway.”

At Harbor of Grace, the communication style mirrors the tone at a police station or firehouse, said Beyer. “We don’t waste time on the feel-good stuff,” he said. “We’re blunt. We call people out if necessary.”

Psychologist Prohaska said it’s important that specialized behavioral treatment centers for first responders exist. But, she said, there must also be better investment on the front end — for hands-on initiatives that teach resiliency to public safety employees, like the one she developed for the Kansas City Police Department.

Robust mental health training needs to be part of the academy curriculum and embedded in police culture, she said. “Just like we teach officers safety, we need to teach them resiliency,” she added. “A two-hour PowerPoint course won’t do it.”

Beyer expects the situation to get worse before it gets better. Over the past two years, he has seen more police officers resign while they’re in treatment. Previously, most went back to work. “Now, once they gain clarity, many say, ‘I want to stay healthy, and the way to stay healthy is get out of police work,’” he said.

Ryan Close decided to return to work in law enforcement. He has become an advocate for peer-to-peer support in his agency and beyond. He said his own mental health journey has made him a better police officer, with more empathy and improved communication skills.

His advice to fellow officers is to learn about the possible effects of trauma before they develop a serious problem. Also, he said, “establish a good dialogue with your family, your supervisors, your peers. Know what your limitations are. And learn healthy coping skills. Alcohol isn’t one.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Embedded Bias: How Medical Records Sow Discrimination

Kaiser Health News - Mon, 09/26/2022 - 5:00am

David Confer, a bicyclist and an audio technician, told his doctor he “used to be Ph.D. level” during a 2019 appointment in Washington, D.C. Confer, then 50, was speaking figuratively: He was experiencing brain fog — a symptom of his liver problems. But did his doctor take him seriously? Now, after his death, Confer’s partner, Cate Cohen, doesn’t think so.

Confer, who was Black, had been diagnosed with non-Hodgkin lymphoma two years before. His prognosis was positive. But during chemotherapy, his symptoms — brain fog, vomiting, back pain — suggested trouble with his liver, and he was later diagnosed with cirrhosis. He died in 2020, unable to secure a transplant. Throughout, Cohen, now 45, felt her partner’s clinicians didn’t listen closely to him and had written him off.

That feeling crystallized once she read Confer’s records. The doctor described Confer’s fuzziness and then quoted his Ph.D. analogy. To Cohen, the language was dismissive, as if the doctor didn’t take Confer at his word. It reflected, she thought, a belief that he was likely to be noncompliant with his care — that he was a bad candidate for a liver transplant and would waste the donated organ.

For its part, MedStar Georgetown, where Confer received care, declined to comment on specific cases. But spokesperson Lisa Clough said the medical center considers a variety of factors for transplantation, including “compliance with medical therapy, health of both individuals, blood type, comorbidities, ability to care for themselves and be stable, and post-transplant social support system.” Not all potential recipients and donors meet those criteria, Clough said.

Doctors often send signals of their appraisals of patients’ personas. Researchers are increasingly finding that doctors can transmit prejudice under the guise of objective descriptions. Clinicians who later read those purportedly objective descriptions can be misled and deliver substandard care.

Discrimination in health care is “the secret, or silent, poison that taints interactions between providers and patients before, during, after the medical encounter,” said Dayna Bowen Matthew, dean of George Washington University’s law school and an expert in civil rights law and disparities in health care.

Bias can be seen in the way doctors speak during rounds. Some patients, Matthew said, are described simply by their conditions. Others are characterized by terms that communicate more about their social status or character than their health and what’s needed to address their symptoms. For example, a patient could be described as an “80-year-old nice Black gentleman.” Doctors mention that patients look well-dressed or that someone is a laborer or homeless.

The stereotypes that can find their way into patients’ records sometimes help determine the level of care patients receive. Are they spoken to as equals? Will they get the best, or merely the cheapest, treatment? Bias is “pervasive” and “causally related to inferior health outcomes, period,” Matthew said.

Narrow or prejudiced thinking is simple to write down and easy to copy and paste over and over. Descriptions such as “difficult” and “disruptive” can become hard to escape. Once so labeled, patients can experience “downstream effects,” said Dr. Hardeep Singh, an expert in misdiagnosis who works at the Michael E. DeBakey Veterans Affairs Medical Center in Houston. He estimates misdiagnosis affects 12 million patients a year.

Conveying bias can be as simple as a pair of quotation marks. One team of researchers found that Black patients, in particular, were quoted in their records more frequently than other patients when physicians were characterizing their symptoms or health issues. The quotation mark patterns detected by researchers could be a sign of disrespect, used to communicate irony or sarcasm to future clinical readers. Among the types of phrases the researchers spotlighted were colloquial language or statements made in Black or ethnic slang.

“Black patients may be subject to systematic bias in physicians’ perceptions of their credibility,” the authors of the paper wrote.

That’s just one study in an incoming tide focused on the variations in the language that clinicians use to describe patients of different races and genders. In many ways, the research is just catching up to what patients and doctors knew already, that discrimination can be conveyed and furthered by partial accounts.

Confer’s MedStar records, Cohen thought, were pockmarked with partial accounts — notes that included only a fraction of the full picture of his life and circumstances.

Cohen pointed to a write-up of a psychosocial evaluation, used to assess a patient’s readiness for a transplant. The evaluation stated that Confer drank a 12-pack of beer and perhaps as much as a pint of whiskey daily. But Confer had quit drinking after starting chemotherapy and had been only a social drinker before, Cohen said. It was “wildly inaccurate,” Cohen said.

“No matter what he did, that initial inaccurate description of the volume he consumed seemed to follow through his records,” she said.

Physicians frequently see a harsh tone in referrals from other programs, said Dr. John Fung, a transplant doctor at the University of Chicago who advised Cohen but didn’t review Confer’s records. “They kind of blame the patient for things that happen, not really giving credit for circumstances,” he said. But, he continued, those circumstances are important — looking beyond them, without bias, and at the patient himself or herself can result in successful transplants.

The History of One’s Medical History

That doctors pass private judgments on their patients has been a source of nervous humor for years. In an episode of the sitcom “Seinfeld,” Elaine Benes discovers that a doctor had condescendingly written that she was “difficult” in her file. When she asked about it, the doctor promised to erase it. But it was written in pen.

The jokes reflect long-standing conflicts between patients and doctors. In the 1970s, campaigners pushed doctors to open up records to patients and to use less stereotyping language about the people they treated.

Nevertheless, doctors’ notes historically have had a “stilted vocabulary,” said Dr. Leonor Fernandez, an internist and researcher at Beth Israel Deaconess Medical Center in Boston. Patients are often described as “denying” facts about their health, she said, as if they’re not reliable narrators of their conditions.

One doubting doctor’s judgment can alter the course of care for years. When she visited her doctor for kidney stones early in her life, “he was very dismissive about it,” recalled Melina Oien, who now lives in Tacoma, Washington. Afterward, when she sought care in the military health care system, providers — whom Oien presumed had read her history — assumed that her complaints were psychosomatic and that she was seeking drugs.

“Every time I had an appointment in that system — there’s that tone, that feel. It creates that sense of dread,” she said. “You know the doctor has read the records and has formed an opinion of who you are, what you’re looking for.”

When Oien left military care in the 1990s, her paper records didn’t follow her. Nor did those assumptions.

New Technology — Same Biases?

While Oien could leave her problems behind, the health system’s shift to electronic medical records and the data-sharing it encourages can intensify misconceptions. It’s easier than ever to maintain stale records, rife with false impressions or misreads, and to share or duplicate them with the click of a button.

“This thing perpetuates,” Singh said. When his team reviewed records of misdiagnosed cases, he found them full of identical notes. “It gets copy-pasted without freshness of thinking,” he said.

Research has found that misdiagnosis disproportionately happens to patients whom doctors have labeled as “difficult” in their electronic health record. Singh cited a pair of studies that presented hypothetical scenarios to doctors.

In the first study, participants reviewed two sets of notes, one in which the patient was described simply by her symptoms and a second in which descriptions of disruptive or difficult behaviors had been added. Diagnostic accuracy dropped with the difficult patients.

The second study assessed treatment decisions and found that medical students and residents were less likely to prescribe pain medications to patients whose records included stigmatizing language.

Digital records can also display prejudice in handy formats. A 2016 paper in JAMA discussed a small example: an unnamed digital record system that affixed an airplane logo to some patients to indicate that they were, in medical parlance, “frequent flyers.” That’s a pejorative term for patients who need plenty of care or are looking for medications.

But even as tech might amplify these problems, it can also expose them. Digitized medical records are easily shared — and not merely with fellow doctors, but also with patients.

Since the ’90s, patients have had the right to request their records, and doctors’ offices can charge only reasonable fees to cover the cost of clerical work. Penalties against practices or hospitals that failed to produce records were rarely assessed — at least until the Trump administration, when Roger Severino, previously known as a socially conservative champion of religious freedom, took the helm of the U.S. Department of Health and Human Services’ Office for Civil Rights.

During Severino’s tenure, the office assessed a spate of monetary fines against some practices. The complaints mostly came from higher-income people, Severino said, citing his own difficulties getting medical records. “I can only imagine how much harder it often is for people with less means and education,” he said.

Patients can now read the notes — the doctors’ descriptions of their conditions and treatments — because of 2016 legislation. The bill nationalized policies that had started earlier in the decade, in Boston, because of an organization called OpenNotes.

For most patients, most of the time, opening record notes has been beneficial. “By and large, patients wanted to have access to the notes,” said Fernandez, who has helped study and roll out the program. “They felt more in control of their health care. They felt they understood things better.” Studies suggest that open notes lead to increased compliance, as patients say they’re more likely to take medicines.

Conflicts Ahead?

But there’s also a darker side to opening records: if patients find something they don’t like. Fernandez’s research, focusing on some early hospital adopters, has found that slightly more than 1 in 10 patients report being offended by what they find in their notes.

And the wave of computer-driven research focusing on patterns of language has similarly found low but significant numbers of discriminatory descriptions in notes. A study published in the journal Health Affairs found negative descriptors in nearly 1 in 10 records. Another team found stigmatizing language in 2.5% of records.

Patients can also compare what happened in a visit with what was recorded. They can see what was really on doctors’ minds.

Oien, who has become a patient advocate since moving on from the military health care system, recalled an incident in which a client fainted while getting a drug infusion — treatments for thin skin, low iron, esophageal tears, and gastrointestinal conditions — and needed to be taken to the emergency room. Afterward, the patient visited a cardiologist. The cardiologist, who hadn’t seen her previously, was “very verbally professional,” Oien said. But what he wrote in the note — a story based on her ER visit — was very different. “Ninety percent of the record was about her quote-unquote drug use,” Oien said, noting that it’s rare to see the connection between a false belief about a patient and the person’s future care.

Spotting those contradictions will become easier now. “People are going to say, ‘The doc said what?’” predicted Singh.

But many patients — even ones with wealth and social standing — may be reluctant to talk to their doctors about errors or bias. Fernandez, the OpenNotes pioneer, didn’t. After one visit, she saw a physical exam listed on her record when none had occurred.

“I did not raise that to that clinician. It’s really hard to raise things like that,” she said. “You’re afraid they won’t like you and won’t take good care of you anymore.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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