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Watch: Covid Increases Risk of Heart Problems, New Data Underlines

Kaiser Health News - Wed, 02/01/2023 - 5:00am

Céline Gounder, KHN’s editor-at-large for public health, discusses new data showing an excess of deaths in 2020 related to heart disease. The deaths — from heart attack and heart failure — show that the virus can affect the heart and that cardiac problems can show up months after an initial covid-19 infection has apparently resolved. Vaccines reduce the risk both of serious infections and subsequent heart problems.

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 Owners Drained Cash During Pandemic While Residents Deteriorated

Kaiser Health News - Wed, 02/01/2023 - 5:00am

After the nursing home where Leann Sample worked was bought by private investors, it started falling apart. Literally.

Part of a ceiling collapsed on a nurse, the air conditioning conked out regularly, and a toilet once burst on Sample while she was helping a resident in the bathroom, she recalled in a court deposition.

“It’s a disgusting place,” Sample, a nurse aide, testified in 2021.

The decrepit conditions Sample described weren’t due to a lack of money. Over seven years, The Villages of Orleans Health & Rehabilitation Center, located in western New York near Lake Ontario, paid nearly $16 million in rent to its landlord — a company that was owned by the same investors who owned the nursing home, court records show. From those coffers, the owners paid themselves and family members nearly $10 million, while residents injured themselves falling, developed bedsores, missed medications, and stewed in their urine and feces because of a shortage of aides, New York authorities allege.

At the height of the pandemic, lavish payments flowed into real estate, management, and staffing companies financially linked to nursing home owners throughout New York, which requires facilities to file the nation’s most detailed financial reports. Nearly half the state’s 600-plus nursing homes hired companies run or controlled by their owners, frequently paying them well above the cost of services, a KHN analysis found, while the federal government was giving the facilities hundreds of millions in fiscal relief.

In 2020, these affiliated corporations collectively amassed profits of $269 million, yielding average margins of 27%, while the nursing homes that hired them were strained by staff shortages, harrowing injuries, and mounting covid deaths, state records reveal.

“Even during the worst year of New York’s pandemic, when homes were desperately short of staffing and their residents were dying by the thousands, some owners managed to come out millions of dollars ahead,” said Bill Hammond, a senior fellow at the Empire Center for Public Policy, a think tank in Albany, New York.

Some nursing home owners moved money from their facilities through corporate arrangements that are widespread, and legal, in every state. Nationally, nearly 9,000 for-profit nursing homes — the majority — outsource crucial services such as nursing staff, management, and medical supplies to affiliated corporations, known as “related parties,” that their owners own, invest in, or control, federal records show. Many homes don’t even own their buildings but rent them from a related company. Homes pay related parties more than $12 billion a year, but federal regulators do not make them reveal how much they charge above the cost of services, and how much money ends up in owners’ bank accounts.

In some instances, draining nursing home coffers through related parties may amount to fraud: Along with The Villages’ investors, a handful of other New York owners are facing lawsuits from Attorney General Letitia James that claim they pocketed millions from their enterprises that the authorities say should have been used for patient care.

Deciphering these financial practices is timely because the Centers for Medicare & Medicaid Services is weighing what kind of stringent staffing levels it may mandate, potentially the biggest change to the industry in decades. A proposal due this spring is sure to spark debate about what homes can additionally afford to spend versus what changes would require greater government support. Federal Medicaid experts warned in January that related-party transactions “may artificially inflate” the true cost of nursing home care in reports that facilities file to the government. And the U.S. Department of Health and Human Services’ inspector general is investigating whether homes properly report related-party costs.

‘A Dog Would Get Better Care’

Beth Martino, a spokesperson for the American Health Care Association, said there is no evidence that related companies charge more than independent contractors do for the same services. “The real story is that nursing homes are struggling right now — to recruit and retain caregivers and to keep their doors open,” Martino said.

Lawyers for The Villages and its investors have asked the judge in the case for a delay until April to respond to the allegations of fraud and resident neglect in the lawsuit that the attorney general filed last November. One of the lawyers, Cornelius Murray, said in court papers that many allegations of short-staffing occurred during the pandemic when workers were out sick and the facility was required to accept any patient with covid-19. Lawyers declined to discuss the case with KHN.

In a deposition for that case, Ephram “Mordy” Lahasky, one of Fulton’s owners, disputed that he and fellow investors improperly depleted The Villages’ resources to the detriment of residents.

“I can assure you there was a lot of money left in the facility to make sure that it was not running on a shoestring budget,” he testified. The Villages, Lahasky said, was a “beautiful facility” with “beautiful gardens” where “residents look great” and employee morale was strong.

That wasn’t the opinion of Margarette Volkmar. She said in an affidavit filed with the state lawsuit that her husband was left in his bed with only a diaper on, was bruised by a fall, choked by another resident, given the wrong medication doses, dressed in other residents’ clothes, and covered in unexplainable bruises. After she moved him to another home, he gained back the 60 pounds he had lost and never fell at the new facility, she testified.

“I wouldn’t put a dog in Villages,” she said. “A dog would get better care than he did.”

Owners Invested in Hundreds of Homes

Both The Villages and its related real estate corporation, Telegraph Realty, were controlled by the same trio of investors, although they arranged for the nursing home to be listed in regulatory filings as solely owned by a silent partner and did not disclose their co-ownership of The Villages, court records show. One co-owner, David Gast, disclosed his net worth was $22 million and revealed that he had shares in more than 100 nursing homes, according to a loan application included in court records. Lahasky, whose disclosed net worth was nearly $73 million, said in a deposition he was the biggest nursing home proprietor in Pennsylvania and owned one of New York’s largest ambulance companies.

A third co-owner, Sam Halper, who reported a net worth of about $23 million, is under federal criminal indictment in Pennsylvania on charges of submitting false reports to the government about staffing and patient health at two nursing homes. He has pleaded not guilty. Added together, all the investors in corporations tied to The Villages have stakes or official roles in 275 other facilities across 28 states, federal records show.

The lease that The Villages had with Telegraph Realty required the home to pay up to $1 million in profits on top of the costs of debts and $50,000 a month for rent, according to a copy filed with the lawsuit. The attorney general alleged that, over seven years, the owners gave themselves and other investors more than $18 million from outsized rent profits, management fees, and proceeds from refinancing the property, an act that saddled The Villages with higher debt.

Lindsay Heckler, a supervising attorney at Center for Elder Law & Justice in Buffalo, which provides free legal help to older, disabled, and low-income adults, said she is concerned other nursing home owners in the state fail to provide quality care after purchasing facilities.

“When you see quality of care decline after an ownership change, the question needs to be asked: What’s going on with the finances?” she said.

Inflated Rents and a Plea to Die

Separating a nursing home operation and its building into two corporations is a common practice around the country. In New York, for-profit nursing homes with related-party realty companies spent 19% more of their operating revenue toward rent in 2020 than did for-profits that leased from unaffiliated firms, KHN found.

Fulton Commons Care Center, a nursing home on Long Island, spent nearly a third of its 2020 revenue on rent, a higher portion than all but three other facilities in New York, financial records show. In a lawsuit filed in December, the attorney general charged that the rent paid to Fulton Commons Realty, the company that owned its East Meadow, New York, building, was grossly inflated. Both the home and real estate company were owned by Moshe Kalter and his extended family, according to documents filed with the lawsuit.

In 2020, the nursing home paid nearly $10 million in rent to Fulton Realty, but an auditor for the attorney general calculated the property expenses that year were less than $6 million. The owners of Fulton and their families gave themselves nearly $16 million over four years from inflated rent, substantial management fees, and “no-show” jobs for Kalter’s eight children, the attorney general alleged.

“Rather than honor their legal duty to ensure the highest possible quality of life for the residents in their care, the Fulton Commons owners allegedly maintained insufficient staffing so they could take more money for their own personal gain,” James said in a statement.

Raul Tabora Jr. and David Yaffe, lawyers for Kalter, called the lawsuit’s charges “one-sided” in a written statement to KHN. They said that the payments to the children were not for jobs but because they were shareholders, and that Fulton kept an average balance of $3 million on hand to cover any pressing needs. “The evidence will demonstrate that any time resources are needed, they are provided by Mr. Kalter,” the lawyers wrote.

Residents’ families told investigators that staff shortages existed well before the pandemic. In an affidavit filed with the lawsuit, Frank Hoerauf Jr. said workers left his father sitting in adult diapers without pants and let his hair grow so long it covered his eyes. Another time, they left him screaming in pain from a urinary tract infection, he said.

“Fulton Commons seems like it was operated to be a cash machine for the owners where the care and the quality of life for residents there was very poor,” Hoerauf said.

Another resident, Elena Milack, who had lost one foot to diabetes, complained about poor care for years, including having to ring the call bell for an hour to get help to get to the bathroom, according to an affidavit filed by her daughter-in-law and health proxy. “GET ME OUT OF HERE OR TELL ME WHAT I CAN TAKE TO KILL MYSELF,” she texted her son in summer 2019. In 2020, she contracted an infection that turned her remaining foot black.

“Toes are all infected now,” Milack, a retired law school secretary, texted. “[M]y upper foot is dying and will soon fall off. I am hoping the good Lord will take me before that happens.” She died in November 2020.

Kalter said in a deposition he had never stepped inside his nursing home and did not supervise the quality of the care. He testified he granted full authority over the facility to its administrator and relied on his nephew, who was the controller of the home, to interact with the home’s leadership, according to court records.

In his deposition, Kalter said: “I have no personal knowledge of anything that’s going on in the nursing home.”

According to an affidavit from an auditor for the attorney general’s office, over the course of four years, Kalter deposited nearly $12 million from Fulton into his joint bank account with his wife, Frady.

KHN data editor Holly K. Hacker contributed to this report.

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

Can They Freaking Do That?!? (2023 Update)

Kaiser Health News - Wed, 02/01/2023 - 5:00am

The “An Arm and a Leg” podcast is back. This season, host Dan Weissmann will tell stories about patients finding creative ways to fight back against outrageous bills. 

This first episode of Season 9 updates a story from 2019 about a listener who got a $35 bill from a medical testing lab she had never heard of. Soon a follow-up bill arrived demanding $1,300 if she didn’t pay right away.

This jump in price left her wondering: Can they freaking do that?!?

The answer: They can try. And they often get away with it. 

But if patients have the time and moxie, they can propose a fair price and even take providers to court to force them to accept the counter offer.

The original version of this story covered a couple of topics the show has explored: Surprise bills (for which new legal protections were enacted in 2022) and how private equity has been expanding into health care and how some doctors are trying to fight back.  

The Host Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Marian Wang Editor Ann Heppermann Editor Adam Raymonda Audio Wizard Click to open the transcript Transcript: Can They Freaking Do that?! (2023 Edition)

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Hey there–

I have to start with a big THANK YOU to everybody who supports this show. It’s January, we wrapped up our big fund-raising campaign at New Year’s, and more than six hundred of you came through for us. We hit all our targets, including our stretch goal. It’s huge.

I’ll have a LOT of people to thank at the end of this episode, and I want to think about how to celebrate. Thanks to you, this year is off to an amazing start.

And for this first episode of 2023, I’m going back to a story we first put out more than three years ago, in 2019.

Because: this story changed my whole conception of what this show can aim to do.

When I meet people today and tell them about An Arm and a Leg for the first time, this is the story I tell them about.

Because this is a story about legal rights I never suspected we had– and how we can sometimes use them to fight back.

I learned a lot of other stuff while reporting this story — about surprise bills, and the role of private equity. It was early days for the show.

We’re leaving out those parts out this time– we’ve gone deeper on them in other episodes, and some of the underlying facts have changed.

Some things have gone out of date in good ways, thanks to the federal No Surprises Act, which took effect last year.

But the part about fighting back? Standing up for our legal rights? That holds up. And it’s ready for some follow-up.

OK, here it is:

Dan: Miriam visited a fertility clinic a couple years ago in Washington and DC where she lives, and she got some tests done. She was lucky. Her insurance actually covered fertility stuff, so she got the bill and her share was like 30 bucks. She paid it. Then this other envelope arrives from someplace she never heard of.

Not the fertility clinic or anyplace else she’s ever been, and it’s hot pink. She thinks it looks fake. It says it’s a bill and they want 35 bucks for some lab work

and perhaps unwisely, Miriam ignores it.

Okay. Uh, definitely unwisely and there are a couple of follow ups also in hot pink envelopes. And on the one hand, Miriam looks more closely and they are connected to her visit to the fertility clinic on the other. The follow ups say this other thing. They say, Hey, pay up now, or This thing’s going up, way up, up to about 1300 bucks from 35, which

Miriam: was so outrageous that I thought, this is definitely bullshit.

Bullshit. . Sorry, can I say that?

Dan: Yes, absolutely. Yeah. So Miriam does a dumb thing and ignores it and a follow up, and then in September she gets a note from a collections agency. They want that $1,300. And can they freaking do that? Can some lab send you a bill for 35 bucks outta nowhere and then be like, Hey, better pay now while we’re in a good mood.

Otherwise it’s gonna be $1,300. Is that even legal?

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.

And what’s more useful than knowing what our rights are?

Because as consumers. No idea. I mean, I get a bill from the electric company. Well, for one thing, it’s not a surprise. I’ve been running the lights and it’s the same rates as last month, and everybody’s paying basically the same rates as me, like whatever I owe this, but a hot pink envelope from some ancillary lab.

And then a follow-up saying they’re gonna take you for 1300, you’d. Well, maybe they can freaking do that.

I mean, how would you even know? Who would you even ask? Well, now you can ask me and I’ll go find out. This whole thing happened to Miriam a couple years ago. She ended up settling with the collections agency for like $217, which was a sixth of what they were asking for, but it was also six times that original $35 charge.

It still bugs her. Like was that even legal? What happened there? It is so messed up. So she wrote to me and I was. I really want to figure this out.

 When I talked to Miriam, she actually had a theory about what I might find.

Miriam: It might just be illegal to have such a, a big jump from, um, what the original copay was to what it ended up being after I was late.

Dan: Yeah! I was off– ready to test that theory out.

So, I made some calls. And I FOUND OUT SOME STUFF.

It took a minute. I started out calling national legal experts and policy nerds, and they were like, “I don’t really know. The law is complicated, it varies from state to state, blah blah blah”

So then I started calling folks who help consumers challenge wild medical bills — like, for a fee, that’s how they make a living. One of them was Braden Pan, his company’s called Resolve Medical bills.

 I described Miriam’s story to him, the pink envelope, the fine print that was like….

…is for a charge of $1,287 for which you get a great discount and will take $35 from you if you pay by date.

Wow. . Okay.

It’s like he was kind of impressed by how brazen this was.

And even though he didn’t know the answer, he had some smart thoughts about what questions to start asking.

Braeden Pan: I’m gonna tell you right now that I’m not a lawyer. Yeah. Um, now I can tell you that the, the idea of what hospitals or clinics can charge for services that hasn’t been settled.

Dan: In other words, he thought you’d need a lawyer if you wanted to fight it, and you don’t know how it’s gonna come out.

Braeden Pan: What might actually be going on with this company is they know this, they know that there’s confusion out there about this, uh, that you need a lawyer to actually figure it out, whether or. Someone can can do this and for a thousand bucks it’s not worth it to hire a lawyer to tell you because they’re gonna charge you 1200 bucks just to tell you whether or not they can do this

Dan: Right, right.

So himself, Braden Pan wasn’t so sure they were good answers here, but he pointed me to a couple of other people and they actually had some very hopeful answers. Some serious self-defense tools. You might wanna grab a pen. We’ll have that right after.

This season of an Arm and a Leg is a co-production of Public Road Productions and Kaiser Health News.

That’s a nonprofit newsroom that covers healthcare in America. Kaiser Health News is not affiliated with the giant healthcare provider, Kaiser Permanente. We’ll have a little more on Kaiser Health News at the end of this episode.

Sir, here’s where we meet the folks who are going to give us our big strong weapons for fighting off totally unreasonable bills.

Lisa Berry Blackstock: My name is Lisa Berry Blackstock, and I have been a patient advocate since 1990.

Dan: That’s like almost 30 years. And I asked her, is there anything you can do in a situation like this when you’re getting hit up for 1300 bucks for some stupid lab test? And she was like, well, You could take ’em to small claims court and you don’t have to be a lawyer to do that.

I was like, wait, you’ve done this?

Lisa Berry Blackstock: Oh, I, I’ve lost count. I can’t tell you how many times I’ve done it and in how many different, uh, counties.

Dan: Huh? So it works.

Lisa Berry Blackstock: Oh, it works. It’s worked for me.

Dan: She says it works every single time. And here’s something I learned in this conversation that I absolutely had not known.

When you go to court, it does not have to be to make somebody else give you. You can go to court and say, judge, this lab says I owe them 1300 bucks, but I have researched it and 35 bucks is fair. I’m offering them 35. Would you please order them to take 35?

It takes a plan to do this and it takes work.

Lisa Berry Blackstock: You have to demonstrate in writing that you have made a good faith effort to resolve this to your best ability and that you’ve been unable to, and that’s why you’re asking the court to intervene.

Dan: And so you’re asking the court basically to approve. A settlement offer that you’re making. Correct?

Lisa Berry Blackstock: Correct.

Dan: That’s what Lisa Berry Blackstock says she does. There’s some serious homework involved. If you grabbed a pen earlier, here’s where you start taking notes first. Lisa says, you call whoever’s sending the bill and make them give you the billing codes for everything on the bill.

itemized. Each one has a five digit code called a C P T Code, C P T. And honestly, this sounds like it could be the hardest part. You gotta get them to cough up this information. You have a right to it, but getting it, once you’ve got that, you figure out what a fair price is in your area, and there are a couple of websites that actually can help you do this.

Lisa uses one from a group called Fair Health. The site is fair health consumer.org. You put in your zip code and that five digit medical billing code, they will tell you what the going rates are in your area.

And that’s my basis of my offer. It’s fair I, I mean, I have independently verified information.

Lisa Berry Blackstock: It’s not a number that I’ve made up and it’s not like you’re trying to rip people off .

Dan: Then you write to whoever’s billing, you use certified mail. So you get a signed receipt, you can prove they got it, and you say, here’s what I’m offering. Here is how I determine this number. I want to hear from you by date X, that you will accept it.

Otherwise

Lisa Berry Blackstock: I will be filing in small claims, you know, against you, and you can expect to receive a notice.

Dan: And you’re saying generally if they get that, they’ll be like, okay, I’ll take it. Is that right?

Lisa Berry Blackstock: Yes. I mean, general, they, they look, they don’t understand anything with billing other than raking people over the coals because that’s what. is generally allowed across the country.

Dan: She says a lot of the time just sending the letter is enough, but sometimes she actually has to file Now, once I’ve filed Yeah. And they’ve been served. Yeah. Oh, then they’re, they’re falling all over themselves to make it go away. Because look, they’re used to sitting in an office sending out pieces of paper saying, send us 1300 bucks, or We’ll ruin your.

and getting 1300 bucks, or maybe getting a phone call and allowing themselves to be talked down to 200 without leaving their desk, they gotta send somebody to court. That person who would go to court could make more money by just accepting this offer and moving on to the next sucker,

Especially because, according to Lisa Berry Blackstock, they’d probably lose in court anyway.

Now, this was cool, but I didn’t just wanna take one person’s word for it. I found somebody else who had actually tried this thing. Somebody with a pretty good credential.

Christopher Robertson: My name’s Christopher Robertson. I’m a professor and associate dean at the James E. Rogers College of Law

Dan: That was his job when we talked in 2019. Now he’s a professor and associate Dean at the Boston University School of Law.

Anyway, I asked him, you can make these people accept a fair offer, and he’s like,

Christopher Robertson: Yeah. Duh. You know, basic contract law, you know, the stuff we teach to first year law students every day purports to just make this a non-pro. Of course you don’t have to pay a number that the other side just invented, um, , you know, this is, this is shooting fish in a barrel from a, from a contract law perspective.

Dan: Whoa, baby. The deal is you see a doc anywhere. You sign something in the business, they call it consent to treat. It says, yeah, examine me, poke, prod, whatever, and it says, I’m gonna give you my insurance info and whatever the insurance doesn’t pay, I’ll pay. The thing I’m signing doesn’t say how much I’ll pay because nobody knows exactly what’s gonna happen at the doctor’s office or the er, wherever.

Anyway. I got a stomach ache. Maybe I ate something weird. Maybe I have an ulcer. So Robertson says, what I’m signing is what lawyers call an open price contract. You know, normally a

Christopher Robertson: contract has a price in it, right? So if you want to go buy a car, your contract to buy the car has a price that’s true of a washing machine or a, or a house.

But when there is no price in the contract, it’s called an open price contract.

Dan:  The courts do not treat an open price contract as a blank check.

Christopher Robertson: If the court is gonna be called upon to enforce the contract to force someone to pay something, then the court has to figure out, well, what, what amount should I force them to pay?

It can’t be just what one side says later.

Dan: In other words, courts would. An open price contract like your agreement with a medical provider does not mean the other side just gets to bill you for whatever they want, and Miriam’s case is special. It’s got this other wrinkle, which is basically the lab said the price was 35 bucks, but if you’re late, it’s 1300.

That’s why I was so interested in this case. And Robertson says, Miriam has the law on her side there too. He says, this involves something else. They teach first year law students

Christopher Robertson: literally on the very first day of contract law

Dan: When you breach a contract, courts don’t treat that like a blank check either, and a late fee, it’s like a penalty for breaching a contract. The contract says you pay on date X. Miriam breached her contract by not paying on time. But Chris Robertson says there’s a limit to what that penalty can be, and it’s gotta have some relationship to what the breach actually cost. The. .

Christopher Robertson: So that’s a second reason. This strategy is completely legally frivolous to take a $35 charge and convert it into a thousand dollars plus.

Right. So yeah, they didn’t get their $35 check in June when they wanted it. They might get it in July. Well, that doesn’t cost them a thousand dollars. So the penalty can’t be a thousand dollars . Even if they don’t get it, it’s now September and they haven’t gotten it. It’s still not costing him a thousand dollars.

Christopher Robertson: Exactly.

Dan: So he’s like, yeah, line it up. Small claims court, that sort of thing can work. I can barely believe it’s this easy.

I’m like, wait, why don’t we do this more often??

Christopher Robertson: I mean, frankly, we shouldn’t have to. We need a systematic solution to this. Uh, you know, we are all have day jobs, you know.

Frankly, a lot of people who are dealing with medical bills surprise, surprise, are sick, right? Yeah. Um, so , they’re busy trying to get well, uh, you know, they’re trying to fight their own battles and so, you know, waging their own legal battle is, is, is a huge distraction and requires a level of attention to detail that not everyone has or should be expected to have.

So that’s why I really need more systematic solutions.

Dan: So Miriam might have had some options, but small claims court, it’s not exactly a blanket solution, especially cuz there’s also the problem of scale. I mean, it’s one thing if you’ve got a lab hawking you for a thousand bucks. What if you’ve got a whole system of hospitals trying to rake untold numbers of patients over the coals for crazy amounts? Then you’re not in small claims court anymore. Christopher Robertson has been there, like he’s gotten involved in lawsuits trying to stop hospitals from doing that sort of thing, and he. It is not pretty.

Christopher Robertson: It’s, it’s the utter, utter breakdown of law. I mean, when we tried to challenge these practices by hospitals, um, we bumped up into courts insisting that for every single charge, we affirmatively prove that the amount they made up is unreasonable. But proving that. Requires, you know, experts and accounting and economics, you could spend tens of thousands of dollars litigating every single one of these thousand dollars charges. And so that’s why you really do need either class action or a more affirmative, you know, regulatory system to police this, this bad behavior.

Dan:But in an individual situation like Miriam’s, where she’s actually healthy, she’s only got one charge to fight off. You can fight back. Get your evidence together, find out the itemized billing codes, and use a website like Fair health consumer.org to figure out what a reasonable price would be. Make an offer, put it in writing. Send it certified mail. Give ’em a deadline to accept your offer or else tell ’em you’ll file in small claims court. . And if that doesn’t make ’em play ball, actually do it. I ran all this down from Miriam and she was like,

Miriam: I wish I had known. That’s my main thing. I wish I had known that I had these other options. I would’ve totally gotten a letter, like if, even if I needed to notarize a letter, get it sent certified mail. I I’m gonna take you to a small claims court. Okay. Maybe I’ll, I’ll give you 50 bucks. That’s my, that’s my offer. Yeah. I wish I had done that.

Dan: YEP! That’s where we left things, a little more than three years ago.

I mean, we’ve followed up a little here and there:

We talked with a guy named Jeffrey Fox, who has made it… kind of a hobby to use small claims courts to stand up for his rights. So when UCLA overbilled him, he was ready.

I mean, maybe we could all use a little of his readiness to fight. Here’s how he describes conversations with their billing department.

Jeffrey Fox: One thing they always do is they always try to make it seem like their policies apply to you. They’re like, well, no, our policy is blah, blah, blah. I’m like, I don’t care. Contract law, the concepts of contract law and what I actually owe you, what a court would say, I owe you is what applies. I remember saying, okay. Well, my policy is you pay me a hundred dollars every time you say something stupid. So does that apply to you? If it does you only about 400 bucks already. Wanna keep going?

Dan: Jeffrey didn’t get paid on that improvised policy of his… but he did get a judge to make UCLA give him a refund of more than two thousand dollars. That episode was called David vs Goliath, and we’ll include a link to it wherever you’re listening.

So we’ve come back to this approach to fighting back. But I’ve been starting to think we haven’t come back to it nearly enough.

Especially since I got a note from a listener named Lauren with the heading: “I sued a hospital in small claims court and lost”

… which ended, “I feel like I won.” She wrote, “the hospital spent way more money on lawyer’s fees than the total amount of my bill.” They sent three lawyers to a preliminary hearing — and her bill wasn’t even that high.

We talked — we’ll have lots of details in our next episode — about what she had learned, and how she wanted to spread it around.

Lauren: I walked out of that thinking , do I , like, just put together a list of tips and leave it on people’s windshields that are parked outside of the er. how do I help other people do this?

If everybody that they screw stands up, they can’t afford to pay a lawyer to defend against all of those.

Dan: I mean, it’s an INTERESTING idea. Not for everybody. But maybe a few more people than have tried it so far…

We’ll pick up that idea next time.

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta. Ann Heppermann edited the original story. 

Marian Wang edited this version– and it looks like Marian’s parental leave from this show, coming up any minute now, will be permanent. 

Marian, I cannot believe how much I am going to miss working with you. It has been such an honor and such a joy.

Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard.  Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. Sarah Ballema is our operations manager.

This season of an arm and a leg is a co production with Kaiser health news. That’s a nonprofit news service about healthcare in America, an editorially-independent program of the Kaiser family foundation.

KHN is not affiliated with Kaiser Permanente, the big healthcare outfit. They share an ancestor: The 20th century industrialist Henry J Kaiser. When he died, he left half his money to the foundation that later created Kaiser health news.

You can learn more about him and Kaiser health news at arm and a leg show dot com slash Kaiser.

Zach Dyer is senior audio producer and Tarena Lofton is audience engagement producer at KHN– they are editorial liaisons to this show.

Thanks to Public Narrative — That’s a Chicago-based group that helps journalists and non-profits tell better stories– for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about Public Narrative at www dot public narrative dot org.

And thanks to everybody who supports this show financially.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

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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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Categories: Health Care

It’s ‘Telehealth vs. No Care’: Doctors Say Congress Risks Leaving Patients Vulnerable

Kaiser Health News - Tue, 01/31/2023 - 5:00am

When the covid-19 pandemic hit, Dr. Corey Siegel was more prepared than most of his peers.

Half of Siegel’s patients — many with private insurance and Medicaid — were already using telehealth, logging onto appointments through phones or computers. “You get to meet their family members; you get to meet their pets,” Siegel said. “You see more into their lives than you do when they come to you.”

Siegel’s Medicare patients weren’t covered for telehealth visits until the pandemic drove Congress and regulators to temporarily pay for remote medical treatment just as they would in-person care.

Siegel, section chief for gastroenterology and hepatology at Dartmouth-Hitchcock Medical Center, is licensed in three states and many of his Medicare patients were frequently driving two to three hours round trip for appointments, “which isn’t a small feat,” he said.

The $1.7 trillion spending package Congress passed in December included a two-year extension of key telehealth provisions, such as coverage for Medicare beneficiaries to have phone or video medical appointments at home. But it also signaled political reluctance to make the payment changes permanent, requiring federal regulators to study how Medicare enrollees use telehealth.

The federal extension “basically just kicked the can down the road for two years,” said Julia Harris, associate director for the health program at the D.C.-based Bipartisan Policy Center think tank. At issue are questions about the value and cost of telehealth, who will benefit from its use, and whether audio and video appointments should continue to be reimbursed at the same rate as face-to-face care.

Before the pandemic, Medicare paid for only narrow uses of remote medicine, such as emergency stroke care provided at hospitals. Medicare also covered telehealth for patients in rural areas but not in their homes — patients were required to travel to a designated site such as a hospital or doctor’s office.

But the pandemic brought a “seismic change in perception” and telehealth “became a household term,” said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association.

The omnibus bill’s provisions include: paying for audio-only and home care; allowing for a variety of doctors and others, such as occupational therapists, to use telehealth; delaying in-person requirements for mental health patients; and continuing existing telehealth services for federally qualified health clinics and rural health clinics.

Telehealth use among Medicare beneficiaries grew from less than 1% before the pandemic to more than 32% in April 2020. By July 2021, the use of remote appointments retreated somewhat, settling at 13% to 17% of claims submitted, according to a fee-for-service claims analysis by McKinsey & Co.

Fears over potential fraud and the cost of expanding telehealth have made politicians hesitant, said Josh LaRosa, vice president at the Wynne Health Group, which focuses on payment and care delivery reform. The report required in the omnibus package “is really going to help to provide more clarity,” LaRosa said.

In a 2021 report, the Government Accountability Office warned that using telehealth could increase spending in Medicare and Medicaid, and historically the Congressional Budget Office has said telehealth could make it easier for people to use more health care, which would lead to more spending.

Advocates like Zebley counter that remote care doesn’t necessarily cost more. “If the priority is preventative care and expanding access, that should be taken into account when considering costs,” Zebley said, explaining that increased use of preventative care could drive down more expensive spending.

Siegel and his colleagues at Dartmouth see remote care as a tool for helping chronically ill patients receive ongoing care and preventing expensive emergency episodes. It “allows patients to not be burdened by their illnesses,” he said. “It’s critical that we keep this going.”

Some of Seigel’s work is funded by The Leona M. and Harry B. Helmsley Charitable Trust. (The Helmsley Charitable Trust also contributes to KHN.)

For the past nine months, Dartmouth Health’s telehealth visits plateaued at more than 500 per day. That’s 10% to 15% of all outpatient visits, said Katelyn Darling, director of operations for Dartmouth’s virtual care center.

“Patients like it and they want to continue doing it,” Darling said, adding that doctors — especially psychologists — like telehealth too. If Congress decides not to continue funding for remote at-home visits after 2024, Darling said, she fears patients will have to drive again for appointments that could have been handled remotely.

The same fears are worrying leaders at Sanford Health, which provides services across the Upper Midwest.

“We absolutely need those provisions to become permanent,” said Brad Schipper, president of virtual care at Sanford, which has health plan members, hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota. In addition to the provisions, Sanford is closely watching whether physicians will continue to get paid for providing care across state lines.

During the pandemic, licensing requirements in states were often relaxed to enable doctors to practice in other states and many of those requirements are set to expire at the end of the public health emergency.

Licensing requirements were not addressed in the omnibus, and to ensure telehealth access, states need to allow physicians to treat patients across state lines, said Dr. Jeremy Cauwels, Sanford Health’s chief physician. This has been particularly important in providing mental health care, he said; virtual visits now account for about 20% of Sanford’s appointments.

Sanford is based in Sioux Falls, South Dakota, and Cauwels recalled one case in which a patient lived four hours from the closest child-adolescent psychiatrist and was “on the wrong side of the border.” Because of the current licensing waivers, Cauwels said, the patient’s wait for an appointment was cut from several weeks to six days.

“We were able to get that kid seen without Mom taking a day off to drive back and forth, without a six-week delay, and we were able to do all the things virtually for that family,” Cauwels said.

Psychiatrist Dr. Sara Gibson has used telehealth for decades in rural Apache County, Arizona. “There are some people who have no access to care without telehealth,” she said. “That has to be added into the equation.”

Gibson, who is also medical director for Little Colorado Behavioral Health Centers in Arizona, said one key question for policymakers as they look ahead is not whether telehealth is better than face-to-face. It’s “telehealth vs. no care,” 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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Some Addiction Treatment Centers Turn Big Profits by Scaling Back Care

Kaiser Health News - Tue, 01/31/2023 - 5:00am

Near the end of his scheduled three-month stay at a rehab center outside Austin, Texas, Daniel McKegney was forced to tell his father in North Carolina that he needed more time and more money, he recently recalled.

His father had already received bills from BRC Recovery totaling about $150,000 to cover McKegney’s treatment for addiction to the powerful opioid fentanyl, according to insurance statements shared with KHN. But McKegney, 20, said he found the program “suffocating” and wasn’t happy with his care.

He was advised against the long-term use of Suboxone, a medication often recommended to treat opioid addiction, because BRC does not consider it a form of abstinence. After an initial five-day detox period last April, McKegney’s care plan mostly included a weekly therapy session and 12-step group meetings, which are free around the country.

McKegney said a BRC staffer recommended he stay a fourth month and even sat in on the call to his dad.

“They used my life and [my] father’s love for me to pull another 20 grand out of him,” said McKegney, who told KHN he began using fentanyl again after the costly stay.

BRC did not respond to specific concerns raised by McKegney. But in an emailed statement, Mandy Baker, president and chief clinical officer of BRC Healthcare, said that many of the complaints patients and former employees shared with KHN are “no longer accurate” or were related to covid safety measures.

But addiction researchers and private equity watchdogs said models like the one used by BRC — charging high patient fees without guaranteeing access to evidence-based care — are common throughout the country’s addiction treatment industry.

The model and growing demand are why addiction treatment has become increasingly attractive to private equity firms looking for big returns. And they’re banking on forecasts that predict the market will grow by $10 billion — doubling in size — by the end of the decade as drug overdose and alcohol-induced death rates mount.

“There is a lot of money to be made,” said Eileen O’Grady, research and campaign director at the Private Equity Stakeholder Project, a watchdog nonprofit that tracks private equity investment in health care, housing, and other industries. “But it’s not necessarily dovetailing with high-quality treatment.”

In 2021, 127 mergers and acquisitions took place in the behavioral health sector, which includes treatment for substance use disorders, a rebound after several years of decline, according to investment banking firm Capstone Partners. Private equity investment drove much of the activity in an industry that is highly fragmented and rapidly growing, and has historically had few guardrails to ensure patients get appropriate care.

Roughly 14,000 treatment centers dot the country. They’ve proliferated as addiction rates rise and as health insurance plans are required to offer better coverage of drug and alcohol treatment. The treatment options vary widely and are not always consistent with those recommended by the federal Substance Abuse and Mental Health Services Administration. While efforts to standardize treatment advance, industry critics say private equity groups are investing in centers with unproven practices and cutting services that, while unprofitable, might support long-term recovery.

Baker said BRC treats people who have been unsuccessful in other facilities and does so with input from both clients and their families.

Private Equity Skimps on the Known Standards

Centers that discourage or prohibit the use of Food and Drug Administration-approved medications for the treatment of substance use disorder are plentiful, but in doing so they do not align with the American Society of Addiction Medicine’s guidelines on how to manage opioid use disorder over the long term.

Suboxone, for example, combines the pain reliever buprenorphine and the opioid-reversal medication naloxone. The drug blocks an overdose while also reducing a patient’s cravings and withdrawal symptoms.

“It is inconceivable to me that an addiction treatment provider purporting to address opioid use disorder would not offer medications,” said Robert Lubran, a former federal official and chairman of the board at the Danya Institute, a nonprofit that supports states and treatment providers.

Residential inpatient facilities, where patients stay for weeks or months, have a role in addiction treatment but are often overused, said Brendan Saloner, an associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

Many patients return to drug and alcohol use after staying in inpatient settings, but studies show that the use of medications can decrease the relapse rate for certain addictions. McKegney said he now regularly takes Suboxone.

“The last three years of my life were hell,” he said.

Along with access to medications, high-quality addiction treatment usually requires long-term care, according to Shatterproof, a nonprofit focused on improving addiction treatment. And, ideally, treatment is customized to the patient. While the “Twelve Steps” program developed by Alcoholics Anonymous may help some patients, others might need different behavioral health therapies.

But, when looking for investments, private equity groups focus on profit, not necessarily how well the program is designed, said Laura Katz Olson, a political science professor at Lehigh University who wrote a book about private equity’s investment in American health care.

With health care companies, investors often cut services and trim staff costs by using fewer and less-trained workers, she said. Commonly, private equity companies buy “a place that does really excellent work, and then cut it down to bare bones,” Olson said. During his stay, McKegney said, outings to movies or a lake abruptly stopped, food went from poke bowls and pork tenderloin to chili that tasted like “dish soap,” and staff turnover was high.

Nearly three years ago, BRC landed backing from NewSpring Capital and Veronis Suhler Stevenson, two private equity firms with broad portfolios. Their holdings include a payroll processor, a bridal wear designer, and a doughnut franchise. With the fresh funds, BRC started an expansion push and bought several Tennessee treatment facilities.

NewSpring Capital and Veronis Suhler Stevenson did not respond to emails and phone calls from KHN.

High Prices and Low Overhead = Big Business

Before the sale to BRC, Nashville Recovery Center co-founder Ryan Cain said, roughly 80% of the center’s offerings were free. Anyone could drop by for 12-step meetings, to meet a sponsor, or just to play pool. But the new owners focused on a new high-end sober living program that cost thousands of dollars per month and relied on staffers who were in recovery themselves.

In 2021, Nanci Milam, 48, emptied her 401(k) retirement fund to go through the sober living program and tackle her alcohol addiction. She had been sober for only six months when she was hired as a house manager, overseeing some of the same residents she had gone through the program with. She had to handle other residents’ medications, which she said she could have abused. Milam said she was fortunate to maintain sobriety.

“I think it served their need. And I was ambitious. But it should not have happened,” said Milam, adding that she left because the company hadn’t helped her start her certification as a drug counselor as promised.

A licensing violation reported to Tennessee regulators in late 2021 involved a staffer who was later fired for having sex with a resident in a storage area. And KHN obtained a copy of a 911 call placed in August 2022 — after a resident drank half a bottle of mouthwash — during which a staffer admitted there was no nurse on-site, which some other states require.

Removing the Burden from Consumers

The regulations of treatment providers largely focus on health and safety rather than clinical guidelines. Only a handful of states, including New York and Massachusetts, require that licensed addiction treatment centers offer medication for opioid use disorder and follow other best practices.

“We have a huge issue in the field where licensing standards don’t comport with what we know to be the most effective quality-of-care standards,” said Michael Botticelli, former director of the Office of National Drug Control Policy during the Obama administration and a member of a clinical advisory board for private equity-backed Behavioral Health Group. Some organizations, including Shatterproof, guide patients toward appropriate care. The federal and state governments largely direct public funds to centers that meet clinical quality-of-care standards.

But access to treatment is limited, and desperate patients and their families often don’t know where to turn. State or federal regulators aren’t policing claims from rehab facilities, like the “99% success rate” touted by BRC.

“We cannot put the burden on patients and their families” to navigate the system, said Johns Hopkins’ Saloner. “My heart really breaks for people who have thrown thousands of their dollars at programs that are bogus.”

When her niece was ready for inpatient rehab in summer 2020, Marina said, sending her to BRC was a “knee-jerk reaction.” Marina, a physician in Southern California, requested to be identified only by her middle name to protect the privacy of her niece, who suffers from alcohol addiction.

She had researched the facility three years earlier but didn’t investigate deeper because she was worried her niece would change her mind. BRC advertised success stories on the television show “Dr. Phil” and posted affirmations on social media.

Marina agreed to BRC’s upfront cost of $30,000 a month for a three-month stay in Texas, which she paid for out-of-pocket because her niece lacked insurance. She allowed KHN to review some of her niece’s pharmacy and treatment bills.

Marina said she paid for a fourth month, but said ultimately the program didn’t help her niece, who remains “horribly sick.” She said her niece felt constant guilt and shame at rehab. Marina thought there was inadequate medical oversight, and said the program “nickeled and dimed” her for additional services, like physicians’ visits, that she thought would be included.

“It almost doesn’t matter if you are educated and intelligent,” Marina said. “When it’s your loved one, you are just desperate.”

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 to the Latest ‘KHN Health Minute’

Kaiser Health News - Tue, 01/31/2023 - 5:00am

Jan. 26

This week’s “KHN Health Minute” nudges listeners to have an antiviral care plan before covid hits, and looks at how medical emergencies like Damar Hamlin’s heart attack can affect NFL players’ mental health.

Jan. 19

Tune in to the “KHN Health Minute” this week to learn how your smartphone could become your doctor’s newest diagnostic tool and the importance of taking morning sickness symptoms seriously.  

Jan. 12

Tune in to the “KHN Health Minute” this week to hear how noise pollution affects our health and why an optimistic outlook may help you live longer.  

The KHN Health Minute is available every Thursday on CBS News Radio.

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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California Author Uses Dark Humor — And a Bear — To Highlight Flawed Health System

Kaiser Health News - Tue, 01/31/2023 - 5:00am

Mother-to-be Kathleen Founds made a routine doctor’s appointment to discuss the risks of antidepressants in pregnancy. After the visit, Founds, who relies on medication to quell the manic highs and despondent lows of bipolar disorder, learned the physician was out of network.

She received a surprise bill for $650, launching her into a maze of claim forms and hours on the phone being routed from one office to the next to dispute the charges — insurance red tape that so many Americans have encountered. A decade later, Founds captured her experience in a graphic novel, “Bipolar Bear and the Terrible, Horrible, No Good, Very Bad Health Insurance,” a richly illustrated, darkly funny fable for adults about the country’s dysfunctional health system.

The book, published in November, follows Theodore, an intelligent but angst-ridden bear, on his quest for treatment for his own manic-depressive illness. But first he must navigate the demands of the WeCare company, a shady outfit run by cigar-smoking felines who profit unfairly from a lopsided economy and a corrupt justice system, among other things. His fellow outcasts include such characters as an overeducated owl drowning in student debt and a bomb-sniffing puppy suffering from PTSD.

America is internationally known for high-quality care, for those who can afford it. A new Gallup Poll shows that a record-high proportion of Americans — 38% — postponed medical care because of high costs in 2022. Federal and state “no surprise” laws of the past few years seek to protect consumers from unexpected medical bills. But they don’t prevent expenses like high deductibles or fees hidden in the fine print of their insurance policies.

“Bipolar Bear” joins other recent works to shine a light on health inequities — part of the emerging genre of graphic medicine. It includes seminal illness narratives such as “Mom’s Cancer” by Brian Fies and nurse MK Czerwiek’s “Taking Turns: Stories from the HIV/AIDS Care Unit 371” as well as “Rx,” Rachel Lindsay’s memoirs about taking a job at a pharmaceutical company to secure insurance to cover treatment for bipolar disorder.

Descended from the underground comics of the 1960s, graphic medicine has grown into a new field of scholarship on the medium’s role in the study and delivery of health care, said Ian Williams, the Welsh physician who coined the term back in 2007. “It’s ideal for exploring subjects having to do with one’s life and well-being in an ironic and funny way,” he said.

As Founds puts it, humor is a powerful weapon against despair.

The 40-year-old mother of two teaches English at a community college in Santa Cruz County on California’s central coast. She has never taken an art class and didn’t set out to write a graphic novel. The book began as a doodle in the margins of her notebook while studying for a master’s degree in fiction writing at Syracuse University in New York. Her 2014 novel in short stories, “When Mystical Creatures Attack,” is about a teacher who suffers a nervous breakdown and communicates with her students from a psychiatric hospital.

KHN contributing reporter Rachel Scheier spoke to Founds about bringing Theodore to life. The interview has been edited for length and clarity.

Q: How did you come to write a book about a bear with bipolar disorder?

I’d been making children’s books for my little brother. They were all about angst-ridden animals: a lonely giant squid, a possum with social anxiety disorder who falls asleep whenever he’s in an awkward situation, a burro who wants to be a unicorn. My goal was to write a novel. But whenever I was too depressed to string a sentence together, I’d draw bears. Then I realized that anyone dealing with a mental health issue in this country is going to have to deal with the labyrinth of health insurance. And I thought it would be fun to depict it as an actual labyrinth with trapdoors and man-eating flowers. Once I went in that direction, it was no longer a children’s book.

Q: Was the book based on your own experience with mental illness?

Yes. I had my first major depressive episode at the end of high school, but I didn’t seek out professional help. I just sort of muddled through it. Then, when I was a sophomore at Stanford, I had my first manic episode. I had a series of realizations about the nature of the universe, and I didn’t sleep or eat very much. Then, in graduate school, I went to a clinic because I was going through a depression, and the psychiatrist asked me questions like “Was there ever a time when you had a lot of energy and didn’t feel a need to sleep?” And I said, “Oh, sure, but that was a spiritual awakening.” So, I had to reframe my life story a bit after that.

Q: But religion still has a role in your life?

I’m a Quaker. It’s something I came to through my interest in nonviolent social change. When I am severely depressed, I feel like life has no purpose. So, following a code that says life does have meaning, that we are all connected by a force of love that undergirds the universe, is something that has helped me a lot.

Q: Why animals?

People are hard to draw! Cartoon animals are a lot easier. I wasn’t interested in art in school — actually, when I started drawing was during that first manic episode. I do not recommend writing a 200-page graphic novel with no artistic training. I mean, it took 13 years, but I did finish it.

Q: Why did it take so long?

I worked on it off and on while I was writing essays and working on the beginnings of several other novels. When I finally finished it, I was so excited. I was ready to see it on bookshelves within a year. I sent it to my agent, and she wrote me a very nice email which said, “I love this. It’s very creative. But there’s no way I can sell it.” Most graphic novels for grownups are memoir — there wasn’t a clear genre. Then another agent I reached out to said, “I can’t take this on, but you should try Graphic Mundi, which had published several novels in the field of graphic medicine.”

Q: What made you want to write about health insurance?

Our system is actually killing people. We have a high suicide rate in this country, and people are not able to access mental health care. And then, when they do get help, it’s not necessarily the psychiatrist who determines the course of care; it’s the insurance company. If you go into a room of 10 Americans, five can tell you a health insurance nightmare story.

But I also wanted to explore what it means to develop a healthy lifestyle and grow a strong community and go through all this growth and healing that Bipolar Bear goes through in the story, only to have the depression come back again. What is the meaning of my journey if I find myself right back where I was before? Ultimately, there’s no answer to that question, but there is a right thing to do, which is to ask for help. We’re all saved by each other.

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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Government Lets Health Plans That Ripped Off Medicare Keep the Money

Kaiser Health News - Mon, 01/30/2023 - 5:53pm

Medicare Advantage plans for seniors dodged a major financial bullet Monday as government officials gave them a reprieve for returning hundreds of millions of dollars or more in government overpayments — some dating back a decade or more.

The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.

But in a surprise action, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.

While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018. Exactly how much is not clear because audits as far back as 2011 have yet to be completed.

In late 2018, CMS officials said the agency would collect an estimated $650 million in overpayments from 90 Medicare Advantage audits conducted for 2011 through 2013, the most recent ones available. Some analysts calculated overpayments to plans of at least twice that much for the three-year period. CMS is now conducting audits for 2014 and 2015.

The estimate for the 2011-13 audits was based on an extrapolation of overpayments found in a sampling of patients at each health plan. In these reviews, auditors examine medical records to confirm whether patients had the diseases for which the government reimbursed health plans to treat.

Through the years, those audits — and others conducted by government watchdogs — have found that health plans often cannot document that they deserved extra payments for patients they said were sicker than average.

The decision to take earlier audit findings off the table means that CMS has spent tens of millions of dollars conducting audits as far back as 2011 — much more than the government will be able to recoup.

In 2018, CMS said it pays $54 million annually to conduct 30 of the audits. Without extrapolation for years 2011-17, CMS won’t come near to recouping that much.

CMS Deputy Administrator Dara Corrigan called the final rule a “commonsense approach to oversight.” Corrigan said she did not know how much money would go uncollected from years prior to 2018.

Health and Human Services Secretary Xavier Becerra said the rule takes “long overdue steps to move in the direction of accountability.”

“Going forward, this is good news. We should all be happy that they are doing that [extrapolation],” said former CMS official Ted Doolittle. But he added: “I do wish they were pushing back further [and extrapolating earlier years]. That would seem to be fair game,” he said.

David Lipschutz, an attorney with the Center for Medicare Advocacy, said he was still evaluating the rule, but noted: “It is our hope that CMS would use everything within their discretion to recoup overpayments made to Medicare Advantage plans.” He said that “it is unclear if they are using all of their authority.”

Mark Miller, who used to work at the Medicare Payment Advisory Commission, a congressional advisory board, said extrapolating errors found in medical coding have always been a part of government auditing. “It strikes me as ridiculous to run a sample and find an error rate and then only collect the sample error rate as opposed to what it presents to the entire population or pool of claims,” he said.

Last week, KHN released details of the 90 audits from 2011-2013, which were obtained through a Freedom of Information Act lawsuit. The audits found about $12 million in net overpayments for the care of 18,090 patients sampled for the three-year period.

In all, 71 of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits. CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient, the records showed.

Since 2010, the federal Centers for Medicare & Medicaid services has threatened to crack down on billing abuses in the popular health plans, which now cover more than 30 million Americans. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies including Humana, UnitedHealthcare, Centene, and CVS/Aetna.

But the industry has succeeded in opposing extrapolation of overpayments, even though the audit tool is widely used to recover overcharges in other parts of the Medicare program.

That has happened despite dozens of audits, investigations, and whistleblower lawsuits alleging that Medicare Advantage overcharges cost taxpayers billions of dollars a year.

Corrigan said Monday that CMS expected to collect $479 million from overpayments in 2018, the first year of extrapolation. Over the next decade, it could recoup $4.7 billion, she said.

Medicare Advantage plans also face potentially hundreds of millions of dollars in clawbacks from a set of unrelated audits conducted by the Health and Human Services inspector general.

The audits include an April 2021 review alleging that a Humana Medicare Advantage plan in Florida had overcharged the government by nearly $200 million in 2015.

Carolyn Kapustij, the Office of the Inspector General’s senior adviser for managed care, said the agency has conducted 17 such audits that found widespread payment errors — on average 69% for some medical diagnoses. In these cases, the health plans “did not have the necessary support [for these conditions] in the medical records, which has caused overpayments.”

“Although the MA organizations usually disagreed with us, they almost always had little disagreement with our finding that their diagnoses were not supported,” she said.

While CMS has taken years to conduct the Medicare Advantage audits, it also has faced criticism for permitting lengthy appeals that can drag on for years. These delays have drawn sharp criticism from the Government Accountability Office, the watchdog arm of Congress.

Leslie Gordon, an acting director of the GAO health team, said that until CMS speeds up the process, it “will fail to recover improper payments of hundreds of millions of dollars annually.”

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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A Baby Spent 36 Days in an In-Network NICU. Why Did the Hospital Next Door Send a Bill?

Kaiser Health News - Mon, 01/30/2023 - 5:00am

Brenna Kearney was seven months pregnant in December 2019 when she experienced what she thought were bad flu symptoms.

Her husband, Casey Trumble, drove her from their Chicago home to her OB-GYN’s office at Northwestern Medicine Prentice Women’s Hospital downtown. With suddenly elevated blood pressure and protein in her urine, she was diagnosed with preeclampsia, a potentially fatal but treatable pregnancy complication. Doctors admitted her to the hospital, saying she could expect to stay up to six weeks and have an induced delivery.

Then Kearney developed a bad headache and her blood platelet count plummeted, signs she was experiencing a rare, dangerous type of preeclampsia and requiring an immediate delivery by cesarean section.

Kearney’s daughter, Joey, born at 31 weeks, was placed on a ventilator and moved to the hospital’s neonatal intensive care unit. Small but healthy, she slowly began breathing on her own and eating normally. She was discharged in late January 2020, after 36 days in the NICU.

Then the bill came.

The Patient: Josephine “Joey” Trumble, now 3, was covered by her mother’s health plan through her employer, an advertising agency. For 2019, it was an Aetna plan, and for 2020, it was a plan from Blue Cross and Blue Shield of Illinois. Both policies were fully insured plans governed by Illinois laws.

Medical Service: Neonatology physician services provided in January 2020. Joey needed tube feeding and ventilator care to provide oxygen.

Service Provider: Ann & Robert H. Lurie Children’s Hospital of Chicago, whose staff physicians treated Joey at Northwestern Medicine Prentice Women’s Hospital. Ownership-wise, Lurie is independent of Northwestern Medicine, but it is physically connected to Prentice Women’s by an enclosed walkway. Lurie has a collaboration agreement with Northwestern Medicine to provide neonatology and pediatric physician services to Prentice Women’s patients.

Total Bill: Aetna paid for nearly all of Joey and her mother’s hospital and physician charges in December, while Blue Cross picked up nearly all of Joey’s hospital charges in January. Physician charges from Lurie in January totaled $14,624.55, of which the family was asked to pay $12,531.58 after payments from Blue Cross.

What Gives: It took Kearney months of calls to Blue Cross and the two hospitals to find out why Lurie billed more than $14,000 for physician services: The physicians treating her daughter at Prentice Women’s — an in-network hospital under her health plan — actually worked for a separate, out-of-network hospital.

Illinois law bars insurers from charging patients out-of-network rates for neonatal care at in-network hospitals.

Kearney said no one had told her or her husband that Lurie doctors were treating their daughter. She said the family never signed an agreement consenting to receive care from out-of-network doctors.

Though it did not happen here, many patients unknowingly sign broad financial agreements — saying they’ll pay for almost anything their insurance doesn’t cover — in the piles of paperwork they receive upon admission to a hospital. In many cases, they are simply asked to sign on a screen, without seeing the document.

Blue Cross agreed to pay Lurie the in-network rate for the doctors’ services, reducing the bill to about $12,500 — which Lurie expected the family to pay.

In November 2020, Kearney started receiving letters from ICS Collection Service, a collection agency.

“Talking to Blue Cross was impossible, and Lurie said it’s not their problem and just wanted to put us on a payment plan,” Kearney said.

Joey’s 36-day stay in the NICU happened before the federal government implemented the No Surprises Act barring surprise out-of-network billing. A state law prohibiting it, though, was in effect.

Since 2011, Illinois law has prohibited insurers from charging out-of-network rates for neonatologists, anesthesiologists, and certain other physicians when patients are treated at in-network hospitals.

Kearney said she repeatedly mentioned the law to Lurie and Blue Cross representatives, who denied knowledge of the provision.

“It definitely appears that under the 2011 law, Brenna can only be billed for in-network cost sharing,” said Kathy Mikos, a registered nurse and patient advocate with the Navocate Group in Woodridge, Illinois, who is not involved with Kearney’s case.

In December 2020, an insurance broker working for Kearney’s employer persuaded Blue Cross to pay the full out-of-network charges for the Lurie doctors, leaving the family owing $289.63 for coinsurance, which they promptly paid.

Having spent nearly the first year of her daughter’s life fighting medical bills from her birth, Kearney thought the ordeal was over.

Then, last month, she got a call from the collection agency, which again demanded payment at the full out-of-network rate for Lurie physician services provided to her daughter three years ago — the bill she believed Blue Cross had paid.

It took five hours on the phone for Kearney to piece together what had happened. Blue Cross had indeed paid the out-of-network charges in December 2020 — but, two days later, had taken back the money, ultimately paying Lurie’s doctors only the in-network rate.

A Lurie representative said Kearney and her husband still owed thousands of dollars. A Blue Cross representative suggested she set up a payment plan.

“I was at wits’ end, and I didn’t know how to fight this anymore,” Kearney said.

Lurie, Blue Cross, and Northwestern Medicine did not respond to numerous requests from KHN for comment. Lurie cited patient privacy, despite receiving a release from Kearney regarding the federal Health Insurance Portability and Accountability Act, or HIPAA, which authorized the hospital to discuss Joey’s case with KHN.

The Resolution: After KHN contacted Lurie and Blue Cross, a Lurie representative called Kearney offering to accept payment at the in-network rates after all.

Kearney said Tracy A. Spicer, manager of consolidated services at Lurie, told her Lurie has a “long-standing policy” of accepting in-network rates for Lurie physician services provided at Prentice Women’s. Spicer subsequently described it as a “long-standing courtesy,” then explained that acceptance of in-network rates was subject to “case-by-case consideration,” Kearney said.

Spicer said the family owed about $3,000 for their coinsurance share and offered to set up a payment plan.

A day later — following additional requests by KHN for comment — Spicer called Kearney and said she would remove all physician charges for her daughter’s care. Spicer did not return KHN’s call seeking comment.

“I’m certain I’m not the only person still dealing with this” kind of predicament, Kearney said.

Kearney has filed complaints with the Illinois Department of Insurance and the Illinois Attorney General’s Office. The attorney general’s office told KHN it had never enforced the 2011 law barring certain out-of-network billing.

Presented with the facts of Kearney’s case, state Sen. Ann Gillespie, who sponsored a 2022 state law expanding consumer protections against out-of-network bills, told KHN she plans to contact Lurie, Blue Cross, and Northwestern Medicine to ask about their billing arrangement and whether they are in compliance with state law.

“We’ll see if it was a pattern and whether they need to look back and see if refunds are warranted,” Gillespie said.

The attorney general’s office told KHN it will investigate Kearney’s complaint, including whether Lurie violated the state Consumer Fraud and Deceptive Business Practices Act by telling her it was extending a “courtesy” by charging her only in-network rates, when that is what the 2011 law required. The insurance department also said it would investigate the complaint.

The Takeaway: Even resourceful consumers who appear to have the law on their side, like Kearney, may find themselves in a losing, time-consuming battle with medical billing bureaucracies and facing collection actions.

Gillespie, the state senator, said Lurie, Northwestern Medicine, and Blue Cross should have known about the state law. She said patients who believe they have been improperly charged should file complaints with their state’s insurance department, which can trigger a broader investigation.

The federal No Surprises Act, which took effect last year, prohibits medical providers or insurers from billing patients for out-of-network physician charges at an in-network hospital, unless the patient formally consents to an out-of-network doctor. To be safe, patients should ask treating doctors whether they are in or out of network, even at an in-network hospital.

While the federal law offers patients new protections from out-of-network bills, many Americans still face problems from before the law took effect, said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy. Illinois is one of relatively few states that had prior laws to protect consumers.

Also, some out-of-network physicians continue to bill patients, despite the new federal protections. So know your rights. Cite the new law. And don’t write the check.

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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When Gun Violence Ends Young Lives, These Men Prepare the Graves

Kaiser Health News - Mon, 01/30/2023 - 5:00am

MILLSTADT, Ill. — It was a late Friday afternoon when a team of men approached a tiny pink casket. One wiped his brow. Another stepped away to smoke a cigarette. Then, with calloused hands, they gently lowered the child’s body into the ground.

Earlier that day, the groundskeepers at Sunset Gardens of Memory had dug the small grave up on a hill in a special section of this cemetery in a southern Illinois community across the river from St. Louis. It was for a 3-year-old girl killed by a stray bullet.

“It can be stressful sometimes,” Jasper Belt, 26, said. “We have to use little shovels.”

More than 30 years ago, Johnnie Haire and the other groundskeepers built a garden site just for children, separate from unlabeled sections of the 30-acre cemetery where they used to bury infants. They added a birdbath and bought angel figurines, carefully painting each one a hue of brown. Haire wanted the angels to be Black, like many of the children laid to rest here.

“This is ‘Baby Land,’” said Haire, 67, Sunset Gardens’ grounds supervisor, as he gestured across the area. “This is where a lot of babies are buried.”

Cemeteries like this one have long honored those who die too young. Such special burial sites exist in Gainesville, Florida; Quincy, Illinois; Owensboro, Kentucky; and beyond. They are for stillborn children and those who died of disease or accidents.

Today, a modern epidemic fills more graves than anything else: In the U.S., firearm-related injuries were the leading cause of death for children in 2020, ahead of motor vehicle crashes, according to researchers from the University of Michigan.

The men at Sunset Gardens are collecting data in their own way, too.

In 2019, Haire broke ground on a new section of the cemetery where teenagers and young adults are buried, including those killed by covid-19 and many who were victims of gun violence. It’s called the “Garden of Grace.” It’s already been used more than anyone would like.

“One time, it was just every weekend. Just a steady flow,” Haire said. “This one getting killed over here. This one getting killed over there. They fighting against each other, some rival gangs or whatever they were. So we had a lot. A lot of that.”

And 2021 was especially deadly nationwide: More than 47,000 people of all ages died from gunshot injuries, the highest U.S. toll since the early 1990s, according to the Centers for Disease Control and Prevention. This past year wasn’t as deadly nationally, though the tally is still being finalized.

The groundskeepers at Sunset Gardens have learned to watch their step in Baby Land because grieving parents drop off toys, candy, and balloons for their deceased children. “They just do things so differently in grief,” said Jocelyn Belt, 35, whose dad, William Belt Sr., 66, has worked at the cemetery since before she was born. Her brother and cousin work there, too.

The groundskeepers work quietly as families grieve. William Belt Jr., 44, said he doesn’t pry, even if he knows the family and would like to know how they’re doing.

“That’s what you learn not to do,” he said. “We let them come to us.”

But often, the men said, they are anonymous amid the rituals of grief. William Belt Jr. said he sometimes runs into those who attended the burials around town. “They don’t know my name. They’ll be like, ‘Gravedigger, you buried my mom. Man, thanks.’”

These men understand the complicated pain of losing loved ones. In the past year alone, the Belt family has experienced three deaths, including a relative who was shot and killed.

And on New Year’s Eve, William Belt Jr. himself was shot while in his truck outside a gas station convenience store.

“Nobody’s exempt,” he said, while recovering at home. “It could have been an old lady going to get some cornmeal or something like that from that store and could have got caught right in the crossfire.”

His family is thankful he’s OK. He is still grappling with his own close call, though.

“I would have probably been overtime for some of my co-workers. That’s something to think about,” Belt said. “And then they wouldn’t been able to go to my funeral ’cause they got to bury me.”

William Belt Sr. said his body froze when his son was shot. And he said he couldn’t hold back his emotions when he buried his brother and niece less than a month apart. Many of their relatives are buried at Sunset Gardens — literally by them.

“I weep,” he said. “Big difference between crying and weeping. Weeping, I’m closer to God.”

Their job is physical, emotional work done in all seasons, all weather. Injuries occur. Heartbreak is everywhere.

To hold their own hearts together, the groundskeepers often decompress as they eat lunch in a shed near the cemetery’s front office, trading stories in front of a wood-burning stove to keep warm during winter. They find joy where they can. The Belts like to fish. And the senior Belt occasionally sings the blues to soothe his soul. Parker, a long-haired cat, provides them company, too — and enjoys investigating the men’s lunches.

And they laugh when they can. William Belt Sr. still remembers his first year on the job. He wanted to be respectful, he said with a smile, even though his clients were deceased.

“‘Excuse me, coming through,’” Belt recalled saying as he walked through the cemetery. “Then I got myself together.”

Digging graves for a living wasn’t on the career list for Belt or his friend Haire. But that’s exactly what the two men have done for some 43 years — whether it’s for those who lived long, full lives or those whose young lives were cut short. They’re caretakers.

“That’s the proper name for it,” Haire said.

As he stood amid the graves on a recent day, he noted that the wooden Baby Land sign that welcomes mourners is worn. The paint on the angels is peeling, too.

“It needs touching up over there,” Haire said. “But I’ve been busy.”

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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Part II: The State of the Abortion Debate 50 Years After ‘Roe’

Kaiser Health News - Fri, 01/27/2023 - 11:10am
The Host Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special, two-part podcast, taped the week of the 50th anniversary of the decision in Roe v. Wade, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Panelists Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories Sarah Varney KHN @sarahvarney4 Read Sarah's stories

Among the takeaways from this week’s episode:

  • Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
  • The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
  • A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
  • Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
  • Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
  • Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
  • Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

And for extra credit, the panelists recommend their most memorable reproductive health stories from the last year:

Julie Rovner: NPR’s “Because of Texas’ Abortion Law, Her Wanted Pregnancy Became a Medical Nightmare,” by Carrie Feibel

Alice Miranda Ollstein: The New York Times Magazine’s “She Wasn’t Ready for Children. A Judge Wouldn’t Let Her Have an Abortion,” by Lizzie Presser

Sandhya Raman: ProPublica’s “’We Need to Defend This Law’: Inside an Anti-Abortion Meeting with Tennessee’s GOP Lawmakers,” by Kavitha Surana

Sarah Varney: Science Friday’s and KHN’s “Why Contraceptive Failure Rates Matter in a Post-Roe America,” by Sarah Varney

Also mentioned in this week’s podcast:

Credits Francis Ying Audio Producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on SpotifyApple PodcastsStitcherPocket Casts, or wherever you listen to podcasts.

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 Pharmacists May Get More Power to Prescribe

Kaiser Health News - Fri, 01/27/2023 - 5:00am

Mark Buck, a physician and pharmacist in Helena, Montana, said he’s been seeing more patients turn to urgent care clinics when they run out of medication. Their doctors have retired, moved away, or left the field because they burned out during the covid-19 pandemic, leaving the patients with few options to renew their prescriptions, he said.

“Access is where we’re really hurting in this state,” Buck said.

Senate Bill 112, sponsored by Republican Sen. Tom McGillvray, would address that need by expanding the limited authority Montana already gives pharmacists to prescribe medications and devices. Supporters said the measure could help fill health care gaps in rural areas in particular, while opponents worried it would give pharmacists physician-like authority without the same education.

Eleven states, including Montana, give pharmacists prescribing authority to some degree for medications such as birth control, naloxone, tobacco cessation products, preventive HIV drugs, and travel-related medications. The FDA has allowed pharmacists nationwide to prescribe the covid drug Paxlovid during the public health emergency.

According to a 2021 report by George Mason University’s Mercatus Center, there were about 228,000 primary care physicians nationwide in 2019 and more than 315,000 pharmacists in 2020. The report found that patients using Medicare visit a pharmacist twice as often as a primary care provider, and the difference is even larger in rural areas.

Pharmacists, who often work in grocery stores, “are open longer hours than most doctors’ offices, and no appointment is needed,” the authors of the Mercatus Center study wrote.

Under the bill, pharmacists could prescribe for patients who do not require a new diagnosis, for minor conditions, or in emergencies. They could not prescribe controlled substances.

During a Jan. 18 committee hearing on the bill, supporters said pharmacists also would be able to provide strep and flu tests, along with diabetic supplies.

Buck, the Helena doctor-pharmacist, said the bill wouldn’t solve the provider shortage, but it would “put a thumb in the dike that’s leaking.”

According to data from the University of Wisconsin Population Health Institute, Montana had one primary care physician per 1,210 people in 2019. Some counties have no primary care providers, but they usually have a pharmacy, said Kendall Cotton, executive director of the Frontier Institute, a public policy think tank in Montana. For example, Powder River County has no physician, he said, but a grocery store in the county seat, Broadus, has a pharmacy.

As a clinical pharmacist practitioner for 15 years, Travis Schule of Kalispell wouldn’t be much affected by the passage of SB 112. In Montana, providers like him with additional education and training already have authority to prescribe under Montana’s existing rules.

But he sees the bill’s potential to expand access to treatment in Montana. In some cases, people might have to drive three hours to see a physician, and SB 112 would allow a pharmacist to serve as a “first triage” before they travel that long distance, Schule said.

“This bill is a patient-centric bill,” Schule said. “It’s not for pharmacists. It’s for patients.”

SB 112 is modeled after a bill passed in Idaho. Tim Flynn, a pharmacist at an Albertsons grocery store in Meridian, Idaho, said the legislation lets patients be treated for minor conditions, such as urinary tract infections, when they can’t schedule a doctor’s appointment or get to an urgent care clinic.

The Montana Medical Association and the Montana chapter of the American Academy of Pediatrics oppose SB 112. They say SB 112 would fragment care, risk patient safety, and substitute pharmacists for emergency care physicians.

But Montana Medical Association CEO Jean Branscum said there was an opportunity to build on the Idaho model, by bringing pharmacists and physicians together while making sure patients get the same standard of care.

“Let’s come up with a model of care that will allow pharmacists to do more than they do now, be a part of that team, practice at the highest level, and also appreciate the value of the physicians as part of that team too,” Branscum told lawmakers at the Jan. 18 hearing.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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Did Your Health Plan Rip Off Medicare?

Kaiser Health News - Fri, 01/27/2023 - 5:00am

Today, KHN has released details of 90 previously secret government audits that reveal millions of dollars in overpayments to Medicare Advantage health plans for seniors.

The audits, which cover billings from 2011 through 2013, are the most recent financial reviews available, even though enrollment in the health plans has exploded over the past decade to over 30 million and is expected to grow further.

KHN has published the audit spreadsheets as the industry girds for a final regulation that could order health plans to return hundreds of millions, if not billions, of dollars or more in overcharges to the Treasury Department — payments dating back a decade or more. The decision by the Centers for Medicare & Medicaid Services is expected by Feb 1.

KHN obtained the long-hidden audit summaries through a three-year Freedom of Information Act lawsuit against CMS, which was settled in late September.

In November, KHN reported that the audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled. In all, 71 of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits. CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

The audit spreadsheets released today identify each health plan and summarize the findings. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies. Contract numbers for the plans indicate where the insurers were based at the time.

Since 2018, CMS officials have said they would recoup an estimated $650 million in overpayments from the 90 audits, but the final amount is far from certain.

Spencer Perlman, an analyst with Veda Partners in Bethesda, Maryland, said he believes the data released by KHN indicates the government’s clawbacks for potential overpayments could reach as high as $3 billion.

“I don’t see government forgoing those dollars,” he said.

For nearly two decades, Medicare has paid the health plans using a billing formula that pays higher monthly rates for sicker patients and less for the healthiest ones.

Yet on the rare occasions that auditors examined medical files, they often could not confirm that patients had the listed diseases, or that the conditions were as serious as the health plans claimed.

Since 2010, CMS has argued that overpayments found while sampling patient records at each health plan should be extrapolated across the membership, a practice commonly used in government audits. Doing so can multiply the overpayment demand from a few thousand dollars to hundreds of millions for a large health plan.

But the industry has managed to fend off this regulation despite dozens of audits, investigations, and whistleblower lawsuits alleging widespread billing fraud and abuse in the program that costs taxpayers billions every year.

CMS is expected to clarify what it will do with the upcoming regulation, both for collecting on past audits and those to come. CMS is currently conducting audits for 2014 and 2015.

UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding the $1,000 average in 10 of 11 audits, according to the records.

That could spell trouble for the Louisville, Kentucky-based insurer, which relies heavily on Medicare Advantage, according to Perlman. He said Humana’s liability could exceed $900 million.

Mark Taylor, Humana’s director of corporate and financial communications, had no comment on the overpayment estimates.

Commenting on the upcoming CMS rule, he said in an emailed statement: “Our primary focus will remain on our members and the potential impact any changes could have on their benefits. ... We hope CMS will join us in protecting the integrity of Medicare Advantage.”

Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.

In a conference call with reporters this week, Tim Noel, who leads UnitedHealthcare's Medicare team, said the company wants CMS to make changes in the regulation but remains “very comfortable” with what the 2011-13 audit results will show.

“Like all government programs, taxpayers and beneficiaries need to know that the Medicare Advantage program is well managed,” he said.

He said the company supports annual auditing of Medicare Advantage plans.

But Perlman said the sheer size of the program makes annual audits “completely impractical.”

These audits are “incredibly time-consuming and labor-intensive” to conduct,” he 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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California’s Resolve Questioned After It Grants Medi-Cal Contract Concessions

Kaiser Health News - Fri, 01/27/2023 - 5:00am

California’s decision last month to cancel the results of a long-planned bidding competition among commercial health plans in its Medicaid program has some industry insiders and consumer advocates wondering whether the state can stand up to insurers and force improvements in care for millions of low-income beneficiaries.

In a backroom agreement announced in the final days of 2022, Gov. Gavin Newsom’s administration, facing lawsuits, granted concessions that allowed major insurers to claw back business they would have lost had health officials stuck with the state’s initial contract awards for managed-care plans. Oakland-based Blue Shield of California and St. Louis-based Centene Corp. — which owns Health Net, the largest commercial health plan in Medi-Cal, the state’s version of Medicaid — were among those that had aggressively challenged the initial results.

“They had this long process, and then they just sort of struck deals,” said Maya Altman, who retired a year ago after nearly 17 years as CEO of the Health Plan of San Mateo, which did not participate in the bidding. “It’s kind of weird. Not transparent — very much behind closed doors.”

It was a remarkable change of course that came four months after the state had announced its initial contract awards. The Department of Health Care Services, which oversees Medi-Cal, had spent years preparing for the bidding competition and touted it as an important means of addressing substandard care. Eight commercial Medi-Cal plans, covering around 30% of the program’s 13 million managed-care enrollees, were required to submit bids for contracts worth about $70 billion over five years.

Noncommercial, locally governed Medi-Cal plans that cover the other 70% of managed-care enrollees did not have to submit bids, but they will be required to sign the same new contract as the commercial plans, scheduled to take effect next year.

State officials said their new decision avoids uncertainty after the losing health plans — Health Net, Blue Shield of California, Community Health Group, and Aetna — threatened drawn-out legal action. It also dramatically reduces the number of Medi-Cal enrollees who will have to switch plans — from an estimated 2.3 million to about 1.2 million. And state officials said it strengthens their ability to enhance Medi-Cal through the new contracts, which will contain requirements for higher-quality care, greater transparency, and more equitable access.

Other states have faced legal disruption after they put their Medicaid contracts up for bid. In Louisiana, for example, Centene and Aetna in 2019 protested the results of a rebidding process, which led that state to nullify its awards and start over. The new results were announced nearly two years later, with Centene and Aetna among the winners.

“When you create disputes, and lawsuits, they always put some uncertainty into things,” Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, told KHN. “We feel that we ended up in a place where we achieved certainty. We have a set of [health] plans who are committed to this.”

Consumer advocates had worried that lingering uncertainty would hinder the rollout of a far-reaching nearly $12 billion, five-year Medi-Cal initiative to provide nonmedical social services that address socioeconomic factors such as homelessness and food insecurity, widely viewed as key health indicators.

Still, the state’s decision to throw out the bidding results has many patient advocates and some health plan executives questioning the value of future contract competitions and even whether health officials will effectively enforce the higher standards in the new contract.

“It would be extremely disappointing if poor-performing plans were able to litigate their way into participating in Medi-Cal,” said Abbi Coursolle, a senior attorney in the Los Angeles office of the National Health Law Program.

Tony Cava, a spokesperson for the Department of Health Care Services, said the bids submitted were still “incredibly valuable,” because they showed how the health plans intend to improve care. He said commitments made in the bids will be incorporated into the new contracts. Cava also said the department, which had not previously held a statewide bidding competition, now intends to hold one every five years.

Patient advocates and industry insiders gave the state credit for fining health plans that fell short of quality and access standards in a report issued late last year. But they also noted that several of the health plans that will continue to operate in Medi-Cal — including Molina Healthcare and Health Net — were among the lowest performers.

When the state announced its initial awards in August, Blue Shield was shut out, despite its large health care footprint statewide and its long-standing efforts to curry favor with the state’s political class. The state also said initially that it would take Los Angeles County, a huge Medi-Cal contract, away from Health Net.

Between 2018 and 2022, Blue Shield spent at least $31 million on lobbying, political donations, and other contributions, including $20 million to a state homelessness fund Newsom set up, according to a KHN analysis of filings with the secretary of state and the California Fair Political Practices Commission. Health Net parent Centene spent at least $5 million over that period, mostly on lobbying and political donations.

Under the new arrangement, Blue Shield will keep its San Diego County Medi-Cal business after initially losing it in the contract competition, though it will not get a contract in any of the other 12 counties where it bid. Its roughly 129,000 San Diego enrollees will not have to switch plans, but over 100,000 other Medi-Cal members in San Diego will still have to switch, as Health Net and Aetna exit.

In Los Angeles County, Health Net will retain its primary Medi-Cal contract, but will have to split its 1.1 million members 50-50 with Molina under a subcontract. Molina already subcontracts with Health Net in the county, but currently has only 80,000 enrollees under that arrangement.

Some observers questioned how the split can be maintained. Cava said half of new Medi-Cal enrollees in L.A. County don’t choose a plan and are assigned to one instead, according to the most recent data. These assignments will be used to help balance enrollment between Health Net and Molina, he said.

The state and the five participating health plans issued an unusual joint statement, and the plans put a positive spin on it. Centene said the state’s revised decision “is in the best interest of millions of members.” A Blue Shield executive said it was “honored to continue serving Medi-Cal beneficiaries in San Diego County.”

In an investor call this month, Molina’s CEO, Joseph Zubretsky, noted that his company’s Medi-Cal membership will double with the new agreement, though it would have tripled under the state’s initial decision. He summarized the situation for Molina as “taking three steps forward, taking one step back, and ending up being two steps ahead.”

Consumer advocates, patients, and medical professionals expressed relief that the new agreement allows Community Health Group, the largest Medi-Cal health plan in San Diego County, to keep operating there. Had the initial results held, it would have lost its contract, and its 335,000 members would have had to choose new plans.

Christine Xayalinh, a member of Community Health Group in Escondido, said the plan afforded her treatment for Type 2 diabetes and referred her to University of California-San Diego for a successful gastric bypass.

“I know some people do have concerns about their health insurance,” Xayalinh, 29, said, “but for me, it’s been a lifesaver.”

With the contract awards decided, the state’s hope of improving Medi-Cal will hinge on its ability to enforce the new contracts.

“The focus now needs to be on making sure that works,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “This is a very vulnerable population of Californians who are not getting what they need.”

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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FDA Experts Are Still Puzzled Over Who Should Get Which Covid Shots and When

Kaiser Health News - Fri, 01/27/2023 - 5:00am

At a meeting to simplify the nation’s covid vaccination policy, the FDA’s panel of experts could agree on only one thing: Information is woefully lacking about how often different groups of Americans need to be vaccinated. That data gap has contributed to widespread skepticism, undervaccination, and ultimately unnecessary deaths from covid-19.

The committee voted unanimously Thursday to support the FDA’s proposal for all vaccine-makers to adopt the same strain of the virus when making changes in their vaccines, and suggested they might meet in May or June to select a strain for the vaccines that would be rolled out this fall.

However, the panel members disagreed with the FDA’s proposal that everyone get at least one shot a year, saying more information was needed to make such a declaration. Several panelists noted that in recent studies, only about a third of people hospitalized with a positive covid test actually were there because of covid illness. That’s because everyone entering a hospital is tested for covid, so deaths of patients with incidental infections are counted as covid deaths even when it isn’t the cause.

The experts questioned the rationale for annual shots for everyone, given that current vaccines do not seem to protect against infection for more than a few months. Yet even a single booster seems to prevent death and hospitalization in most people, except for the very old and people with certain medical conditions.

“We need the CDC to tell us exactly who is getting hospitalized and dying of this virus — the ages, vulnerability, the type of immune compromise, and whether they were treated with antivirals. And we need immunological data to indicate who’s at risk,” said Dr. Paul Offit, director of the Vaccine Education Center and a pediatrician at Children’s Hospital of Philadelphia. “Only then can we decide who gets vaccinated with what and when.”

Offit and others have expressed frustration over the lack of clear government messaging on what the public can expect from covid vaccines. While regular boosters might be important for keeping the elderly and medically frail out of the hospital, he said, the annual boosters suggested by the FDA and the drug companies may not be necessary for everyone.

“The goal is to keep people out of the hospital,” he said. “For the vulnerable, it would be important for vaccines to keep up with circulating strains. But for the general population, we already have a vaccine that prevents hospitalization.”

Other panelists said the government needs to push research harder to get better vaccines. Pamela McGinnis, a retired official of the National Institutes of Health, said she had trouble explaining to her two young-adult sons why they promptly got sick after venturing out to bars one night only weeks after getting their bivalent booster.

“‘Think how sick you would have gotten if you weren’t fully vaccinated’ is not a great message,” she said. “I’m not sure ‘You would have landed in the hospital’ resonates with recipients of the disease.”

Members of the FDA’s advisory committee have been irked in recent months, saying the agency didn’t present them with all the data it had on the bivalent vaccine before it was released in September. And some critics have said the FDA should have instructed drug companies to include only the newer strains of the virus in the shot.

Asked about that Thursday, Jerry Weir, a senior FDA vaccine officer, said his “gut feeling” was that a vaccine matched to a single omicron strain would have performed better than the bivalent shot, which also contains the original covid strain. “But the real question is where we’re headed,” he said, “and I don’t know the answer.”

Perhaps the most important presentation Thursday was from Heather Scobie, who keeps tabs on covid at the Centers for Disease Control and Prevention. She reported that fewer than half of Americans 65 and older had gotten the latest booster, and that only two-thirds of that age group had gotten even a single booster.

Yet evidence continues to mount that it’s mostly the elderly who are at serious risk from covid. Death rates from the disease have declined in every age group except those over 75 since April, despite the uptick in new strains. Except for the very old, the death rate has hovered around 1 in 100,000 since April. Earlier in 2022, babies 6 months old and younger were hospitalized and died at relatively high rates. Vaccination levels in the 4-and-under group hover at about 10%.

While acknowledging the FDA’s desire to regularize its covid vaccine policy, panel members said it’s still too early to know for sure whether covid will surge only in the winter, like flu, respiratory syncytial virus, and other respiratory infections.

“For the next few years we may not know how often we need to make a strain change in the vaccine,” said Dr. Steven Pergam, medical director of infection prevention at the Seattle Cancer Care Alliance. Or even if people who are not in poor health or elderly need additional boosters.

One vaccine-maker represented at the meeting, Novavax, said it would need to know by the end of March which strain to include in its vaccine for fall. Companies with mRNA vaccines like Pfizer and Moderna can change their formulas faster, but their products aren’t clearly better than Novavax’s.

All three of those vaccine-makers revealed at the meeting that they are developing single-dose vials or prefilled syringes. Up to now, they’ve delivered their vaccines in multidose vials, but since the government has run out of money to buy vaccines, individual pediatricians may order them in the future. Since the vaccine must be used quickly once a vial is open, doctors are leery of wasting vaccine and losing money.

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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Part I: The State of the Abortion Debate 50 Years After ‘Roe’

Kaiser Health News - Thu, 01/26/2023 - 3:35pm
The Host Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special two-part podcast, taped the week of the 50th anniversary of the Roe decision, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Panelists Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories Sarah Varney KHN @sarahvarney4 Read Sarah's stories

Among the takeaways from this week’s episode:

  • Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
  • The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
  • A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
  • Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
  • Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
  • Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
  • Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

Also this week, Rovner interviews Elizabeth Nash, who tracks state reproductive health policies for the Guttmacher Institute, a reproductive rights research group.

Credits Francis Ying Audio Producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on SpotifyApple PodcastsStitcherPocket Casts, or wherever you listen to podcasts.

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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More Californians Are Dying at Home. Another Covid ‘New Normal’?

Kaiser Health News - Thu, 01/26/2023 - 5:00am

The covid-19 pandemic has spurred a surge in the proportion of Californians who are dying at home rather than in a hospital or nursing home, accelerating a slow but steady rise that dates back at least two decades.

The recent upsurge in at-home deaths started in 2020, the first year of the pandemic, and the rate has continued to climb, outlasting the rigid lockdowns at hospitals and nursing homes that might help explain the initial shift. Nearly 40% of deaths in California during the first 10 months of 2022 took place at home, up from about 36% for all of 2019, according to death certificate data from the California Department of Public Health. By comparison, U.S. Centers for Disease Control and Prevention data shows that about 26% of Californians died at home in 1999, the earliest year for which data on at-home deaths is accessible in the agency’s public database.

The trend is amplified among California residents with serious chronic conditions. About 55% of Californians who died of cancer did so at home during the first 10 months of 2022, compared with 50% in 2019 and 44% in 1999. About 43% of Californians who died of Alzheimer’s disease in the first 10 months of 2022 did so at home, compared with 34% in 2019 and nearly 16% in 1999.

Nationwide, the share of deaths occurring at home also jumped in 2020, to 33%, then rose to nearly 34% in 2021. Nationwide data for 2022 is not yet available.

Covid’s early, deadly sweep across California does not in itself explain the increase in at-home death rates; the vast majority of people who have died of covid died in a hospital or nursing home. Instead, medical experts said, the surge — at least initially — appears to coincide with sweeping policy changes in hospitals and nursing homes as caregivers struggled to contain a virus both virulent and little understood.

The sweeping bans on in-person visitation in hospitals and nursing homes, even to the bedsides of dying patients, created an agonizing situation for families. Many chose to move a loved one back home. “It was devastating to have Mom in a nursing home and dying, and the only way you can see Mom is through the window,” said Barbara Karnes, a registered nurse who has written extensively about end-of-life care.

At the same time, fears of covid exposure led many people to avoid hospitals in the first years of the pandemic, in some cases neglecting treatment for other serious conditions. That, too, is thought to have contributed to the rise in at-home deaths.

Those who specialize in end-of-life care say it is no surprise the trend has continued even as visitation policies have eased. They said more people simply want to die in a comfortable, familiar place, even if it means not fighting for every second of life with medical interventions.

“Whenever I ask, ‘Where do you want to be when you breathe your last breath? Or when your heart beats its last beat?’ no one ever says, ‘Oh, I want to be in the ICU,’ or ‘Oh, I want to be in the hospital,’ or ‘I want to be in a skilled nursing facility.’ They all say, ‘I want to be at home,’” said John Tastad, coordinator for the advance care planning program at Sharp HealthCare in San Diego.

Meanwhile, the physicians who specialize in the diseases that tend to kill Americans, such as cancer and heart disease, have become more accepting of discussing home hospice as an option if the treatment alternatives likely mean painful sacrifices in quality of life.

“There's been a little bit of a culture change where maybe oncologists, pulmonologists, congestive heart failure physicians are referring patients to palliative care earlier to help with symptom management, advanced care planning,” said Dr. Pouria Kashkouli, associate medical director for hospice at UC Davis Health.

The trends have created a booming industry. In 2021, the California Department of Health Care Access and Information listed 1,692 licensed hospice agencies in its tracking database, a leap from the 175 agencies it listed in 2002.

That much growth — and the money behind it — has sometimes led to problems. A 2020 investigation by the Los Angeles Times found that fraud and quality-of-care issues were common in California’s hospice industry, a conclusion bolstered by a subsequent state audit. Gov. Gavin Newsom signed a bill in 2021 that placed a temporary moratorium on most new hospice licenses and sought to rein in questionable kickbacks to doctors and agencies.

When done correctly, though, home hospice can be a comfort to families and patients. Hospice typically lasts anywhere from a few days to a few months, and while services vary, many agencies provide regular visits from nurses, health aides, social workers, and spiritual advisers.

Most people using hospice are insured through the federal Medicare program. The amount Medicare pays varies by region but is usually around $200 to $300 a day, said Dr. Kai Romero, chief medical officer at the nonprofit Hospice by the Bay.

To find quality end-of-life care, Andrea Sankar, a professor at Wayne State University and author of “Dying at Home: A Family Guide for Caregiving,” recommends seeking out nonprofit providers and having a list of questions prepared: How often will nurses visit in person? In what circumstances do patients have access to a physician? What help will be available for a crisis in the middle of the night?

While hospice providers offer crucial guidance and support, families need to be prepared to shoulder the bulk of the caregiving. “It really takes a pretty evolved family system to be able to rally to meet all of the needs,” said Tastad at Sharp HealthCare.

Several end-of-life experts said they expect the proportion of Californians choosing to die at home to keep climbing, citing a variety of factors: Medical advances will make it easier for patients to receive pain management and other palliative care at home; telemedicine will make it easier for patients to consult doctors from home; and two powerful forces in American health care — insurance companies and the federal government — increasingly see dying at home as an affordable alternative to lengthy hospital stays.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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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Florida Gov. DeSantis Falsely Claims Bivalent Booster Boosts Chances of Covid Infection

Kaiser Health News - Thu, 01/26/2023 - 5:00am

“Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

Florida Republican Gov. Ron DeSantis, on Jan. 17, 2023, during a press conference

As he proposed to extend the state’s ban on mandates for covid vaccines and face masks, Florida Republican Gov. Ron DeSantis lobbed a flurry of criticism at President Joe Biden and “the medical establishment.” 

“They were not following the science,” DeSantis said at a Jan. 17 press conference in Panama City Beach. “Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

Fewer than 11% of eligible Floridians have received an updated booster vaccine, according to the Centers for Disease Control and Prevention

The bivalent booster, which contains components of the original covid virus and the omicron variant, is designed to provide broad protection against illness or hospitalization from those covid strains. 

Research into the efficacy of the bivalent booster in preventing infection continues. 

Broadly speaking, covid vaccines do not prevent infection; they prevent the virus from spreading within the body and causing severe illness, according to Johns Hopkins University. Early CDC research shows that people who got the booster were 84% less likely to be hospitalized from covid.

The data collected on the booster’s ability to curb infection is early and limited. Some clinical trials have shown that bivalent shots are no more equipped to prevent people from contracting covid than the original vaccines. 

Although some people have suggested the bivalent booster offers little protection against infection, DeSantis went further. He said people who received the bivalent booster shot were more susceptible to covid than those who hadn’t.

The governor’s press office responded to PolitiFact’s inquiry about the claim, citing two articles and three studies, two of which are not yet peer-reviewed. The most recent came from the Cleveland Clinic and was discussed in an opinion article in The Wall Street Journal.

Dr. Nabin Shrestha, an infectious-disease physician and one of the study’s authors, told PolitiFact the data did not find a link between the bivalent shot and a higher risk of contracting covid. The early conclusion was the opposite of what DeSantis said: The dose is, in fact, effective in preventing infection.

DeSantis’ Conclusion Could Not Be Drawn From That Study

Cleveland Clinic researchers examined the bivalent booster’s effectiveness in preventing infection among 51,011 health care workers — some of whom had not received the booster — from September to December 2022. Pfizer and Moderna offer the bivalent booster, which the FDA authorized in August. 

Over those four months, about 5% of the clinic’s employees contracted covid. The researchers then estimated that the bivalent booster was about 30% effective in reducing the likelihood of contracting the virus. 

The Cleveland Clinic researchers were not trying to determine the bivalent vaccine’s effectiveness in preventing severe illness or hospitalization. 

“The study wasn’t measuring the vaccine causing infection,” said Jill Roberts, a public health professor at the University of South Florida. “The study was measuring the efficacy of the bivalent vaccine in preventing infection.”

What drove coverage in outlets like The Wall Street Journal was an “unexpected” association researchers found between the number of prior vaccine doses and an increased risk of contracting covid. People with three or more doses of the vaccine had a higher chance of getting infected. 

That finding quickly overshadowed the protection the bivalent shot provided. The Wall Street Journal opinion piece cited the Cleveland Clinic’s study as evidence that vaccine boosters are making “the population as a whole” more vulnerable to covid. 

Andrea Pacetti, the Cleveland Clinic’s public and media relations director, told PolitiFact that the study population, whose average age was 42, is not reflective of the general public. 

“The study was done in a younger, relatively healthy, health care employee population. It included no children, very few elderly individuals and likely few immunocompromised individuals,” Pacetti said. “Therefore, we urge caution in generalizing the findings to the public, which can include different populations.” 

More than 50% of the health care workers participating in the clinic’s study had received three or more doses of a covid vaccine; only 12% were not vaccinated. 

Dr. René Najera, an epidemiologist and director of the Center for Public Health at the College of Physicians of Philadelphia, said the Cleveland Clinic study’s outcome was unsurprising given the characteristics of the research subjects — mostly vaccinated health care workers.

If the majority of the study population received three or more doses of a covid vaccine, for instance, then it is reasonable to assume that the majority of covid cases would occur in that population.

“Those who were studied were health care workers: more likely to be exposed, more likely to be vaccinated as well,” Najera told PolitiFact. “If the study is found to be sound through peer review, its findings would only be applicable to health care workers in large settings such as the Cleveland Clinic, not the general public.”

Pacetti further emphasized that the study has not yet been peer-reviewed, and “more research is needed to either confirm or refute this finding.” 

The Cleveland Clinic acknowledged that two other studies had found a similar association between the number of prior vaccine doses and an increased risk of contracting covid, though it had similar limitations. 

One of the studies had not yet been peer-reviewed, and the other examined only health care employees. And even with that finding, the Cleveland Clinic’s study did not suggest the bivalent booster increased the likelihood of infection. 

DeSantis’ “statement is incorrect,” Najera said. “That conclusion cannot be drawn from that study, and the authors state that it is not designed to evaluate that association.” 

Our Ruling

DeSantis said, “Almost every study now has said with these new boosters, you’re more likely to get infected with the bivalent booster.”

An unpublished study from the Cleveland Clinic examined the bivalent covid booster’s effectiveness in preventing infection among a group of about 50,000 health care workers. 

However, one of the study’s authors told PolitiFact that the research did not find an association with the bivalent booster and a higher risk of covid. The study found that the bivalent booster is 30% effective in preventing infection from the virus.

The researchers did find that there could be an association between the number of prior vaccine doses and an increased risk of contracting covid. Still, that finding did not suggest the bivalent booster could cause infection or increase the likelihood of infection. 

We rate DeSantis’ claim False.

Our Sources

Gov. Ron DeSantis’ Rumble, “Permanent Protections Against the COVID-19 Biomedical Security State,” Jan. 17, 2023

Cleveland Clinic, “Effectiveness of the Coronavirus Disease 2019 (COVID-19) Bivalent Vaccine,” accessed Jan. 19, 2023

Email interview with Bryan Griffin, press secretary for Gov. Ron DeSantis, Jan. 19, 2023

Email interview with Jill Roberts, professor of public health at the University of South Florida, Jan. 19, 2023

Email interview with Dr. René Najera, an epidemiologist and director of the Center for Public Health at the College of Physicians of Philadelphia, Jan. 19, 2023

Email interview with Andrea Pacetti, director of public and media relations for the Cleveland Clinic, Jan. 19, 2023

The Washington Post, “No, Vaccines Aren’t Making New Covid Variants Worse,” Jan. 6, 2023

U.S. Centers for Disease Control and Prevention, COVID data tracker, accessed Jan. 19, 2023

U.S. Centers for Disease Control and Prevention, “Early Estimates of Bivalent mRNA Vaccine Effectiveness in Preventing COVID-19–Associated Hospitalization,” Jan. 20, 2023

The Wall Street Journal, “Are Vaccines Fueling New Covid Variants?” Jan. 1, 2023

U.S. Food and Drug Administration, “Rumor Control,” accessed Jan. 19, 2023

The Lancet, “The Vaccinated Proportion of People With COVID-19 Needs Context,” accessed Jan. 19, 2023

Tampa Bay Times, “DeSantis Wants Ban on COVID Mask and Vaccine Mandates to Be Permanent,” Jan. 17, 2023

PolitiFact, “Why Were the Recent COVID-19 Boosters Authorized Before Human Trials Were Completed?” Sept. 13, 2022

MedRxiv, “A Bivalent Omicron-Containing Booster Vaccine Against Covid-19,” accessed Jan. 19, 2023

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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Unmet Needs: Critics Cite Failures in Health Care for Vulnerable Foster Children

Kaiser Health News - Wed, 01/25/2023 - 5:00am

Need Help? If you or someone you know is in a crisis, please call or text 988 to reach the 988 Suicide & Crisis Lifeline.

One night last month, a 9-year-old boy who had autism and talked about killing himself was among about 70 foster care children and youth under state supervision sleeping in hotels across Georgia.

Georgia’s designated health insurer for foster care, Amerigroup Community Care, had denied the boy placement in a psychiatric residential treatment facility, said Audrey Brannen, coordinator of complex care for Georgia’s child welfare agency. He stayed in a hotel for more than a month before receiving a temporary emergency placement in a foster home, she said.

The boy and the other children staying in the hotels lacked permanent placements, Brannen said, and many weren’t getting help for their complex mental and behavioral needs.

The frustration over gaps in care had gotten so bad that Candice Broce, commissioner of the Georgia Department of Human Services, sent a scathing six-page letter to the state Medicaid agency in August — signaling an unusual interagency conflict. She argued that Amerigroup, a unit of Elevance Health, isn’t being held accountable for failures in care, and that its foster care contract should not be renewed.

“Simply put, the state’s most vulnerable children cannot access the physical, mental, or behavioral health treatment they need — and deserve,” Broce wrote.

Amerigroup declined to comment on Broce’s remarks specifically, saying it had not seen her letter. But Michael Perry, an Amerigroup Georgia spokesperson, said the insurer hosts collaborative monthly meetings with state agencies to hear any concerns and will “continue to work on behalf of these vulnerable individuals to ensure they have access to the appropriate healthcare and support services they need to be successful.”

Such problems extend beyond Georgia, according to Sandy Santana, executive director of the national advocacy group Children’s Rights. While foster care grabs headlines mainly in cases of abuse or neglect — even deaths — the failures of states and insurers in providing adequate health care for these children are widespread and occur largely without public scrutiny.

“These kids cycle in and out of ERs, and others are not accessing the services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care problems. “This is an issue throughout the country.”

Nearly all children in foster care are eligible for Medicaid, the state-federal program for those with low incomes, but states decide on the delivery mechanism. Georgia is among at least 10 states that have turned to managed-care companies to deliver specialized services exclusively for foster kids and others under state supervision. At least three more — North Carolina, New Mexico, and Oklahoma — are taking similar steps. But regardless of the structure, getting timely access to care for many of these vulnerable kids is a problem, Santana said.

Obtaining mental health care for privately insured children can be a struggle too, of course, but for children in state custody, the challenge is even greater, said Dr. Lisa Zetley, a Milwaukee pediatrician and chair of the American Academy of Pediatrics’ Council on Foster Care, Adoption, and Kinship Care.

“This is a unique population,” she said. “They have experienced quite of bit of toxic stress prior to entering foster care.”

For states that use specialty managed care for these kids, transparency and oversight remain spotty and the quality of the care remains a troubling unknown, said Andy Schneider, a research professor at Georgetown University’s Center for Children and Families.

Illinois, for example, has paid more than $350 million since 2020 to insurance giant Centene Corp. to manage health coverage for more than 35,000 current and former foster care children. But last year, an investigation by the Illinois Answers Project newsroom found Centene’s YouthCare unit repeatedly failed to deliver basic medical services such as dental visits and immunizations to thousands of these kids. Federal officials are now probing allegations about the contract.

Centene said YouthCare has not been informed of any probe. In a statement, the company said Illinois Answers Project’s reporting was based on outdated information and didn’t account for its recent progress as it works “to ensure that families have the access they need to high-quality care and services.”

In some cases, child advocates say, the care kids do get is not appropriate. In Maryland, the local branch of the American Civil Liberties Union, Disability Rights Maryland, and Children’s Rights filed a lawsuit this month against the state accusing it of failing to conduct adequate oversight of psychotropic drug prescribing for children in its foster care system. As many as 34% the state’s foster children are given psychotropic drugs, court documents said, although most of them don’t have a documented psychiatric diagnosis.

In Georgia, Lisa Rager said she and her husband, Wes, know well the hurdles to obtaining services for foster kids. The suburban Atlanta couple has cared for more than 100 foster children and adopted 11 of them from state custody.

She said one child waited more than a year to see a specialist. Getting approvals for speech or occupational therapy is “a lot of trouble.”

Rager said she pays out-of-pocket for psychiatric medications for three of her children because of insurance hassles. “It’s better for me to pay cash than wait on Amerigroup,” she said.

Such problems occur often, Broce said in her letter. Amerigroup’s “narrow definition for ‘medically necessary services’ is — on its face — more restrictive than state and federal standards,” she wrote.

“Far too often, case managers and foster families are told that the next available appointment is weeks or months out,” she told the state’s Joint Appropriations Committee on Jan. 17. Broce added that her agency has formed a legal team to fight Amerigroup treatment denials.

Amerigroup’s Perry said its clinical policies are approved by the state, and follow regulatory and care guidelines.

In a recent 12-month period, Amerigroup received $178.6 million in government funds for its specialty foster care plan that serves about 32,000 Georgia children, with the large majority being foster children and kids who have been adopted from state custody. The contract is currently up for rebidding.

David Graves, a spokesperson for the Department of Community Health, which runs Medicaid in the state, said the agency would not comment on Broce’s letter because it’s part of the contract renewal process. Graves said the agency regularly monitors the quality of care that children in state custody receive. He pointed to a state report that showed Amerigroup did well on several metrics, such as use of asthma medication.

But Melissa Haberlen DeWolf, research and policy director for the nonprofit Voices for Georgia’s Children, said the majority of kids cycling through the state’s emergency departments for mental illness are in foster care.

“The caregivers we speak to are desperate for behavioral health care coordination help — finding providers and getting appointments, understanding how to manage behaviors and medication, and prevent crises, and sharing health information between providers,” she said.

To fix these problems, Zetley, the pediatrician, recommends creating a larger benefit package for foster kids, coordinating care better, and raising Medicaid reimbursement rates to attract more providers to these managed-care networks.

Contracts with managed-care companies also should be performance-based, with financial penalties if needed, said Kim Lewis, managing attorney of the National Health Law Program’s Los Angeles offices.

“Managed care is only as good as the state’s ability to manage the contract and to make sure that what they’re getting is what they are paying for,” she said. “It doesn’t work by just, you know, hoping for the best and ‘Here’s the check.’”

But in Georgia, the state has never financially penalized Amerigroup for failing to meet contractually mandated quality standards, Department of Community Health spokesperson Graves confirmed. He said the agency and Amerigroup work to resolve any issues brought to their attention.

Georgia has set up an oversight committee, with public meetings, to monitor the quality of Amerigroup’s performance. But the committee hasn’t met since August 2020, the state said last month. After KHN queries, Graves said the panel would start meeting again this year.

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

Wave of Rural Nursing Home Closures Grows Amid Staffing Crunch

Kaiser Health News - Wed, 01/25/2023 - 5:00am

WAUKON, Iowa — Marjorie Kruger was stunned to learn last fall that she would have to leave the nursing home where she’d lived comfortably for six years.

The Good Samaritan Society facility in Postville, Iowa, would close, administrators told Kruger and 38 other residents in September. The facility joined a growing list of nursing homes being shuttered nationwide, especially in rural areas.

“The rug was taken out from under me,” said Kruger, 98. “I thought I was going to stay there the rest of my life.”

Her son found a room for her in another Good Samaritan center in Waukon, a small town 18 miles north of Postville. Kruger said the new facility is a pleasant place, but she misses her friends and longtime staffers from the old one. “We were as close as a nice family,” she said.

The Postville facility’s former residents are scattered across northeastern Iowa. Some were forced to move twice, after the first nursing home they transferred to also went out of business.

Owners say the closures largely stem from a shortage of workers, including nurses, nursing assistants, and kitchen employees.

The problem could deepen as pandemic-era government assistance dries up and care facilities struggle to compete with rising wages offered by other employers, industry leaders and analysts predict. Many care centers that have managed to remain open are keeping some beds vacant because they don’t have enough workers to responsibly care for more residents.

The pandemic brought billions of extra federal dollars to the long-term care industry, which was inundated with covid-19 infections and more than 160,000 resident deaths. Many facilities saw business decline amid lockdowns and reports of outbreaks. Staff members faced extra danger and stress.

The industry is still feeling the effects.

From February 2020 to November 2021, the number of workers in nursing homes and other care facilities dropped by 410,000 nationally, according to the federal Bureau of Labor Statistics. Staffing has rebounded only by about 103,000 since then.

In Iowa, 13 of the 15 nursing homes that closed in 2022 were in rural areas, according to the Iowa Health Care Association. “In more sparsely populated areas, it’s harder and harder to staff those facilities,” said Brent Willett, the association’s president. He noted that many rural areas have dwindling numbers of working-age adults.

The lack of open nursing home beds is marooning some patients in hospitals for weeks while social workers seek placements. More people are winding up in care facilities far from their hometowns, especially if they have dementia, obesity, or other conditions that require extra attention.

Colorado’s executive director of health care policy and financing, Kim Bimestefer, told a conference in November that the state recognizes it needs to help shore up care facilities, especially in rural areas. “We’ve had more nursing homes go bankrupt in the last year than in the last 10 years combined,” she said.

In Montana, at least 11 nursing homes — 16% of the state’s facilities — closed in 2022, the Billings Gazette reported.

Nationally, the Centers for Medicare & Medicaid Services reported recently that 129 nursing homes had closed in 2022. Mark Parkinson, president of the American Health Care Association, said the actual count was significantly higher but the federal reports tend to lag behind what’s happening on the ground.

For example, a recent KHN review showed the federal agency had tallied just one of the 11 Montana nursing home closures reported by news outlets in that state during 2022, and just eight of the 15 reported in Iowa.

Demand for long-term care is expected to climb over the next decade as the baby boom generation ages. Willett said his industry supports changing immigration laws to allow more workers from other countries. “That’s got to be part of the solution,” he said.

The nursing home in Postville, Iowa, was one of 10 care centers shuttered in the past year by the Good Samaritan Society, a large chain based in South Dakota.

“It’s an absolute last resort for us, being a nonprofit organization that would in many cases have been in these communities 50 to 75 years or more,” said Nate Schema, the company’s CEO.

The Evangelical Lutheran Good Samaritan Society, the full name of the company, is affiliated with the giant Sanford Health network and serves 12,500 clients, including residents of care facilities and people receiving services in their homes. About 70% of them live in rural areas, mainly in the Plains states and Midwest, Schema said.

Schema said many front-line workers in nursing homes found less stressful jobs after working through the worst days of the covid pandemic, when they had to wear extra protective gear and routinely get screened for infection in the face of ongoing risk.

Lori Porter, chief executive officer of the National Association of Health Care Assistants, said nursing home staffing issues have been building for years. “No one that’s been in this business is in shock over the way things are,” she said. “The pandemic put a spotlight on it.”

Porter, who has worked as a certified nursing assistant and as a nursing home administrator, said the industry should highlight how rewarding the work can be and how working as an aide can lead to a higher-paying job, including as a registered nurse.

Care industry leaders say that they have increased wages for front-line workers but that they can’t always keep up with other industries. They say that’s largely because they rely on payments from Medicaid, the government program for low-income Americans that covers the bills for more than 60% of people living in nursing homes.

In recent years, most states have increased how much their Medicaid programs pay to nursing homes, but those rates are still less than what the facilities receive from other insurers or from residents paying their own way. In Iowa, Medicaid pays nursing homes about $215 per day per resident, according to the Iowa Health Care Association. That compares with about $253 per day for people paying their own way. When nursing homes provide short-term rehabilitation for Medicare patients, they receive about $450 per day. That federal program does not cover long-term care, however.

Willett said a recent survey found that 72% of Iowa’s remaining nursing homes were freezing or limiting admissions below their capacity.

The Prairie View nursing home in Sanborn is one of them. The facility, owned by a local nonprofit, is licensed for up to 73 beds. Lately, it has been able to handle only about 48 residents, said administrator Wendy Nelson.

“We could take more patients, but we couldn’t give them the care they deserve,” she said.

Prairie View’s painful choices have included closing a 16-bed dementia care unit last year.

Nelson has worked in the industry for 22 years, including 17 at Prairie View. It never has been easy to keep nursing facilities fully staffed, she said. But the pandemic added stress, danger, and hassles.

“It drained the crud out of some people. They just said, ‘I’m done with it,’” she said.

Prairie View has repeatedly boosted pay, with certified nursing assistants now starting at $21 per hour and registered nurses at $40 per hour, Nelson said. But she’s still seeking more workers.

She realizes other rural employers also are stretched.

“I know we’re all struggling,” Nelson said. “Dairy Queen’s struggling too, but Dairy Queen can change their hours. We can’t.”

David Grabowski, a professor of health care policy at Harvard Medical School, said some of the shuttered care facilities had poor safety records. Those closures might not seem like a tragedy, especially in metro areas with plenty of other choices, he said.

“We might say, ‘Maybe that’s the market working, the way a bad restaurant or a bad hotel is closing,’” he said. But in rural areas, the closure of even a low-quality care facility can leave a hole that’s hard to fill.

For many families, the preferred alternative would be in-home care, but there’s also a shortage of workers to provide those services, he said.

The result can be prolonged hospital stays for patients who could be served instead in a care facility or by home health aides, if those services were available.

Rachel Olson, a social worker at Pocahontas Community Hospital in northwestern Iowa, said some patients wait a month or more in her hospital while she tries to find a spot for them in a nursing home once they’re stable enough to be transferred.

She said it’s particularly hard to place certain types of patients, such as those who need extra attention because they have dementia or need intravenous antibiotics.

Olson starts calling nursing homes close to the patient’s home, then tries ones farther away. She has had to place some people up to 60 miles away from their hometowns. She said families would prefer she find something closer. “But when I can’t, I can’t, you know? My hands are tied.”

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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