In September 2022, Elyse Greenblatt of Queens returned home from a trip to Rwanda with a rather unwelcome-back gift: persistent congestion.
She felt a pain in her sinuses and sought a quick resolution.
COVID-19 couldn't be ruled out, so rather than risk passing on an unknown infection to others in a waiting room, the New Yorker booked a telehealth visit through her usual health system, Mount Sinai — a perennial on best-hospitals lists.
That proved an expensive decision. She remembers the visit as taking barely any time. The doctor decided it was likely a sinus infection, not COVID, and prescribed her fluticasone, a nasal spray that relieves congestion, and an antibiotic, Keflex. (The Centers for Disease Control and Prevention says antibiotics "are not needed for many sinus infections, but your doctor can decide if you need" one.)
Then the bill came.
The Patient: Elyse Greenblatt, now 38, had insurance coverage through Empire BlueCross BlueShield, a New York-based insurer.
Medical Services: A telehealth urgent care visit through Mount Sinai's personal record app. Greenblatt was connected with an urgent care doctor through the luck of the draw. She was diagnosed with sinusitis, prescribed an antibiotic and Flonase, and told to come back if there was no improvement.
All this meant a big bill. The insurer said the telehealth visit was deemed an out-of-network service — a charge Greenblatt said the digital service didn't do a great job of warning her about. It came as a surprise. "In my mind, if all my doctors are ‘in-insurance,' why would they pair me with someone who was ‘out-of-insurance'?" she asked. And the hospital system tried its best to make contesting the charge difficult, she said.
Service Provider: The doctor was affiliated with Mount Sinai's health system, though where the bill came from was unclear: Was it from one of the system's hospitals or another unit?
Total Bill: $660 for what was billed as a 45- to 59-minute visit. The insurer paid nothing, ruling it out of network.
What Gives: The bill was puzzling on multiple levels. Most notably: How could this be an out-of-network service? Generally, urgent care visits delivered via video are a competitive part of the health care economy, and they're not typically terribly expensive.
Mount Sinai's telehealth booking process is at pains to assure bookers they're getting a low price. After receiving the bill, Greenblatt went back to the app to recreate her steps — and she took a screenshot of one particular part of the app: the details. She got an estimated wait time of 10 minutes, for a cost of $60. "Cost may be less based on insurance," the app said; this information, Mount Sinai spokesperson Lucia Lee said, is "for the patient's benefit," and the "cost may differ depending on the patient's insurance."
A $60 fee would be in line with, if not a bit cheaper than, many other telehealth services. Doctor on Demand, for example, offers visits from a clinician for $79 for a 15-minute visit, assuming the customer's insurance doesn't cover it. Amazon's new clinic service, offering telehealth care for a wide range of conditions, advertises that charges start at $30 for a sinus infection.
The Health Care Cost Institute, an organization that analyzes health care claims data, told KFF Health News its data shows an urgent care telehealth visit runs, on average, $120 in total costs — but only $14 in out-of-pocket charges.
So how did this visit end up costing astronomically so much more than the average? After all, one of the selling points of telemedicine is not only convenience but cost savings.
First, there was the length of the visit. The doctor's bill described it as moderately lengthy. But Greenblatt recalled the visit as simple and straightforward; she described her symptoms and got an antibiotic prescription — not a moderately complex visit requiring the better part of an hour to resolve.
The choice of description is a somewhat wonky part of health care billing that plays a big part in how expensive care can get. The more complex the case, and the longer it takes to diagnose and treat, the more providers can charge patients and insurers.
Greenblatt's doctor billed her at a moderate level of care — curious, given her memory of the visit as quick, almost perfunctory. "I think it was five minutes," she recalled. "I said it was a sinus infection; she told me I was right. ‘Take some meds, you'll be fine.'"
Ishani Ganguli, a doctor at Brigham and Women's Hospital in Boston who studies telehealth, said she didn't know the exact circumstances of care but was "a bit surprised that it was not billed at a lower level" if it was indeed a quick visit.
That leaves the out-of-network aspect of the bill, allowing the insurer to pay nothing for the care. (Stephanie DuBois, a spokesperson for Empire BlueCross BlueShield, Greenblatt's insurer, said the payer covers virtual visits through two services, or through in-network doctors. The Mount Sinai doctor fit neither criteria.) Still, why did Mount Sinai, Greenblatt's usual health care system, assign her an out-of-network doctor?
"If one gets their care from the Mount Sinai system and the care is within network, I don't think it is reasonable for the patients to expect or understand that one of the Mount Sinai clinicians is suddenly going to be out of network," said Ateev Mehrotra, a hospitalist and telehealth researcher at Beth Israel Deaconess Medical Center.
It struck the doctors specializing in telehealth research whom KFF Health News consulted as an unusual situation, especially since the doctor who provided the care was employed by the prestigious health system.
The doctor in question may have been in network for no insurers whatsoever: A review of the doctor's Mount Sinai profile page — archived in November 2022 — does not list any accepted insurance. (That's in contrast to other doctors in the system.)
Lee, Mount Sinai's spokesperson, said the doctor did take at least some insurance. When asked about the doctor's webpage not showing any accepted plans, she responded the site "instructs patients to contact her office for the most up-to-date information."
Attempting to solve this billing puzzle turned into a major league headache for Greenblatt. Deepening the mystery: After calling Mount Sinai's billing department, she was told the case had been routed to disputes and marked as "urgent."
But the doctor's office would seemingly not respond. "In most other professions, you can't just ignore a message for a year," she observed.
The bill would disappear on her patient portal, then come back again. Another call revealed a new twist: She was told by a staffer that she'd signed a form consenting to the out-of-network charge. But "when I asked to get a copy of the form I signed, she asked if she could fax it," Greenblatt said. Greenblatt said no. The billing department then asked whether they could put the form in her patient portal, for which Greenblatt gave permission. No form materialized.
When KFF Health News asked Mount Sinai about the case in mid-October of this year, Lee, the system's spokesperson, forwarded a copy of the three-page form — which Greenblatt didn't remember signing. Lee said the forms are presented as part of the flow of the check-in process and "intended to be obvious to the patient as required by law." Lee said on average, a patient signs two to four forms before checking into the visit.
But, according to the time stamp on the forms, Greenblatt's visit concluded before she signed. Lee said it is "not standard" to sign forms after the visit has concluded, and said that once informed, patients "may contact the office and reschedule with an ‘in-network provider.'"
"If it was provided after the service was rendered, that is an exception and situational," she concluded.
The business with the forms — their timing and their obviousness — is potentially a vital distinction. In December 2020, Congress enacted the No Surprises Act, designed to crack down on so-called surprise medical bills that arise when patients think their care is covered by insurance but actually isn't. Allie Shalom, a lawyer with Foley & Lardner, said the law requires notice to be given to patients, and consent obtained in advance.
But the legislation provides an exception. It applies only to hospitals, hospital outpatient facilities, critical access hospitals, and ambulatory surgery centers. Greenblatt's medical bill variously presents her visit as "Office/Outpatient" or "Episodic Telehealth," making it hard to "tell the exact entity that provided the services," Shalom said.
That, in turn, makes its status under the No Surprises Act unclear. The rules apply when an out-of-network provider charges a patient for care received at an in-network facility. But Shalom couldn't be sure what entity charged Greenblatt, and, therefore, whether that entity was in network.
As for Mount Sinai, Lee said asking for consent post-visit does not comply with the No Surprises Act, though she said the system needed more time to research whether Greenblatt was billed by the hospital or another entity.
The Resolution: Greenblatt's bill is unpaid and unresolved.
The Takeaway: Unfortunately, patients need to be on guard to protect their wallets.
If you want to be a smart shopper, consider timing the length of your visit. The "Bill of the Month" team regularly receives submissions from patients who were billed for a visit significantly longer than what took place. You shouldn't, for example, be charged for time sitting in a virtual waiting room.
Most important, even when you seek care at an in-network hospital, whose doctors are typically in network, always ask if a particular physician you've not seen before is in your network. Many practices and hospitals offer providers in both categories (even if that logically feels unfair to patients). Providers are supposed to inform you that the care being rendered is out of network. But that "informed consent" is often buried in a pile of consent forms that you auto-sign, in rapid fire. And the language is often a blanket statement, such as "I understand that some of my care may be provided by caregivers not in my insurance network" or "I agree to pay for services not covered by my insurance."
To a patient trying to quickly book care, that may not feel like "informed consent" at all.
"It's problematic to expect patients to read the fine print, especially when they feel unwell," Ganguli said.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
The marketing pitches are bold and arriving fast: Invest opioid settlement dollars in a lasso-like device to help police detain people without Tasers or pepper spray. Pour money into psychedelics, electrical stimulation devices, and other experimental treatments for addiction. Fund research into new, supposedly abuse-deterrent opioids and splurge on expensive, brand-name naloxone.
Opioid manufacturers and distributors are paying more than $54 billion in restitution to settle lawsuits about their role in the overdose epidemic, with little oversight on how the money is spent. We're tracking how state and local governments use — or misuse — the cash.
These pitches land daily in the inboxes of state and local officials in charge of distributing more than $50 billion from settlements in opioid lawsuits.
The money is coming from an array of companies that made, sold, or distributed prescription painkillers, including Johnson & Johnson, AmerisourceBergen, and Walgreens. Thousands of state and local governments sued the companies for aggressively promoting and distributing opioid medications, fueling an epidemic that progressed to heroin and fentanyl and has killed more than half a million Americans. The settlement money, arriving over nearly two decades, is meant to remediate the effects of that corporate behavior.
But as the dollars land in government coffers — more than $4.3 billion as of early November — a swarm of private, public, nonprofit, and for-profit entities are eyeing the gold rush. Some people fear that corporations, in particular — with their flashy products, robust marketing budgets, and hunger for profits — will now gobble up the windfall meant to rectify it.
"They see a cash cow," said JK Costello, director of behavioral health consulting for the Steadman Group, a firm that is being paid to help local governments administer the settlements in Colorado, Kansas, Oregon, and Virginia. "Everyone is interested."
Costello receives multiple emails a week from businesses and nonprofits seeking guidance on how to apply for the funds. To keep up with the influx, he has developed a standard response: Thanks, but we can't respond to individual requests, so here's a link to your locality's website, public meeting schedule, or application portal.
KFF Health News obtained email records in eight states that show health departments, sheriffs' offices, and councils overseeing settlement funds are receiving a similar deluge of messages. In the emails, marketing specialists offer phone calls, informational presentations, and meetings with their companies.
Alabama Attorney General Steve Marshall recently sent a letter reminding local officials to vet organizations that reach out. "I am sure that many of you have already been approached by a variety of vendors seeking funding for opioid initiatives," he wrote. "Please proceed with caution."
Of course, not all marketing efforts should prompt concern. Emails and calls are one way people in power learn about innovative products and services. The country's addiction crisis is too large for the public sector to tame alone, and many stakeholders agree that partnering with industry is crucial. After all, pharmaceutical companies manufacture medications to treat opioid addiction. Corporations run treatment facilities and telehealth services.
"It's unrealistic and even harmful to say we don't want any money going to any private companies," said Kristen Pendergrass, vice president of state policy at Shatterproof, a national nonprofit focused on addiction.
The key, agree public health and policy experts, is to critically evaluate products or services to see if they are necessary, evidence-based, and sustainable — instead of flocking to companies with the best marketing.
Otherwise, "you end up with lots of shiny objects," Costello said.
And, ultimately, failure to do due diligence could leave some jurisdictions holding an empty bag.
Take North Carolina. In 2022, state lawmakers allotted $1.85 million of settlement funds for a pilot project using the first FDA-approved app for opioid use disorder, developed by Pear Therapeutics. There were high hopes the app would help people stay in treatment longer.
The state hadn't paid the company yet, so the money isn't lost, according to the North Carolina Department of Health and Human Services. But the department and lawmakers have not decided what to do with those dollars next.
$1M for Drug Disposal Pouches
Jason Sundby, CEO of Verde Environmental Technologies, said the Deterra pouches his company sells are a low-cost way to prevent expensive addictions.
Customers place their unused medications in a Deterra pouch and add water, deactivating the drugs before tossing them, ensuring they cannot be used even if fished out of the trash. A medium Deterra pouch costs $3.89 and holds 45 pills.
The goal is to "get these drugs out of people's homes before they can be misused, diverted, and people start down the path of needing treatment or naloxone or emergency room visits," Sundby said.
It may be paying off, as Deterra is set to receive $1 million in settlement funds from the health department in Delaware County, Pennsylvania, and $12,000 from the sheriff's office in Henry County, Iowa. The company also has partnerships with St. Croix and Milwaukee counties in Wisconsin, and is working on a deal in Connecticut.
Several other companies with similar products have also used their product sites to urge jurisdictions to consider the settlements as a funding stream — and they're seeing early success.
DisposeRx makes a drug deactivation product — its version costs about a dollar each — and received $144,000 in South Carolina for mailing 134,000 disposal packets to a program that educated high school football players, coaches, and parents about addiction.
SafeRx makes $3 pill bottles with a locking code to store medications and was awarded $189,000 by South Carolina's opioid settlement council to work with the Greenville County Sheriff's Office and local prevention groups. It also won smaller awards from Weld and Custer counties in Colorado.
None of the companies said they are dependent on opioid settlements to sustain their business long-term. But the funds provide a temporary boost. In a 2022 presentation to prospective investors, SafeRx called the opioid settlements a "growth catalyst."
Critics of such investments say the products are not worthwhile. Today's crisis of fatal overdoses is largely driven by illicit fentanyl. Even if studiessuggest the companies' products make people more likely to safely store and dispose of medications, that's unlikely to stem the record levels of deaths seen in recent years.
"The plausible mechanism by which they would even be able to reduce overdose is a mystery because prescription medications are not driving overdose," said Tricia Christensen, policy director with the nonprofit Community Education Group, which is tracking settlement spending across Appalachia.
Safe storage and disposal can be accomplished with a locking cabinet and toilet, she said. The FDA lists opioids on its flush list for disposal and says there is no evidence that low levels of the medicines that end up in rivers harm human health.
But Milton Cohen, CEO of SafeRx's parent company, Caring Closures International, said keeping prescription medicines secure addresses the root of the epidemic. Fentanyl kills, but often where people start, "where water is coming into the boat still, is the medicine cabinet," he said. "We can bail all we want, but the right thing to do is to plug the hole first."
Products to secure and dispose of drugs also provide an opportunity for education and destigmatization, said Melissa Lyon, director of the Delaware County Health Department in Pennsylvania. The county will be mailing Deterra pouches and postcards about preventing addiction to three-quarters of its residents.
"The Deterra pouch is to me a direct correlation" to the overprescribing that came from pharmaceutical companies' aggressive marketing, she added. Since the settlement money is to compensate for that, "this is a good use of the funds."
Tools for Law Enforcement That Superheroes Would Envy
Other businesses making pitches for settlement funds have a less clear relationship to opioids.
Wrap Technologies creates tools for law enforcement to reduce lethal uses of force. Its chief product, the BolaWrap, shoots a 7½-foot Kevlar tether more than a dozen feet through the air until it wraps around a person's limbs or torso — almost like Wonder Woman's Lasso of Truth.
Terry Nichols, director of business development for the company, said the BolaWrap can be used as an alternative to Tasers or pepper spray when officers need to detain someone experiencing a mental health crisis or committing crimes related to their addiction, like burglary.
"If you want to be more humane in the way you treat people in substance use disorder and crisis, this is an option," he said.
The company posts body camera footage of officers using BolaWrap on YouTube and says that out of 192 field reports of its use, about 75% of situations were resolved without additional use of force.
When officers de-escalate situations, people are less likely to end up in jail, Nichols said. And diverting people from the criminal justice system is among the suggested investments in opioid settlement agreements.
That argument convinced the city of Brownwood, Texas, where Nichols was police chief until 2019. It has spent about $15,000 of opioid settlement funds to buy nine BolaWrap devices.
"Our goal is to avoid using force when a citizen is in need," said James Fuller, assistant police chief in Brownwood. "If we're going to take someone to get help, the last thing we want to do is poke holes in them with a Taser."
After Brownwood's purchase, Wrap Technologies issued a press release in which CEO Kevin Mullins encouraged more law enforcement agencies to "take the opportunity afforded by the opioid settlement funds to empower their officers." The company has also sent a two-page document to police departments explaining how settlement funds can be used to buy BolaWraps.
Language from that document appeared nearly word-for-word in a briefing sheet given to Brownwood City Council before the BolaWrap purchase. The council voted unanimously in favor.
But the process hasn't been as smooth elsewhere. In Hawthorne, California, the police department planned to buy 80 BolaWrap devices using opioid settlement funds. It paid its first installment of about $25,000 in June. However, it was later informed by the state Department of Health Care Services that the BolaWrap is not an allowable use of these dollars.
"Bola Wraps will not be purchased with the Settlement Funds in the future," Hawthorne City Clerk Dayna Williams-Hunter wrote in an email.
Carolyn Williams, a member of the advocacy group Vocal-TX, said she doesn't see how the devices will address the overdose crisis in Texas or elsewhere.
Her son Haison Akiem Williams dealt with mental health and addiction issues for years. Without insurance, he couldn't afford rehab. When he sought case management services, there was a three-month wait, she said. Police charged him with misdemeanors but never connected him to care, she said.
In February, he died of an overdose at age 47. His mother misses how he used to make her laugh by calling her "Ms. Carol."
She wants settlement funds to support services she thinks could have kept him alive: mental health treatment, case management, and housing. BolaWrap doesn't make that list.
"It's heartbreaking to see what the government is doing with this money," she said. "Putting it in places they really don't need it."
Three years after more than 3,600 health workers died of covid-19, occupational safety experts warn that those on the front lines may once again be at risk if the Centers for Disease Control and Prevention takes its committee's advice on infection control guidelines in health care settings, including hospitals, nursing homes, and jails. In early November, the committee released a controversial set of recommendations the CDC is considering, which would update those established some 16 years ago.
The pandemic illustrated how a rift between the CDC and workplace safety officials can have serious repercussions. Most recently, the giant hospital system Sutter Health in California appealed a citation from the state's Division of Occupational Safety and Health, known as Cal/OSHA, by pointing to the CDC's shifting advice on when and whether N95 masks were needed at the start of the pandemic. By contrast, Cal/OSHA requires employers in high-risk settings like hospitals to improve ventilation, use air filtration, and provide N95s to all staff exposed to diseases that are — or may be — airborne.
The agencies are once again at odds. The CDC's advisory committee prescribes varying degrees of protection based on ill-defined categories, such as whether a virus or bacteria is considered common or how far it seems to travel in the air. As a result, occupational safety experts warn that choices on how to categorize covid, influenza, and other airborne diseases — and the corresponding levels of protection — may once again be left to administrators at hospitals, nursing homes, and jails or prisons.
Eric Berg, deputy chief of health at Cal/OSHA, warned the CDC in November that, if it accepted its committee's recommendations, the guidelines would "create confusion and result in workers being not adequately protected."
Also called respirators, N95 masks filter out far more particles than looser-fitting surgical masks but cost roughly 10times as much, and were in short supply in 2020. Black, Hispanic, and Asian health workers more often went without N95 masks than white staffers, which helped explain why members of racial and ethnic minorities tested positive for covid nearly five times as often as the general population in the early months of the pandemic. (Hispanic people can be of any race or combination of races.)
Cal/OSHA issued dozens of citations to health care facilities that failed to provide N95 masks and take other measures to protect workers in 2020 and 2021. Many appealed, and some cases are ongoing. In October, the agency declined Sutter's appeal against a $6,750 citation for not giving its medical assistants N95 masks in 2020 when they accompanied patients who appeared to have covid through clinics. Sutter pointed to the CDC's advice early in the pandemic, according to court testimony. It noted that the CDC called surgical masks an "acceptable alternative" in March 2020, "seemed to recommend droplet precautions rather than airborne precautions," and suggested that individuals were unlikely to be infected if they were farther than 6 feet away from a person with covid.
This is a loose interpretation of the CDC's 2020 advice, which was partly made for reasons of practicality. Respirators were in short supply, for example, and physical distancing beyond 6 feet is complicated in places where people must congregate. Scientifically, there were clear indications that the coronavirus SARS-CoV-2 spread through the air, leading Cal/OSHA to enact its straightforward rules created after the 2009 swine flu pandemic. Workers need stiffer protection than the general population, said Jordan Barab, a former official at the federal Occupational Safety and Health Administration: "Health workers are exposed for eight, 10, 12 hours a day."
The CDC's advisory committee offers a weaker approach in certain cases, suggesting that health workers wear surgical masks for "common, often endemic respiratory pathogens" that "spread predominantly over short distances." The draft guidance pays little attention to ventilation and air filtration, and advises N95 masks only for "new or emerging" diseases and those that spread "efficiently over long distances." Viruses, bacteria, and other pathogens that spread through the air don't neatly fit into such categories.
"Guidelines that are incomplete, weak, and without scientific basis will greatly undermine CDC's credibility," said a former OSHA director, David Michaels, in minutes from an October meeting where he and others urged CDC Director Mandy Cohen to reconsider advice from the committee before it issues final guidance next year.
Although occupational safety agencies — not the CDC — have the power to make rules, enforcement often occurs long after the damage is done, if ever. Cal/OSHA began to investigate Sutter only after a nurse at its main Oakland hospital died from covid and health workers complained they weren't allowed to wear N95 masks in hallways shared with covid patients. And more than a dozen citations from Cal/OSHA against Kaiser Permanente, Sharp HealthCare, and other health systems lagged months and years behind health worker complaints and protests.
Outside California, OSHA faces higher enforcement obstacles. A dwindling budget left the agency with fewer workplace inspectors than it had in 45 years, at the peak of the pandemic. Plus, the Trump and Biden administrations stalled the agency's ongoing efforts to pass regulations specific to airborne infections. As a result, the agency followed up on only about 1 in 5 covid-related complaints that employees and labor representatives officially filed with the group from January 2020 to February 2022 — and just 4% of those made informally through media reports, phone calls, and emails. Many deaths among health care workers weren't reported to the agency in the first place.
Michaels, who is now on the faculty at the George Washington University School of Public Health, said the CDC would further curtail OSHA's authority to punish employers who expose staff members to airborne diseases, if its final guidelines follow the committee's recommendations. Such advice would leave many hospitals, correctional facilities, and nursing homes as unprepared as they were before the pandemic, said Deborah Gold, a former deputy chief of health at Cal/OSHA. Strict standards prompt employers to stockpile N95 masks and improve air filtration and ventilation to avoid citations. But if the CDC's guidance leaves room for interpretation, she said, they can justify cutting corners on costly preparation.
Although the CDC committee and OSHA both claim to follow the science, researchers arrived at contradictory conclusions because the committee relied on explicitly flawed trials comparing health workers who wore surgical masks with those using N95s. Cal/OSHA based its standards on a variety of studies, including reviews of hospital infections and engineering research on how airborne particles spread.
In decades past, the CDC's process for developing guidelines included labor representatives and experts focused on hazards at work. Barab was a health researcher at a trade union for public sector employees when he helped the CDC develop HIV-related recommendations in the 1980s.
"I remember asking about how to protect health care workers and correction officers who get urine or feces thrown at them," Barab said. Infectious disease researchers on the CDC's committee initially scoffed at the idea, he recalled, but still considered his input as someone who understood the conditions employees faced. "A lot of these folks hadn't been on hospital floors in years, if not decades."
The largest organization for nurses in the United States, National Nurses United, made the same observation. It's now collecting signatures for an online petition urging the CDC to scrap the committee's guidelines and develop new recommendations that include insights from health care workers, many of whom risked their lives in the pandemic.
Barab attributed the lack of labor representation in the CDC's current process to the growing corporate influence of large health systems. Hospital administrators prefer not to be told what to do, particularly when it requires spending money, he said.
In an email, CDC communications officer Dave Daigle stressed that before the guidelines are finalized, the CDC will "review the makeup of the workgroups and solicit participation to ensure that the appropriate expertise is included."
Judgments against patients in these suits can derail someone's life but, according to experts, they don't bring hospitals much money. So why do they do it?
Some hospitals sue patients over unpaid medical bills in bulk, sometimes by the hundreds of thousands. The defendants are often already facing financial hardship or even bankruptcy.
Judgments against patients in these suits can derail someone's life but, according to experts, they don't bring hospitals much money.
Host Dan Weissmann investigates this practice with The Baltimore Banner and Scripps News and speaks to patients who've found themselves on the receiving end of such lawsuits.
Weissmann also speaks with Nick McLaughlin, an entrepreneur who’s making the business case for hospitals to stop trying to collect money from people who simply don't have it.
The money is part of the approximately $50 billion that states and local governments will receive nationwide in opioid settlement funds over nearly two decades.
This article was published on Wednesday, December 13, 2023 in KFF Health News.
Nearly a year after Montana began receiving millions of dollars to invest in efforts to combat the opioid crisis, much of that money remains untouched. Meanwhile, the state's opioid overdose and death counts continue to rise.
Opioid manufacturers and distributors are paying more than $54 billion in restitution to settle lawsuits about their role in the overdose epidemic, with little oversight on how the money is spent. We're tracking how state and local governments use — or misuse — the cash.
The money is part of the approximately $50 billion that states and local governments will receive nationwide in opioid settlement funds over nearly two decades. The payments come from more than a dozen companies that made, distributed, or sold prescription opioid painkillers that were sued for their role in fueling the overdose epidemic.
Many places have begun deciding where that money will go and making payments to schools, public health departments, and local governments. South Carolina, for example, has awarded more than $7 million to 21 grantees. Wisconsin has posted two years' worth of spending plans that total nearly $40 million.
Montana, West Virginia, and Hawaii are among the states moving slower.
Montana began receiving its first settlement payments in January, and, by fall, payments totaled roughly $13 million. As of early December, the Montana Opioid Abatement Trust — a private nonprofit created to oversee 70% of the state's share — had met once to agree to its rules of operation, and its money remained locked behind an inactive grant portal. The remainder, divided among the state and local governments, either hadn't been spent or wasn't publicly recorded.
Those charged with distributing the money say they're building a framework to spend it in ways that last. Meanwhile, some addiction treatment providers are eager to use the funds to plug gaps in services.
The tension in Montana reflects a nationwide push-pull. Those handling settlement dollars say governments should take their time planning how to use the enormous windfall. Others argue for urgency as the drug supply has become increasingly deadly. More than 100,000 Americans died of overdoses in 2022, surpassing the previous year's record-setting death toll.
Nearly 200 Montanans died of a drug overdose in 2021, the latest year state data is available. That number, likely an undercount, is roughly 40 more deaths than the year before. Emergency medical responders have continued to record an increasing number of opioid-related emergencies this year.
In Billings, the Rimrock Foundation, one of the state's largest behavioral health providers, has seen its number of clients with opioid use dependency more than triple since 2021. Like other treatment facilities, Rimrock has a waitlist, and addiction treatment providers worry about the limited community resources that exist for patients once they are discharged. "The result of not addressing this is a lot of deaths," said Jennifer Verhasselt, Rimrock Foundation's chief clinical officer.
Debbie Knutson, Rimrock's medical unit and nursing supervisor, said there is widespread confusion about how and when the state's settlement dollars can be used.
"It's very concerning if we have money available that we could use to help people that is just kind of sitting, waiting for somebody to decide where it should go," Knutson said.
Rusty Gackle, the Montana Opioid Abatement Trust executive director, said a lot of work has happened behind the scenes to get local governments ready to accept their initial payments and for regional leaders to form systems to request money from the trust. That included hosting a series of town hall-style meetings to share information about the process. He said many of those local regions are still finalizing their governance structures.
"I would love to progress a little bit faster," Gackle said. "But I'd rather do it right so that we're not having to go backwards."
Montana officials got a late start too, he added. Some states began receiving settlement dollars last year, but Montana was toward the tail end of the line.
Montana is dividing its money three ways: 15% to the state, 15% to local governments, and the rest to the Montana Opioid Abatement Trust, with some money set aside for attorneys' fees.
As of late November, the state hadn't begun spending the $2.4 million it had in hand for state agencies. Officials also aren't tracking how and when local governments spend their direct payments.
Similarly, West Virginia and Hawaii hadn't — by late November — begun spending the largest shares of their funding. In West Virginia, the makeup of the foundation board that will oversee roughly 70% of the state's settlement dollars was announced only in August, six weeks after the state's deadline, and the board is now sitting on more than $217 million.
Nationwide, state and local governments have received more than $4.3 billion as of Nov. 9. How much of that has been used remains uncertain due to states' lack of public reporting. But from what is known, it varies.
Colorado, whose spending plan is similar to Montana's but received its settlement money earlier, has allocated millions toward school and community-based programs, recovery housing services, and expanded treatment services.
Sara Whaley, a Johns Hopkins researcher who tracks states' uses of opioid settlement funds, said a slower start isn't inherently wrong. She prefers governments take time to spend the money well rather than fund outdated or untested practices. In some cases, governments are building entirely new systems to dole out the money. Several waited until the courts finalized the settlement amounts and details.
"There are definitely states that were like, 'We are going to get money at some point. We don't know how much or when, but let's start setting up our system,'" Whaley said. "Other folks were like, 'We have a lot going on already. We'll just wait until we get it and then we'll know what the settlement terms are.'"
Even once committees start meeting, it can take months for the money to reach front-line organizations.
Connecticut's opioid settlement advisory committee made its first allocation in November, eight months after it was formed. Maine's recovery council, which controls half the state's settlement funds, has been meeting since November 2022, but just recently voted on priorities for the more than $14 million it has on hand and still needs to establish a grant application process.
Tennessee's Opioid Abatement Council accepted grant applications this fall. Stephen Loyd, council chair, said the process — from picking awardees to processing payments — will take roughly six months. Within that time, he said, 2,808 Tennesseans are likely to die of drug overdoses.
As an interim step, Loyd proposed at an October meeting to award $7.5 million to an emergency six-month initiative to flood the state with naloxone, a medication that reverses opioid overdoses.
But his proposal was met with protests from council members, who pushed back on what they saw as a circumvention of the grant process they had spent months establishing. The council didn't vote on the emergency initiative but instead created an expedited review process to consider fast-tracking future applications.
Gackle said he doesn't think Montana is far behind others. Now that spending systems are almost in place, he said, things should move faster.
Lewis and Clark County, home to the state capital, Helena, has a yearlong plan and budget for opioid settlement funds. A cohort of 17 counties in rural eastern Montana defined its regional settlement decision-makers in November and, by early December, had yet to begin official talks about where the money should go.
Brenda Kneeland, CEO of Eastern Montana Community Mental Health Center and an advisory committee member for the Montana Opioid Abatement Trust, said eastern Montana has one inpatient treatment center for substance use disorders and zero detox facilities, so emergency rooms end up serving as a fallback resource.
Kneeland said local officials want to ensure they understand the rules to avoid trouble later and to stretch the funding.
"You don't get an opportunity to try to correct such a wrong very often," Kneeland said. "It's just a huge job at a county level. I've never seen an undertaking like this in my career."
The Montana Opioid Abatement Trust advisory committee will meet quarterly, meaning its next chance to review any submitted grants will be next spring.
GRAND RAPIDS, Minn. ― Myrna Peterson predicts self-driving vehicles will be a ticket out of isolation and loneliness for people like her, who live outside big cities and have disabilities that prevent them from driving.
Peterson, who has quadriplegia, is an enthusiastic participant in an unusual test of autonomous vehicles in this corner of northern Minnesota. She helped attract government funding to bring five self-driving vans to Grand Rapids, a city of 11,000 people in a region of pine and birch forests along the Mississippi River.
The project's self-driving vans always have a human operator in the driver's seat, poised to take over in complicated situations. But the computers are in control about 90% of the time, and they've given 5,000 rides since 2022 without any accidents, organizers say.
"It's been fun. I'm really sold on it," said Peterson, who used to rely on her power wheelchair to travel around town, even in winter.
Autonomous vehicles, which can drive themselves at least part of the time, are making news in urban areas, such as San Francisco, where extensive tests of the technology are underway.
Rural experiments have been set up in a few other states, including Iowa and Ohio. Peterson hopes the pilot projects help bring a day when fully autonomous cars and vans assist the estimated 25 million Americans whose travel is limited by disabilities.
Fully independent vehicles remain far from everyday options, as tech companies and automakers struggle to perfect the technology. Recently, for example, General Motors recalled all its self-driving cars after one struck and dragged a pedestrian who had been hit by another vehicle.
But Waymo, a corporate relative of Google, is forging ahead with fully autonomous taxi rides in multiple cities.
Peterson is among those who believe autonomous vehicles someday will become safer than human-driven models.
"Look at how many times the lightbulb failed before it worked," she said.
Unlike many smaller towns, Grand Rapids has public buses and a taxi service. But Peterson said those options don't always work well, especially for people with disabilities. The autonomous vehicle program, known as goMARTI, which stands for Minnesota's Autonomous Rural Transit Initiative, offers a flexible alternative, she said. She hopes it eventually will ease a national shortage of drivers, which tends to be especially acute in rural regions.
The project is funded through the spring of 2027 with more than $13 million from federal, state, and local sources, much of it coming from the 2021 federal infrastructure bill.
The project's distinctive Toyota minivans are outfitted by a Michigan company, May Mobility, which is backed by the Japanese auto giant and other investors. Slogans painted on the side invite the public to "Experience Self Driving in Minnesota's Nature." The vans bristle with technology, including cameras, radar, GPS, and laser sensors. Their computer systems constantly monitor surroundings and learn from situations they encounter, said Jon Dege, who helps manage the project for May Mobility.
Users arrange free rides via a smartphone app or the 211 social service telephone line.
On a recent chilly afternoon, a goMARTI van pulled up near Peterson's house. She soon emerged, bundled in a bright purple parka honoring her beloved Minnesota Vikings football team. She rolled her electric wheelchair to the van, up a ramp, and into the back. Van operator Mark Haase helped strap the wheelchair in, then climbed into the driver's seat for a demonstration.
As the van pulled onto the street, the steering wheel seemed to shudder, reflecting tiny adjustments the computer made. Haase kept his foot poised near the brake pedal and his hands cupped around the steering wheel, ready to take over if a complication came up. After moments when he needed to take control of the vehicle, he pressed a button telling the computer system to resume command. "It was weird at first, but it didn't take long to get used to it and trust the system," Haase said.
The Minnesota Department of Transportation helped direct federal money toward the Grand Rapids project, which followed a similar effort in the southern Minnesota city of Rochester. Tara Olds, the department's director of connected and automated vehicles, said her agency sought smaller communities that wanted to give autonomous vehicles a shot.
Neither kind of driver will ever be perfect, Olds said. "You know, humans make mistakes, and computers make mistakes," she said. But the public would understandably react differently if a fatal crash were caused by an autonomous vehicle instead of a human, she said.
Frank Douma, a research scholar at the University of Minnesota's Center for Transportation Studies, has analyzed the Grand Rapids project and other autonomous vehicle programs. He said running such projects in smaller towns isn't necessarily harder than doing so in urban areas. "It's just different."
For the foreseeable future, such services probably will need to run on predetermined routes, with regular stops, he said. It would be more complicated to have autonomous vehicles travel on demand to unfamiliar addresses out in the countryside.
Developers will need to overcome significant challenges before autonomous vehicles can become a regular part of rural life, he said. "But it's no longer something that can be dismissed as impossible."
A 2022 report from the National Disability Institute predicted that autonomous vehicles could help many people with disabilities get out of their homes and obtain jobs.
Tom Foley, the group's executive director, said a lack of transportation often causes isolation, which can lead to mental health problems. "There's an epidemic of loneliness, particularly for older people and particularly for people with disabilities," he said.
Foley, who is blind, has tried fully autonomous vehicles in San Francisco. He believes someday they will become a safe and practical alternative to human drivers, including in rural areas. "They don't text. They don't drink. They don't get distracted," he said.
For now, most riders who use wheelchairs need attendants to secure them inside a van before it starts moving. But researchers are looking into ways to automate that task so people who use wheelchairs can take advantage of fully autonomous vehicles.
The Grand Rapids project covers 35 miles of road, with 71 stops. The routes initially avoided parking lots, where human drivers often make unexpected decisions, Dege said. But organizers recognized the street-side stops could be challenging for many people, especially if they're among the 10% of goMARTI riders who use wheelchairs. The autonomous vans now drive into some parking lots to pick riders up at the door.
During the recent demonstration ride with Peterson and Haase, the van turned into a clinic parking lot. A lady in an orange car cut across the lot, heading for the front of the van. The computer driving the van hit the brakes. A split second later, Haase did the same. The orange car's driver smiled and gave a friendly Midwestern wave as she drove past.
The autonomous vans have gone out in nearly all kinds of weather, which can be a challenge in northern Minnesota. Grand Rapids received more than 7 feet of snow last winter.
"There were only three or four times when it was so snowy we had to pull it in," Dege said. The autonomous driving systems can handle snowflakes in the air and ice on the pavement, he said. They tend to get confused by snow piles, however. The human operators step in to assist in those situations while the computers learn how to master them.
The robot drivers can get stymied as well by roundabouts, also known as traffic circles. The setups are touted as safer than four-way stops, but they can befuddle human drivers too.
Haase took control each time the van approached a roundabout. He also took the wheel as the van came up on a man riding a bicycle along the right side of the road. "Better safe than sorry," Haase said. Once the van was a few yards past the bicycle, he pressed a button that told the robot to resume control.
Peterson takes the vans to stores, restaurants, community meetings, hockey games — "and church, of course, every Sunday and Wednesday," she said.
She said the project has brought Grand Rapids residents together to imagine a more inclusive future. "It's not just a fancy car," she said.
Jasen Gundersen never considered a career in business when he entered medical school nearly three decades ago to become a rural primary care doctor.
But, today, he isn't working in rural America and he doesn't do primary care. In fact, he no longer practices medicine at all.
As CEO of CardioOne, which provides back-office support to cardiologists, Gundersen is part of a growing trend: physicians and medical school students earning advanced business degrees to work the business side of the booming health care industry.
Just over 60% of medical schools now offer dual MD-MBA programs, more than twice the number two decades ago, a recent study shows. And researchers estimate the number of dual-degree graduates has nearly tripled. Still, it's difficult to know exactly how many physicians now have business degrees. While the medical school students who simultaneously earned both a medical and business degree represent almost 1% of the roughly 28,000 medical school students who graduate each year, that doesn't include physicians, like Gundersen, who later go back to school to pursue an executive MBA.
For years, some doctors have sought auxiliary degrees, including master's degrees in public health and law degrees. But more and more, doctors want to pair their clinical expertise with management skills and financial literacy as the American health system focuses on maximizing profits. Often that's so they can become business executives, especially as lucrative health tech startups proliferate and hospital systems, pharmacy benefit managers, and insurers have swelled into formidable companies.
However, this pursuit of advanced business degrees begs the question: Whom will these doctors end up serving more, patients or shareholders?
Long gone are the days when nuns ran many local hospitals. Now, many hospitals are part of multibillion-dollar systems, some of which, such as HCA Healthcare Inc. and Tenet Healthcare Corp., outrank some of America's most recognizable brands on the Fortune 500 list.
Still, it's one of the few sectors of the economy where the people who know the most about what's going on in their companies aren't the ones running them, said J.B. Silvers, a management professor at Case Western Reserve University who has been teaching business fundamentals to medical students and physicians for decades.
In the past, doctors rarely left medicine to join the ranks of management because they tended to earn more as practicing physicians. But that's changing, Silvers said, especially as new career paths emerge. The MBA can serve as the doorway to those new opportunities — and the potentially lucrative ownership stakes that can come from leading successful medical technology companies.
Physicians earn, on average, $350,000 a year, making them among the highest-paid workers in the U.S. Doctors in primary care tend to make less than that, while the top 1% of physicians can make more than $1.7 million annually.
"There's a lot of other ways to make more money now," said Rich Joseph, who, as an MD-MBA graduate from Stanford, is an example of the trend. Joseph, an outspoken critic of how U.S. doctors are trained, is chief medical officer for Restore Hyper Wellness, which offers cryotherapy and IV drips at locations across the country.
Doctors are considered the face of the health care system, but a lot of big decisions are made in the boardroom, said Folawiyo Laditi, a recent graduate of Yale's MD-MBA program and a urology resident at the University of Pittsburgh.
Laditi wants to leverage his business degree to tackle systemic issues in health care that sometimes don't always feel "fixable" as a doctor treating a single patient at a time. He hopes "to make changes that can affect a lot of patients and a lot of people at once."
Medical schools are selling the power that comes from the dual degree. "Ready to pair your clinical expertise with business best practices to transform your organization? Hone your business acumen to assume a greater scope of leadership," touts the website of the University of Tennessee's physician executive MBA program.
Harvard University says on its website that its dual-degree program is intended to "develop outstanding physician leaders, skilled in both medicine and management, to take positions of influence through which they will contribute substantially to the health and well-being of individuals and society."
Gundersen, the CardioOne CEO, who attended the University of Tennessee program and now lives outside of Denver, found it useful to practice medicine for years after he got his business degree, juggling executive and clinical work. He stopped treating patients nearly four years ago.
It helps to speak the language of physicians, Gundersen said while in Florida during a summer business trip to sell cardiologists on using his company's platform. He pitches alleviating a pain point for most doctors — the nondoctoring work — so they can focus on patient care. It's something he felt as a practicing physician.
Gundersen said the nation needs more doctors, especially ones who remain independent from sprawling health care companies. As he promotes that message to prospective cardiac doctors, Gundersen recognizes the irony. "We need more doctors, and here I am the doctor who doesn't doctor anymore," he said.
Colorado officials say their plan to import cheaper medicines from Canada has been stymied by opposition from drugmakers and inaction by the Biden administration, according to a state report obtained by KFF Health News.
The Dec. 1 report, prepared for the state legislature by Colorado's Department of Health Care Policy & Financing, says that state officials approached 23 drugmakers in the last year about an importation program. Only four agreed even to discuss the proposal; none expressed interest in participating.
"Generally, the challenges that remain are outside state authority and rely on action by FDA and/or drug manufacturers," the report reads.
Lawmakers in both parties, at the state and national level, have sought for decades to legalize importing drugs from Canada. Since 2020, when President Donald Trump's administration opened the door to Canadian drug imports with regulations issued just weeks before he lost reelection, only a few states have filed applications with the Food and Drug Administration to create importation programs.
The FDA hasn't yet ruled on any of them. Colorado filed its application in December 2022. Florida, which applied in 2020, has been waiting nearly three years for a decision from the Biden administration on its importation plan, pushed by Gov. Ron DeSantis, now a Republican presidential candidate.
FDA spokesperson Cherie Duvall-Jones said the FDA has not acted on states' importation applications because it has not determined whether they would save significant money for consumers without posing risks to public health.
U.S. consumers pay some of the highest prices in the world for brand-name pharmaceuticals. Drugs are generally less expensive in Canada, where the government controls prices.
Under Trump, the federal government declared that importing drugs from Canada could be done safely — satisfying for the first time a condition spelled out in a 2003 law.
But Colorado officials cited another catch: The rule didn't take into account that states would have to negotiate directly with drug manufacturers, which oppose selling their brand-name drugs in the United States at Canadian prices.
"As the federal Final Rule did not contemplate the need for this negotiation step, we have urged FDA to release further guidance regarding how states can operationalize the program with this in mind, but to date, no guidance has been released," the Colorado report said.
Unlike many other Trump administration health policies, Biden hasn't revoked or revised the importation rule. But his administration hasn't shown much support for the idea, either. Health and Human Services Secretary Xavier Becerra told KFF Health News last December that he wouldn't commit to the FDA ruling on any state application in 2023.
The president has repeatedly suggested that under his watch Americans would be able to import drugs from Canada.
During his 2020 campaign, Biden said he'd allow for the importation of drugs the government certified as safe. In 2021, he ordered the FDA to work with states to import prescription drugs from Canada. In a 2022 speech about how he planned to reduce drug prices, he cited Colorado estimates of how much people in the state could save through importation.
FDA officials responded to Colorado's application in March by asking for more information and a smaller list of drugs to target, to prove that importation could save money. Colorado's initial application listed 112 high-cost drugs. The state estimates residents and employers could save an average of 65% on the costs of those medicines, including drugs for diabetes, asthma, and cancer.
Colorado said it plans to submit an updated application early next year. By then, it's possible the FDA will have ruled on Florida's application.
The Colorado and Florida importation proposals differ. Colorado's program is intended to directly help consumers obtain cheaper medicines. Florida's plan aims to cut spending on drugs in government programs such as Medicaid, the prison system, and facilities run by the state Department of Children and Families.
The drug industry has argued the Trump administration didn't properly certify that drugs imported from Canada would be safe, jeopardizing Americans' health. Canada's government, too, has expressed concern that U.S. imports would lead to shortages and higher prices in its country.
Drug manufacturers "will do anything to protect their golden goose that is United States consumers and patients who pay the largest amount for drugs in the world," said Colorado state Sen. Sonya Jaquez Lewis, a Democrat, pharmacist, and leading advocate for drug importation.
The White House and Congress, she said, should force drugmakers to negotiate with states to start importation programs.
In its initial response to Colorado's application, the FDA listed several types of information it still needed, including plans on labeling and drug eligibility, according to a March letter from the FDA to the state. Another problem, the FDA said: The state planned to import medicines across the U.S. border in Buffalo, New York. The FDA said the only port of entry it allows for medicines is in Detroit.
Colorado officials told the FDA in March that without federal approval of its application, it was having difficulty securing commitments from drug manufacturers to obtain medicines.
"It has been made clear that potential partners will be more interested in committing to participate once our program has been approved by the FDA," Kim Bimestefer, executive director of the Colorado Department of Health Care Policy & Financing, wrote to the FDA.
"While we understand the regulatory framework does not permit for a provisional approval, we know that showing progress towards an approved program will aid in our negotiations with drug manufacturers," she added.
Another complication is that the FDA's rule doesn't allow states to buy drugs directly from secondary drug wholesalers. Instead, they must purchase medicines directly from manufacturers, said Marc Williams, a spokesperson for the Colorado agency.
That's proven challenging because drug manufacturers have prohibited the export of products intended for sale in Canada to the U.S., Williams said.
"Without their permission and a supply agreement directly with a manufacturer, Colorado is unable to buy and import these lower-priced drugs that would save people money," he said.
The Biden administration plans to push states to boost oversight of the number of doctors, hospitals, and other health providers insurers cover in Obamacare plans, under rules proposed in November.
The annual regulatory proposal, known as the payment parameters rule, also seeks to expand access to adult dental coverage in Affordable Care Act marketplaces and would require states to hold open enrollment periods for Obamacare plans at the same time of year. It's likely one of the last major ACA policy efforts of President Joe Biden's first term — and, if he loses reelection, could represent his final touches on the landmark health program created when he was vice president.
Biden has been a staunch supporter of Obamacare and has taken steps during his own first term in the White House to expand the program through rules and legislation, including measures that increased premium subsidies. In part because of those subsidies, enrollment has increased steadily and hit records under his watch.
The proposal for 2025 would continue administration efforts to expand coverage, making it easier for states to offer plans that include adult dental care. The rules also set additional guardrails on the growing number of states that have chosen to run their own ACA marketplaces.
The rules need to be finalized in the spring and would affect plans starting in January 2025, not long before Inauguration Day.
So expect some controversy.
Already, the ACA has entered the political debate, with the current GOP front-runner, former President Donald Trump, taking to his Truth Social site on Thanksgiving weekend to call the failure of the GOP to repeal the ACA "a low point for the Republican Party."
Trump also said he was "seriously" considering alternatives, which harked back to his presidency when he frequently promised an Obamacare replacement was soon to be revealed. It never was.
Biden quickly seized on Trump's comments, saying on Nov. 27 that "my predecessor has once again — God love him — called for cuts that could rip away health insurance for tens of millions of Americans."
Many of the changes made during Biden's term, especially to rules that spell out how the law is to be implemented, could be altered if a Republican wins the White House — just as occurred in the transition from the Obama administration to the Trump term and, again, when Biden took office.
When Trump came into office, for example, he made a number of moves to roll back ACA rules set by the program's namesake, President Barack Obama, including sharply reducing funding for enrollment assistance, shortening the annual sign-up period, and allowing less expensive but less protective short-term plans to cover longer periods of time. Biden's team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans, which don't cover many of the benefits included in ACA plans and are often called "junk insurance" by critics.
"If the past is any guide, and the next administration is different, the first thing they will do is roll things back," said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
Politics may be one reason the administration's latest proposal doesn't include larger changes to the ACA. Doing anything more aggressive in an election year "might disrupt a program that Biden fully supports," said Joseph Antos, senior fellow at the American Enterprise Institute, a right-leaning think tank.
But the proposal from the Department of Health and Human Services does respond to concerns about "network adequacy," or whether insurers' doctor and hospital networks are large enough to meet demand. The rules would require states to set numerical standards, such as a maximum "time and distance" that patients must travel to access in-network care, that are at least as rigorous as federal limits that kicked in this year.
The proposal would affect the 18 states, plus the District of Columbia, that run their own ACA marketplaces.
While many of them already set some network parameters, the standards vary. The administration's latest proposal notes that 25% of existing state rules fail to set any quantitative requirements, such as how long or far a patient might have to drive to find a participating provider, or the acceptable ratio of the number of enrollees in a plan to the number of covered medical providers.
Requiring standards at least as tough as federal exchange rules across all states "would enhance consumer access to quality, affordable care," the document says.
Some states "may not be doing enough to ensure compliance," said Corlette. "States will have to step up their game."
States would also have to review insurer networks to see if they meet the standards before giving the go-ahead to sell their plans. While the federal marketplace will, beginning in 2025, require insurers to meet new rules aimed at limiting patients' wait times for appointments, especially for primary care and behavioral health, state marketplaces won't yet have to impose similar standards.
More prescriptive state requirements for ACA insurers might draw some pushback during the public comment period for the rules, which runs through Jan. 8. They could also be a target for change if the GOP wins the White House, said Chris Condeluci, a health law attorney who worked as counsel to the Senate Finance Committee when the ACA was drafted.
"On the one hand, it makes sense to have standardized rules so everyone is working off the same song sheet," said Condeluci. But he said there's support for the idea that state marketplaces were not "to be nationally run or overly prescriptive from a federal government regulatory perspective."
The HHS proposal also seeks to expand access to routine adult dental coverage by eliminating a prohibition against states including the care as an "essential health benefit" in their benchmark plans. The rules would also standardize open enrollment periods across all states, requiring them to begin Nov. 1 and run through at least Jan. 15. Most states already do that, although Idaho's period currently begins Oct. 15 and ends Dec. 15, and New York's begins Nov. 16 and ends Jan. 31.
The payment parameter notices, though dryly named, are a big deal not only for insurers, who plan their benefits and set their rates based in part on such rules, but also for consumers.
The ACA marketplaces "cover millions of people and it's very important to make sure they are working and people understand what they are buying," said Bethany Lilly, executive director of public policy at the Leukemia & Lymphoma Society.
Bradley Little, a physical education teacher in Arizona, was leading his class through a school hallway in 2017 when he collapsed. Little feared he was having a stroke. Or, in a sign of the times, that he'd been shot. He tried to stand, but his leg wouldn't move.
A student ran for help. Firefighters arrived and hoisted Little onto a gurney. At the hospital, an X-ray revealed that the artificial hip implant in Little's right leg had "suddenly and catastrophically structurally failed," according to a lawsuit Little would later file in federal court. The implant severed at its "neck" — a 2-inch-long titanium part linking Little's thigh to his torso.
"It looked like a laser went through it," Little said in an interview. "It was like someone just went in there and cut it right in the middle."
Profemur artificial hips were once considered innovative for a feature known as a "dual modular neck," intended to modernize total hip replacement surgery. Hundreds of thousands of Americans undergo hip implant surgery each year and devices are expected to last at least 20 years, according to the American College of Rheumatology. The Profemur necks, available in an array of lengths and angles, made it easier to customize the hip implants for patients.
But the neck also proved to be a weak point. Over the past two decades, more than 750 Profemur hips like Little's have fractured at the neck, an attorney for the manufacturer once said in court while defending the device as not defective. In interviews, patients said they were left unable to walk and in need of emergency surgery. Reports submitted to the FDA describe Profemur patients stranded in the midst of routine life, while hiking, golfing, bowling, mowing the lawn, lifting a potted plant, getting out of a chair, putting on pants, and leaning over to pick up a key.
After each break, patients endure an hours-long repair surgery that can be traumatic because the broken implant is embedded in their bone and difficult to remove, according to three orthopedic surgeons who've performed such a procedure. The repair surgery, which can cost tens of thousands of dollars and may not be fully reimbursed by insurance, often requires a patient's femur to be cracked open to extract a metal stem that was inserted down its length. Lawsuits have likened removing the bone around the stem to peeling a banana.
"It's gruesome," said Lee E. Rubin, an orthopedic surgeon and expert on prosthetic hips at Yale School of Medicine. "There's no way around the fact that there's a failed or broken implant in that patient's thigh. We have to remove it."
Many Profemur fractures in patients' bodies could have been avoided if the manufacturer or the FDA responded to early signs of failure with more urgency, according to a months-long investigation by KFF Health News and CBS News. An FDA database shows reports of Profemur's titanium modular necks breaking inside U.S. patients since at least 2005, but the corresponding parts were not recalled until 15 years later, if at all. Ten sizes of the titanium neck eventually were recalled in 2020 after being identified in more than 650 reports of fractures submitted to the FDA. Six other sizes of titanium necks, identified in about 75 additional fracture reports, have not been permanently recalled.
"This implant should have been pulled out of the market earlier," he said.
Profemur's original manufacturer, Wright Medical Technology, in 2009 switched the metal of the modular neck from titanium to a stronger cobalt-chromium alloy, FDA documents show. Then, after some of those necks also began to break, the company recalled one size but left 11 others on the market despite reports of corrosion causing the implants to fail, FDA documents show.
In total, at least 28 sizes of the Profemur artificial hips with a dual modular neck have allegedly fractured or corroded, but just 11 sizes have been permanently recalled, according to FDA data and records.
Wright Medical, a Tennessee company founded in 1950, has made implantable medical devices since at least the 1970s, according to the company website. Wright sold its hip and knee implant division, including the Profemur, to Chinese company MicroPort for $285 million in 2013, according to the Securities and Exchange Commission. Stryker Corp., one of the nation's largest device companies, paid about $4 billion for the rest of Wright in 2020.
Wright Medical declined to comment in an email from Stryker spokesperson Jon Zimmer. MicroPort did not respond to more than a dozen requests for comment sent to its attorneys, public relations firm, and U.S. offices. MicroPort still advertises Profemur hip implants with dual modular necks on its website, where the devices are listed as "not marketed/registered in United States."
The FDA declined to provide an official for an interview and did not answer written questions about why some Profemur sizes were not permanently recalled. In an email, FDA spokesperson Audra Harrison said medical device manufacturers are largely responsible for deciding which products to recall and when to do so, while the agency "monitors" this process and requests recalls only in "urgent situations." In the case of the Profemur modular necks, all recalls were initiated by MicroPort, and the FDA "took action accordingly," the agency said.
For this investigation, journalists with KFF Health News and CBS News analyzed thousands of reports of Profemur complications submitted over the past two decades to the FDA's nationwide MAUDE database, which catalogs reports of medical device problems and malfunctions. MAUDE is unverified, incomplete, and imperfect — for example, not all device problems are properly submitted to the database, and a single issue may be reported more than once. However, the database still offers the best available perspective on medical device complications in the United States. The FDA has used MAUDE to identify device problems since the early '90s.
KFF Health News and CBS News also reviewed about 180 lawsuits filed in federal court in the past decade alleging Profemur modular necks broke or corroded. Plaintiffs have alleged severe pain, swelling, a "debilitating lack of mobility," and, in at least a few cases, nerve damage and neurological issues from cobalt and chromium ions leaking into their bloodstream.
Most of the lawsuits have been resolved through out-of-court settlements without Wright Medical or MicroPort publicly admitting fault, according to court filings. The remainder of the lawsuits are ongoing.
Wright Medical has denied liability in some lawsuits before settling them and has defended Profemur implants in court in the years before some of the implants were recalled for fracturing.
"A device fracture does not mean it is defective," Wright Medical attorney Tiffany Carpenter said in federal court in 2018, according to a hearing transcript. "Devices fracture all the time."
Collectively, the lawsuits allege that Profemur artificial hips broke or corroded at the neck in about 7½ years, on average. Profemur necks made from titanium broke on average in about 10 years while necks made from the cobalt-chromium alloy broke or corroded in just six years, the lawsuits allege.
Some plaintiffs say they got Profemur implants in both legs — then they both ended up breaking.
Mark Feld, 75, of New Hampshire, who was an avid runner, said he was implanted with Profemur artificial hips in his right and left legs in 2005 and 2008, then the right hip fractured within 10 years, according to a lawsuit he filed. Wright Medical denied liability in court filings and settled out of court for an undisclosed amount.
Feld said that because he surrendered all claims against Wright in the settlement, he could not sue again when his left implant broke in 2020 as he was walking across a bridge near his apartment.
He crawled home to call 911, he said, and was rushed to the hospital.
"I couldn't walk across that bridge for a year," Feld said. He now has new hip implants made by another company, but his fear lingers. "To this day, I still feel like a ticking time bomb. … Nobody could confirm for me that it can't happen again."
Little, the Arizona teacher, also suffered a second Profemur break, four years after his first, according to his lawsuit, in which Wright Medical denied liability and settled out of court. Little said in an interview that this time he was teaching class on a tennis court when he felt a sensation in his left leg that reminded him of crushing an aluminum can. He said he narrowly avoided tumbling onto his students.
After his two broken hip implants and replacement surgeries, Little said, he had to stop coaching basketball and will retire from teaching at the end of this school year — four years earlier than planned. He still feels unsteady and is afraid to climb a stepladder to change a lightbulb, he said.
"I've been robbed of some things," Little said. "There should be accountability for it."
It is not publicly known how many Profemur hips have failed. According to a federal court transcript, Carpenter, the attorney for Wright Medical, said in court in 2018 that the company was aware of 768 fractures among about 353,000 Profemur necks sold. That's a fracture rate of about 0.2%.
Other sources report a much higher rate. The Profemur devices that were permanently recalled in 2020 had a U.S. fracture rate of 2.2% — 11 times what was described in court — according to FDA documents. Peer-reviewed studies estimate fracture rates as low as 1% and as high as 6% for some Profemur models.
Even the lowest estimates are "unacceptable," said Samo Fokter, an orthopedic surgeon and Profemur expert at University Medical Center Maribor in Slovenia.
Fokter has co-authored more than 10 peer-reviewed studies on the Profemur, including one this year, and said he implanted about 50 of them before they were known to fracture.
"This should not happen," Fokter said. "If you put too much force on any implant, it can fracture, of course, but this is very, very rare. Not approaching 1%. It should be less than one in 100,000, let's say."
‘Like a Black Hole Developed Under Their Foot'
The Profemur's problems originate from its "neck," which is a metal connector between the upper components in the hip socket to a lower "stem" that is inserted into a patient's thigh bone, according to peer-reviewed studies, court records, and expert interviews.
Historically, an artificial hip's stem and neck were a single piece of metal. The Profemur line added a junction at the top of the stem so the neck was separate. Because these dual modular necks detached on both ends, the size and angle could be changed to better fit a patient.
But the Profemur's additional junction was also its downfall. Rubin, one of the Yale experts, who also maintains an exhibit of the history of prosthetic hips at the university, said in some patients tiny cracks formed on the portion of the neck that slotted into the socket of the stem. Patients had no idea their implant was cracking until the neck snapped, he said.
"From a patient's perspective, they're walking around on what otherwise would seem like a successful hip implant," Rubin said. "And all of a sudden, as they took a step, they could not bear weight … like a black hole had developed under their foot."
The dual modular neck was developed by a European company, Cremascoli Ortho Group, in the '80s, then purchased by Wright Medical in 1999 to be introduced as the Profemur in the United States. The Profemur was cleared for sale by the FDA in 2000 through the 510(k) program, which permits new medical devices to be sold without extensive testing if they are deemed to have "substantial equivalence" to other devices already on the market. Through this process, new medical devices can piggyback on a single approval for decades.
Wright Medical told the FDA that the Profemur was substantially equivalent to five existing artificial hip systems, and the agency agreed, according to FDA documents obtained through a Freedom of Information Act request. However, of those five hip systems, at least three had significantly different necks than the Profemur, Rubin said. And one was later recalled because of its high failure rate, according to the FDA.
The FDA documents state that although the Profemur is different from the older hip implants that its approval was based on, those differences were "not expected to affect the device's safety and effectiveness." Spokesperson Harrison said in an email that the FDA "followed the statutory framework" when the Profemur was reviewed and cleared.
Once it was cleared by the FDA, Wright touted the Profemur's dual modular neck as a feature.
In a 2004 promotional document obtained by KFF Health News and CBS News, Wright guaranteed the "structural reliability" and "absence of fretting corrosion" at the junction of the stem and neck. Then Wright marketed the Profemur to people with an "active lifestyle," saying the product was for patients who wanted to return to activities like golf, tennis, karate, and wrestling after their hip replacements, according to at least two dozen lawsuits filed against the company.
Wright also hired Jimmy Connors, who was the world's top-ranked tennis player in the ‘70s, as a spokesperson.
"This hip has given me back my quality of life. It's allowed me to do anything I did before," Connors said on JimmysNEWHip.com, a website launched by Wright in 2006, according to screen captures of the site preserved by the Internet Archive.
When the website launched, Wright Medical knew of at least some reports of modular neck fractures. Multiple lawsuits allege the company was aware as of 2000 that some Cremascoli hips had fractured at the modular neck, and then became aware of more fractures in 2003 and 2004. The FDA database shows Wright was also aware of two Profemur implants that allegedly fractured at the neck and were returned to Wright in spring 2005.
In 2006, FDA data showed six reports of Profemur fractures that identified the neck as the part that allegedly broke. By 2007, there were 11 such reports. By 2008, there were 30.
Connors, reached on his cellphone, said Wright Medical did not inform him of Profemur fractures at the time of his endorsement or since. Connors said his own hip implant did not fracture but had to be replaced in 2012 because of other complications.
If he had been told about a fracture risk, Connors said, he might have chosen another implant.
"If I was going through it now, I'd know a lot more to ask than I did back in the first time," Connors said.
Perry Parks, 79, who played football for the Los Angeles Rams in the '60s, said Connors' endorsement persuaded him to get a Profemur hip in 2007. His implant snapped six years later during a bike ride, according to his lawsuit. Wright Medical denied liability and settled out of court.
In an interview, Parks said he was lucky to be biking at the beach at the time of the break, where he tumbled into sand, instead of in traffic.
"The thing that incenses me more is that they knew this," Parks said. "There was some intentionality here to put … profits over the health of people."
New Metal, New Complications
In 2009, Wright Medical introduced a new version of the Profemur modular neck that once again was cleared for sale by the FDA. Agency documents show that the neck material was switched from titanium to a cobalt-chromium alloy, a stronger metal.
"That was a big mistake," Fokter said.
While the cobalt-chromium necks were less susceptible to fracture, they created a new problem at the same junction between the neck and stem, said Fokter and the two Yale experts. Once implanted, the cobalt-chromium neck could rub against the stem's titanium socket, leading to a form of bimetallic corrosion that can cause pain and swelling and leak small amounts of metal ions into a patient's bloodstream, potentially causing a long list of complications, the three experts said.
Robert Rembisz, 75, a retiree in Vero Beach, Florida, alleged in an ongoing lawsuit that Profemur corrosion in his right leg caused elevated metal levels in his blood and "neurologic symptoms" including nerve damage, tinnitus, and balance and coordination problems. Wright Medical has not yet responded to the allegations in Rembisz's lawsuit.
Rembisz added in an interview that he believes the implant hindered his memory and cognition, leading him to question whether he was suffering early signs of dementia. He provided to KFF Health News and CBS News lab reports showing the metals in his blood rising over years, with cobalt levels peaking at nearly 12 times the normal range. Rembisz said most of the symptoms faded after his implant was removed in 2021.
"The problems I developed weren't even close to my hip," Rembisz said. "This problem could be occurring in [other people's] bodies as well. And they don't even know it."
Six years after Profemur switched metals, MicroPort recalled one size of the cobalt-chromium neck affecting about 10,500 implants, citing an "unexpected rate of postoperative fractures," according to FDA records. But it is unknown how many could not be returned because they'd already been implanted.
Kristin Biorn had one.
Biorn, 74, of Pasadena, California, alleged in a lawsuit that this particular size of Profemur neck was implanted in her left leg in 2013 and broke within two years — four months before the recall. Wright Medical and MicroPort denied liability in her lawsuit, then settled out of court.
In an interview, Biorn said the break occurred as she was working at her burgeoning home-staging business. While putting final touches on a client's home with her teenage son, she fell to the floor, unable to stand or crawl, she said.
"Honestly, it gives me nightmares about what could have happened had my son not been there," Biorn said. "My phone was downstairs and there was no way I could have gotten down the stairs alone. No one was scheduled to come in for four days."
Biorn said in her interview that it took three surgeries to fix her hip after the Profemur fracture and she was ultimately forced to close her business and retire.
She now walks with a cane.
Although MicroPort recalled one cobalt-chromium size in 2015, the company did not recall 11 other sizes made of the same metal with the same design, and some lawsuits have faulted the company for leaving "interchangeable" products on the market. MicroPort also did not at that time recall any of the titanium necks, which as of 2015 were identified in more than 500 fracture reports in FDA's database. MicroPort recalled 10 titanium sizes in 2020.
Finally, also in 2020, MicroPort issued a sweeping recall for all available Profemur modular necks, regardless of whether they were made of titanium or cobalt-chromium, according to FDA records.
The recall was temporary so MicroPort could update the documents included in the packaging of Profemur implants. The revised documents added a "general precaution" that doctors should consider a patient's activity level and weight before implanting them with a Profemur, and said that patients should not have "unrealistic" expectations that include "substantial walking, running, lifting, or muscle strain."
Afterward, the recall was lifted, and the FDA once again allowed the implants to be put up for sale.
KFF Health News data editor Holly K. Hacker and CBS News producer Nicole Keller contributed to this report.