The rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in one Oregon county after the Affordable Care Act expanded insurance coverage.
If 22 million Americans lose their health care coverage by 2026 under the GOP Senate’s plan to repeal and replace the Affordable Care Act, how many people could die? The question is at the heart of the debate raging in Washington, D.C., but has been difficult to answer.
“Show me the data on lives saved by Obamacare, please,” conservative political scientist Charles Murray requested in a recent tweet.
A pilot study published Wednesday in the Journal of the American Heart Association may provide an answer: Researchers found that the rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in Multnomah County, Ore., after the Affordable Care Act expanded insurance coverage.
The study analyzed sudden cardiac arrest data from the emergency medical system in 2011-12 before the ACA, and compared the data from 2014-15, after insurance coverage expanded. During that time, the percentage of people in Multnomah County with Medicaid coverage nearly doubled, from 7 percent to 13.5 percent.
Cardiac arrest can serve as an early indicator to show how an increase in health insurance coverage under the ACA might affect mortality.
Each year, about 350,000 people in the United States have a sudden cardiac arrest, in which the heart unexpectedly stops beating. It is one of the most deadly types of heart attacks — only 1 in 10 patients survive it. “It speaks to the importance of predicting and preventing [cardiac arrest], because once it happens, it’s much too late,” said Dr. Sumeet Chugh, medical director of the Heart Rhythm Center of the Cedars-Sinai Heart Institute in California and one of the authors of the study.
The good news is that nearly half of patients experience warning symptoms, offering an opportunity for intervention, said Chugh. Cholesterol and blood pressure medication, diet and exercise, and surgical interventions can all help stave off sudden cardiac arrest. But patients without health insurance might ignore their symptoms and avoid seeing a doctor.
“Imagine that you’re someone with a warning symptom. If you had insurance or access to health care that was relatively easy, you might be more inclined to see a provider. If you didn’t,you might let it go for a while,” said Chugh.
Chugh cautions that the study population was small and did not examine other factors that could have led to a decline in cardiac arrests. Still, it is consistent with other studies that found a link between Medicaid expansion and a decline in mortality. Chugh and fellow author Eric Stecker of the Oregon Health & Science University plan follow-up studies to narrow in on the causes in Multnomah County.
J. Michael McWilliams of the Department of Health Care Policy at Harvard Medical School, who was not involved in the study, questioned the large reduction in cardiac arrests seen in the study, saying it “seems too good to be true.”
James Frank (Courtesy of James Frank)
Still, he said assessing the effects of health insurance on clinical outcomes like cardiac arrest is notoriously difficult, and there is good evidence that health insurance improves access to care and diagnosis of important conditions.
“I think when we focus on the lack of consensus evidence on the effects of coverage on hard outcomes like mortality, and use that as an argument against covering the uninsured, I think we let perfect be the enemy of good,” McWilliams said.
Take James Frank, 64, of Lancaster, Calif., who was uninsured several years ago when he first started experiencing the symptoms of heart disease.
“I couldn’t catch my breath, I was wheezing,” Frank recalled. “I felt like I had like a chest cold. My feet were tingling. I was getting the sweats.” In 2013, Frank had a heart attack and was taken to the emergency room.
He signed up for coverage under Covered California, the state’s health insurance exchange, which opened in 2013 for coverage that began in January 2014. His doctor put him on a statin and blood pressure medication to prevent another heart attack, and he started watching his weight religiously.
Frank was quick to add that the coverage he gained under the ACA has not been perfect — his premium and deductibles are high, and he thinks that Congress should repair it. Still, he believes the health law saved his life. “I had the same heart attack that killed my mother,” he said. “Had it not been for Obamacare, I probably would have had another one.”
Some experts say hyperbaric therapy’s increased use for diabetic wounds owes more to hospitals’ pursuit of Medicare revenue than to the treatment’s proven value. The American Diabetes Association does not recommend the treatment.
The Villages Regional Hospital did not sweat its decision to add hyperbaric oxygen therapy in 2013.
Hyperbaric treatment, increasingly given to diabetics — many of them elderly with persistent wounds — involves breathing pure oxygen inside a pressurized air chamber typically for two hours each weekday, often for more than a month. Twenty outpatient sessions can bring a hospital $9,000 in revenue.
Villages serves a central Florida retirement community that supplied nearly half of the hyperbaric patients at another hospital 30 minutes away. Hospital officials knew their clientele preferred their medical appointments only a golf-cart’s ride from home.
“Wound care was a service line we saw as low-hanging fruit,” said Todd Powell, who oversees hyperbaric therapy at Villages hospital.
Many hospitals seem to agree. Enticed by healthy Medicare payments — about $450 for a two-hour session — and for-profit management companies that do much of the work, nearly 1,300 U.S. hospitals have installed hyperbaric facilities. That’s triple the number that an industry group says offered the service in 2002, when Medicare first decided to pay for the therapy for certain diabetic wounds.
Medicare — the largest payer of hyperbaric services — has flagged evidence of overuse in at least some parts of the country. Medicare officials declined to comment for this story, but they have retained coverage for more than 15 years, even as studies have questioned the therapy’s effectiveness.
The American Diabetes Association does not recommend the treatment. After an ADA committee of experts in diabetes care reviewed the available research last year, it concluded there was “not enough supporting data on the efficacy of this treatment to recommend its use,” said William Cefalu, the association’s chief medical officer.
Some experts say hyperbaric therapy’s increased use for diabetic wounds owes more to hospitals’ pursuit of Medicare revenue than to the treatment’s proven value.
“The science remains poor to support its use, but it is being widely used [in the United States], and one possible explanation to this may be related to reimbursement,” explained Dr. Andrew Boulton, an internationally recognized expert on hyperbaric therapy, and a professor of medicine at University of Manchester medical school in Great Britain.
“Some folks are chasing the money. It’s seen as a money grab because reimbursement has been favorable,” acknowledged John Peters, executive director of the Undersea & Hyperbaric Medical Society, which accredits 200 hyperbaric oxygen facilities nationally and has inspected 500 for accreditation in the past 15 years.
Offered at a handful of hospitals in the last decades of the 20th century, hyperbaric chambers were a niche treatment for deep-sea divers suffering with the bends — a painful and potentially fatal condition where gas bubbles accumulate in the bloodstream during too-rapid ascents from depth. In 2002 — after industry lobbying and some suggestive research — Medicare approved hyperbaric therapy for certain diabetic wounds that did not respond to conventional treatments.
That decision drove a building boom in outpatient wound care centers over the next half-decade, featuring hyperbaric therapy. Medicare covers the treatment for more than a dozen conditions in which skin fails to heal, such as failing grafts and tissue damage from anti-cancer from radiation, but the USA’s rising diabetic population supplies much of the demand.
It costs about $500,000 to install a hyperbaric unit with two chambers. With Medicare’s lucrative reimbursement policies, “hospitals can generate cash almost immediately,” Peters said. During hyperbaric sessions, patients merely lie on a bed in a glass-enclosed tube containing high-pressure oxygen under a physician’s supervision.
The business model is so compelling that management companies typically pay for the equipment and staff. Hospitals provide space for the chamber, make patient referrals and handle billing. The companies and the hospitals split revenue from insurers.
Because of poor blood circulation, diabetics are susceptible to developing ulcers in their lower legs and feet that heal poorly and can sometimes lead to amputations. Hyperbaric oxygen therapy, in theory, works by stimulating the body’s creation of new blood vessels and aiding the formation of new skin around a wound. Side effects are uncommon but include ear and sinus pressure, paralysis and air embolisms.
In 2015, Medicare imposed stricter billing procedures in three states where its expenses for hyperbaric services were 21 percent above the national average — possible evidence of overuse or overbilling. Providers in Illinois, Michigan and New Jersey must get regulators’ preauthorization of expenses before treating Medicare patients for the most commonly approved conditions in non-emergency cases. Elsewhere, Medicare requires documentation supporting hyperbaric therapy’s need only after services begin.
Signs of abusive industry practices predate the 2015 action. A critical report by the Health and Human Services Department’s inspector general in 2000 disclosed that Medicare was billed millions of dollars for non-diabetic wound care treatments that were inappropriate or excessive. The office has promised a follow-up report before Oct. 1 — its first since 2000.
The Justice Department alleged fraud or other wrongdoing involving hyperbaric therapy in at least five cases from 2008 to 2014. It has won more than $11 million in penalties and restitution — along with some jail sentences — in court rulings and settlements.
(The FDA warned in 2013 about some treatment centers’ falsely promoting the therapy for unapproved uses, including as a cure for cancer, autism and diabetes.)
Medicare’s crackdown on billing in three states saved $5.3 million in its first 13 months, the government said in November. Medicare’s total spending on hyperbaric therapy — including all approved conditions — in 2015 fell about 10 percent to $230 million. That was the first annual decline in a decade.
Debates about the utility of the treatment continue despite decades of use.
In fact, few large, controlled studies have explored hyperbaric oxygen therapy for diabetic wounds — and nearly all were done outside the United States.
Some studies have found the treatment benefits certain patients while others have concluded it neither increases a wound’s chances of healing nor prevents amputations. The problem is knowing which wounds would have healed over time on their own.
Businesses and individuals invested in the facilities remain unalloyed boosters. The treatment “used to be considered voodoo medicine. But today more doctors have been swayed, and it’s now seen as mainstream therapy,” said Marc Kaiser, owner of Precision Health Care, which manages hyperbaric centers at five hospitals in New York and Connecticut.
Based on studies and anecdotal experience, Dr. Geoffrey Gurtner, a plastic surgeon who helped establish the Stanford University Wound Care Center in 2014, believes the therapy has some merit. But he said that research is needed to understand how the treatment works, which patients need it and the right number of sessions for each wound.
And, critics say, companies are profiting from and abusing the current state of uncertainty. Medicare pays for hyperbaric therapy for diabetic wounds that have not healed after 30 days of standard treatments. If hospitals provide more than 30 treatments, they must document that patients’ wounds are improving.
Twenty to 30 sessions of hyperbaric therapy should heal diabetic wounds, but radiation-damaged skin might require 40 treatments, said Dr. Phi-Nga Jeannie Le, a Houston physician.
“The problem is, we see these financially motivated centers keep doing the treatment into the hundreds of visits,” she said.
Also, Medicare pays nearly double the standard rate when the treatment is performed at hospital-affiliated facilities, which can add on a “facility fee.” Because of this quirk in the rules, hyperbaric management companies tend to court hospitals to install their devices.
April Hall underwent 50 sessions of hyperbaric oxygen therapy at MedStar Good Samaritan Hospital in Baltimore last summer.
April Hall receives hyperbaric oxygen therapy at MedStar Good Samaritan Hospital in Baltimore in 2016. (Phil Galewitz/Kaiser Health News)
Stretched out in one of the hospital’s four hyperbaric chambers, wrapped in blankets with her head propped up to watch television, Hall breathed pure oxygen for two hours at a time.
One wound on the bottom of her left foot healed. The other did not.
“I did what I had to do to save my foot,” said Hall, 50, who is on Medicare disability.
William Padgett Jr. of Culpeper, Va., received dozens of hyperbaric oxygen therapy sessions in 2013 and again in 2016 for diabetic wounds on his lower legs. Part of his right leg still had to be amputated, but the left one was saved. (Phil Galewitz/Kaiser Health News)
Sometimes even dozens of treatments do not avert amputations, as diabetic William Padgett Jr., 65, of Culpeper, Va., can attest. He lost his right leg in 2013 after nearly 90 hyperbaric sessions failed to heal a wound.
Last year, he tried hyperbaric oxygen again to close a wound on his left leg, taking about 80 sessions over four months at a hospital in Arlington, Va. The wound healed. “It’s been a slow process … but well worth the time,” he said.
In any one case, it is hard to say whether the treatment was key to success.
A 2014 federal whistleblower lawsuit against Healogics, which manages about half — 750 — of the nation’s hospital-owned wound-care and hyperbaric centers, raised other concerns. Two doctors and a third employee who worked for Healogics alleged a company conspiracy to defraud the federal government by billing it for unnecessary wound care and hyperbaric services.
Healogics denied the claims in its court-filed responses, and a judge dismissed the case for lack of detail. It is under appeal.
The lawsuit alleged Healogics “actively targeted each and every [wound care] patient for conversion” to hyperbaric therapy and set benchmarks for each center on the amount of hyperbaric care that would be provided.
According to Healogics, 5 percent of its 326,000 patients last year had hyperbaric treatment. Only 2 percent of those received more than 50 sessions.
The Better Care Reconciliation Act bill may make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.
Senate Majority Leader Mitch McConnell is well aware of the political peril of taking health benefits away from millions of voters. He also knows the danger of reneging on the pledge that helped make him the majority leader: to repeal Obamacare.
Caught between those competing realities, McConnell’s bill offers a solution: go ahead and repeal Obamacare, but hide the pain for as long as possible. Some of the messaging on the bill seems nonsensical (see: the contention that $772 billion squeezed out of Medicaid isn’t a cut). But McConnell’s timetable makes perfect sense — if you are looking at the electoral calendar.
Here are a few key dates in McConnell’s “Better Care Reconciliation Act” (BCRA) that seem aimed more at providing cover for lawmakers than coverage for Americans:
2019: First major changes and cuts to the Affordable Care Act exchanges happen after the 2018 midterm cycle, allowing congressional Republicans to campaign on a “fixed” health system, even though Obamacare is still largely in place next year.
2019: States share $2 billion in grants to apply for waivers under a much looser process through this fiscal year. These waivers could allow insurers to sell skimpy plans that have low price tags but don’t take adequate care of people with preexisting conditions. None of those waivers has to go into effect, however, until after 26 Republican governors face re-election in 2018.
2020: Stabilization cash that makes the markets more predictable and fair for insurers flows through the congressional midterm cycle and the 2020 presidential cycle. Then it disappears. Medicaid expansion funds hold steady through this crucial political window, too.
2024: States enjoy their last few sips of Medicaid expansion cash at the end of 2023 — just as, perhaps, a second Republican presidential term is ending.
2025: The bill changes the formula for the entire Medicaid budget (not just the Obamacare expansion), dramatically reducing federal funding over time. That starts eight years and two presidential election cycles from now.
McConnell insists everything about the bill has been aboveboard and transparent.
“Nobody’s hiding the ball here. You’re free to ask anybody anything,” McConnell said on June 13.
But he and his working group did literally hide the bill from Democrats and most Republicans, crafting it behind closed doors until there was just a week left before his goal to secure a vote on it. (That timing was thrown off Tuesday with the announcement the vote was delayed, but the dealmaking is just beginning.)
Meanwhile, at least two policy details in the bill may obscure the effects for several years and make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.
One is a stipulation that compels the federal government, for two years, to pay the cost-sharing reduction payments to insurance companies that President Donald Trump has threatened to end. The payments are part of the Affordable Care Act, and they flow to insurers on behalf of low-income marketplace customers to cover their out-of-pocket health expenses. Republicans had sued to stop the payments, adding considerable instability to ACA marketplaces next year. McConnell ends that uncertainty for two years.
On top of that cash infusion, the BCRA proposes a “Short-Term Stabilization Fund” that would also aim to help lower premium costs and could attract a few more insurers into counties that are sparsely covered now. It would dish out $50 billion to insurers — $15 billion per year in 2018 and 2019 and $10 billion per year in 2020 and 2021.
The money would make up for the billions that the Republican-led Congress has refused to appropriate for insurance companies under the ACA’s risk corridors program. Risk corridors aimed to offset losses for insurers whose costs were more than 103 percent of expected targets. Congress has so far paid only 12.6 cents on the dollar of those obligations and faces lawsuits from insurers that were stiffed.
In short, the two pots of money would go a long way toward addressing the instability in Obamacare created by the Republican-led Congress, but only through the next presidential cycle in 2020.
Beyond timing, the legislation’s features allow senators to make truthful arguments that disguise negative effects.
Perhaps the key claim is that the Senate bill would increase access to insurance. It might, in that insurance companies in states that waive standards would be free to offer much cheaper plans. But those plans would be cheaper because they wouldn’t cover essential health benefits or adequately cover preexisting conditions. Lower-income Americans might be able to buy a plan — possibly a $6,000 deductible for someone who makes less than $12,000 a year.
A spokesman for McConnell did not answer a request for comment. But Democrats are keenly aware of the electoral machinations in the bill.
“Everything about this legislation, from the process to the effective dates of many of the provisions, is driven by political expediency,” said Brian Fallon, a Democratic consultant and former lead spokesman for Hillary Clinton’s campaign. “Mitch McConnell only cares about getting the ‘win,’ not about the substance of the bill.”
Senate Democratic aides who spoke on background were not sure that the steps the bill takes to shore up markets for the next two elections would work when insurance companies can see what lies ahead. But they agreed the timing and short-term fixes might help McConnell twist the arms of reluctant Republican senators.
“I think it will be enormously helpful to McConnell in a room with a moderate Republican who wants to be told, ‘Hey, a lot of this stuff that’s going to happen in this bill that you’re hearing about, that’s worrisome is past your re-elect, it’s past 2018, it’s past 2020,’” one senior aide said. “‘Just vote for it, it’ll be fine, we’ll figure the rest out later.’”
Democrats said McConnell’s hide-the-ball strategy will not work with voters, and they want Republican senators to know that before they vote.
“The polling already shows that, based on the fact that they control every aspect of government, Trump and the Republicans own everything that happens from now on in the health care system,” Fallon said.
Sen. Patty Murray (D-Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee who has the task of leading the arguments against the GOP bill, thinks senators will imperil their political futures if they buy McConnell’s arguments.
“Sen. McConnell is doing everything he can to persuade Senate Republicans that Trumpcare won’t be devastating for the people they serve, but the facts are that Trumpcare is going to cause families to pay more, gut Medicaid, and take coverage away from millions of people,” Murray said. “Any Senate Republican who votes for Trumpcare and believes patients and families won’t hold them accountable is being sold a bill of goods.”
Still, McConnell knows how to work a legislative calendar. Expect a July full of closed-door dealmaking with reluctant senators, leading up to maximum leverage before the August recess.
Adults with a mental illness receive more than 50 percent of the 115 million opioid prescriptions in the United States annually, according to a study released Monday. The results prompted researchers to suggest that improving pain management for people with mental health problems “is critical to reduce national dependency on opioids.”
People with mental health disorders represent 16 percent of the U.S. population.
The findings are worrisome, the researchers reported. They had expected that physicians were more conservative in prescribing these painkillers to people with mental illness.
“We are prescribing way too much opioids,” said Dr. Brian Sites, an anesthesiologist at Dartmouth-Hitchcock Medical Center in New Hampshire and one of the study’s researchers. “And that prescription behavior is resulting in significant morbidity in the country.”
“Because patients with mental health disorders are a vulnerable population, [they’re] probably more likely to develop addiction and abuse,” he added. Sites suggested that physicians consider using different criteria when prescribing opioids for people with mental illness.
“The opioids are prescribed primarily for pain,” but patients with mental illness find that the drugs alleviate their mental issues too, said Dr. Edwin Salsitz, an attending physician in the Division of Chemical Dependency of Mount Sinai Beth Israel Medical Center in New York who was not involved in the study. And this, he said, is what can lead to long-term use.
The study, published in the Journal of the American Board of Family Medicine, found that nearly 19 percent of Americans with a mental health illness use prescription opioids, while the same is true for only 5 percent of those without a mental health condition.
According to the federal Centers for Disease Control and Prevention, the number of opioid sales in the U.S. quadrupled from 1999 to 2015, yet the amount of pain adults experience remained the same. In addition to that, more than 183,000 people died from overdoses related to prescription opioid use during this time.
With no objective scale for measuring pain, doctors are hampered in treating patients with chronic discomfort.
“Since [pain is] a subjective phenomenon, it’s very difficult to measure those things and to treat because some patients [report] 10-out-of-10 pain forever,” Sites said.
Dr. Andrew Saxon, director of the Addiction Psychiatry Residency Program at the University of Washington, said that “most people with chronic pain who end up on opioids do have a co-occurring psychiatric disorder.” Yet too often the drugs don’t provide lasting relief, he said.
“We have found that opioids for most of these people in the long term improve their subjective sense of pain for a little bit, but they don’t usually improve people’s level of function,” said Saxon, who was not involved in this study.
Many opioid patients, and especially those with mental health issues, should be offered an alternative treatment, Saxon said.
“It actually turns out … that the best treatment for chronic pain is going to be behavioral interventions, not medications,” he explained. That involves teaching people to understand the underlying cause of their pain and skills to better cope with it, the psychiatrist said.
Sites said alternatives to opioids could include cognitive behavioral therapy, acupuncture, meditation techniques and physical therapy.
“The idea is that we want to improve the health and well-being of the patient. And if that’s not occurring, we need alternatives to opioids,” Sites said.
Under the House bill, states that have caps on non-economic damage awards could keep those in place. In states without such caps, even if the state constitution prohibits them or state courts have struck them down, the federal $250,000 cap would apply.
Last week, a jury awarded a Pennsylvania man $620,000 for pain and suffering in a medical malpractice lawsuit he filed against a surgeon who mistakenly removed his healthy testicle, leaving the painful, atrophied one intact.
However, if a bill before the House of Representatives passes, the maximum he would be able to receive for such “non-economic” damages would be $250,000.
Non-economic damages cover losses that are hard to put a dollar amount on such as suffering, loss of a limb, pain, and loss of companionship. In addition, medical malpractice awards may include monetary damages to cover medical costs and loss of future wages. Sometimes punitive damages may be awarded as well as punishment for reckless or other harmful behavior.
The bill is part of a package of proposed reforms that supplement the American Health Care Act, the House measure to replace the Affordable Care Act that was narrowly approved in May. The Trump administration pledged to support the tort reform legislation.
Passage is far from certain. Groups across the political spectrum oppose the measure. Patients advocates say it would be unfair to seriously injured people whose lives are changed forever because of medical negligence. Many conservatives don’t embrace it either because it would impose federal standards on tort law, an area where states have traditionally determined the rules.
The Congressional Budget Office estimated that the bill would lower health care costs by reducing medical liability insurance premiums and the use of health care services by providers worried about being sued. This would lead to lower spending on federal health care programs and lower medical insurance liability premiums. The effect would be to reduce deficits by nearly $50 billion over 10 years.
Supporters say caps on medical malpractice awards discourage frivolous lawsuits and reduce the cost of health care because providers no longer need to practice defensive medicine.
Yet research shows that costs from medical liability make up just 2 to 2.5 percent of total health care spending.
About half of states have a cap of some sort on non-economic damages in medical malpractice cases, according to Joanne Doroshow, executive director of the Center for Justice and Democracy, a consumer advocacy organization for civil justice issues.
Under the House bill, states that have caps on non-economic damage awards could keep those in place. In states without such caps, even if the state constitution prohibits them or state courts have struck them down, the federal $250,000 cap would apply.
The case of the Pennsylvania man’s surgery is a “never event,” one that experts on patient safety say should never occur. Since that state doesn’t have a cap on non-economic damages, if the House bill had been in effect, it would limit the amount that the jury could award the patient to $250,000. The patient, Steven Hanes, 54, also was awarded $250,000 in punitive damages.
Hanes declined to be interviewed, but his attorney, Braden Lepisto, said his client was shocked to learn of the proposed cap. “He felt that the $250,000 cap was ridiculous because that amount would not compensate him for what he has gone through and will go through moving forward,” Lepisto said in an email. He added, “The reality is that there are many individuals who are injured from medical negligence who do not have ‘economic loss’ as defined by the law. Nonetheless, their lives are altered from the pain and suffering, loss of life’s pleasures, and the emotional effects of the injuries.”
The House bill would also come into play in Florida, where earlier this month the state Supreme Court struck down caps on non-economic damages in medical negligence cases because the court ruled they violate the equal protection clause of the state constitution. The House bill would supersede the state court decision and impose the cap in Florida cases.
Although the damages cap is noteworthy, other elements of the House bill also trouble consumer advocates. For example, it would establish a three-year statute of limitations following an injury for consumers to bring a lawsuit, or a one-year limit from the date that the consumer discovers or should have discovered an injury.
“Because it’s [worded as] whichever comes first, for all intents and purposes it’s one year,” said Doroshow. “That is a drastic change. Almost no state has a statute of limitations that severe.”
The bill would also set limits on the amounts that lawyers can recover in contingency fees from consumer judgments. This seemingly consumer-friendly provision could actually harm patients, said Doroshow.
Medical malpractice cases are complex and expensive to bring, she noted. “If you have a law that caps the ability of the attorney to recover from the judgment, they’ll think twice before taking a case,” Doroshow said. “It hurts the patient’s ability to have a competent attorney or any attorney at all.”
Meanwhile, some supporters of tort reform say the House bill goes about it the wrong way.
“The federal government doesn’t really have a legitimate role to play here,” said Dr. Jeffrey Singer, a general surgeon in Phoenix who is an adjunct scholar at the libertarian Cato Institute, located in Washington, D.C.
Conservatives might be relying too much on the idea of tort reform to bring down health care costs, he said.
“It’s become almost a part of the canon of people who align themselves with the market-oriented conservative reforms school,” he said. “But it should be done at the state level and we’re fooling ourselves if we think that it’ll be the magic bullet.”
State officials are hoping to win a 21-month extension of an agreement that began in 2011 and will expire in December. The Trump administration signed off on a similar pact with Florida in April.
Texas rejected billions in federal aid to expand Medicaid under the Affordable Care Act, calling the program “broken.” But now it’s asking the Trump administration to renew a deal that’s brought the state an additional $6.2 billion a year under Medicaid to help care for the poor.
Half the money is used to help hospitals finance care for the uninsured, and the rest goes to hospitals and other providers to test regional programs to improve care and access, such as opening school-based health clinics to steer people away from expensive emergency room visits.
State officials are hoping to win a 21-month extension of an agreement that began in 2011 and will expire in December.
The Trump administration signed off on a similar pact with Florida in April, increasing extra Medicaid funds to that state from $600 million a year to $1.5 billion annually. In December, the Obama administration extended a pact with Tennessee to 2021. It is worth at least $500 million a year to the state.
Several states receive such funds but Texas’ allocation is the highest. To put Texas’ request in perspective, $6.2 billion represents more than a third of what the federal government now contributes to the state’s Medicaid program annually. Texas kicks in the balance to pay for its $29 billion Medicaid program, which covers nearly 4.8 million people.
Hospitals are counting on the cash to absorb the costs of uncompensated care, which they say has escalated even as the state’s uninsured rate fell from 20 percent in 2013 to 16 percent in 2015, according to the Kaiser Family Foundation’s estimates. (Kaiser Health News is an editorially independent program of the foundation.)
Without the money, programs and services to the poor will have to be cut, including many new health clinics opened to expand access, hospitals say.
“Absent the dollars from the waiver, we would have to start to close the clinics and cut back on the manpower,” said George Masi, CEO of Harris Health System, a large public health system based in Houston.
The uninsured rate has fallen in Houston, but surrounding Harris County still has more than 1 million people without health insurance.
George Masi, CEO of Harris Health System in Houston, meets with staff at one of the system's health centers. (Courtesy of Harris Health System)
Between population growth and demand from undocumented immigrants, “there is growing need for more uncompensated care,” Masi said. Undocumented individuals are ineligible for Medicaid but cannot be refused emergency care.
When the Obama administration first approved Texas’ Medicaid waiver — and billions in extra Medicaid dollars to go with it — federal officials viewed the action as a glide path toward a formal Medicaid expansion starting in 2014, which the Affordable Care Act encouraged states to undertake. The law required the federal government to fully pay the extra costs of bringing more people onto Medicaid rolls for the first three years in every state that took the offer. Thirty-one states, plus the District of Columbia, did so.
Obamacare Medicaid funding would have added 1 million Texans to the program.
But after the U.S. Supreme Court made the Medicaid expansion optional for states, Texas lawmakers bristled at having anything to do with Obamacare or expanding government health coverage. That left the state’s hospitals in a tough financial spot since they lost some federal funding under the law without gaining patients covered by a Medicaid expansion. Texas hospitals are eager to keep the federal waiver in place as the turmoil in Congress over repealing and replacing Obamacare only increases their jitters.
Last year, the Obama administration was reluctant to promise to maintain extra funding levels to states that did not expand Medicaid and left their hospitals on the hook for treating uninsured people who would have been covered under the law. The Centers for Medicare & Medicaid Services told Texas to expect its Medicaid waiver funding to be cut by billions starting in 2018.
Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Texas, a left-leaning think tank, said Texans would be better served by expanding Medicaid but, since that isn’t politically possible, the waiver money is vital to help hospitals care for the uninsured. “The hospitals still have tons of uncompensated care and it will be painful for them without this money,” she said.
Texas set up 21 regional health programs to oversee hundreds of pilot programs paid for by the waiver money intended to improve care to the poor. The demonstration projects paid for by the waiver money probably could not continue without the federal funds, according to an evaluation report released last month by Texas Department of Health and Human Services. The report concluded some projects did help improve patient outcomes, but it’s too soon to determine if they can help lower hospitals’ costs of uncompensated care.
At Baylor Scott & White Health, based in Dallas with facilities in north and central Texas, the waiver money has provided more than $200 million in funding over the past five years for uncompensated care and another $132 million for health projects. “This money allows us to care for uninsured folks that otherwise might not get care,” said Bill Galinsky, vice president for government finance at the health system.
Baylor Scott & White has participated in 37 health projects funded by the waiver to develop ways to treat more than 100,000 low-income people. Other efforts included placing 10 social workers in primary care clinics to provide one-stop care for patients with mental health and physical health needs. The system has also worked with community agencies to increase providing healthy meals to families. “We are cautiously optimistic” that the waiver money will continue, Galinsky said.
Harris Health used part of its $350 million a year in Medicaid waiver dollars to open six primary care clinics with integrated mental health services. “Before the waiver, the primary care doctors could treat the backache or strep throat but would struggle to deal with the depression or bipolar,” Masi said.
Adding psychiatrists and psychologists to work alongside primary care doctors has helped reduce demand for inpatient mental health care, he said.
Without continued federal funding, most of the new positions would disappear, according to Masi.
Memorial Hermann, one of the state’s largest hospital systems, which is also in Houston, also allocated a portion of its waiver money — $150 million a year — to do more than care for the uninsured, said Dr. Benjamin Chu, the former CEO, who was interviewed before his resignation was announced June 19.
The hospital system opened crisis prevention units and school-based health clinics. Other funds paid for a team that manages mental health patients after discharge from hospitals, connecting them with follow-up services to reduce repeated visits to an emergency room.
Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.
Republicans in the U.S. Senate on Thursday unveiled a bill that would dramatically transform the nation’s Medicaid program, make significant changes to the federal health law’s tax credits that help lower-income people buy insurance and allow states to water down changes to some of the law’s coverage guarantees.
The bill also repeals the tax mechanism that funded the Affordable Care Act’s benefits, resulting in hundreds of billions of dollars in tax cuts for the wealthy and health care industry.
Most senators got their first look at the bill as it was released Thursday morning, and some immediately voiced concerns. It had been crafted in secret over the past several weeks. Senate Majority Leader Mitch McConnell (R-Ky.) is seeking a vote on the bill before Congress leaves next week for its Fourth of July recess.
Four conservative Republicans - a number large enough to stop the bill from passage - announced in the afternoon that they were withholding support. “Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor," said the statement from Sens. Rand Paul (R-Ky.), Ted Cruz (R-Texas), Ron Johnson (R-Wis.), and Mike Lee (R-Utah). "There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”
Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.
At lightning speed and with a little over a week for wider review, the Republicans' bill could influence health care and health insurance of every American. Reversing course on some of the more popular provisions of the Affordable Care Act, it threatens to leave tens of millions of lower-income Americans without insurance and those with chronic or expensive medical conditions once again financially vulnerable.
Like the House measure, the Senate bill, which is being called a “discussion draft,” would not completely repeal the ACA but would roll back many of the law’s key provisions. Both bills would also - for the first time - cap federal funding for the Medicaid program, which covers more than 70 million low-income Americans. Since its inception in 1965, the federal government has matched state spending for Medicaid. The new bill would shift much of that burden back to states.
The bill would also reconfigure how Americans with slightly higher incomes who don't qualify for Medicaid would get tax credits to help pay insurance premiums and eliminate penalties for those who fail to obtain insurance and employers who fail to provide it. It also would make it easier for states to waive consumer protections in the ACA that require insurance companies to charge the same premiums to sick and healthy people and to provide a specific set of benefits.
"We agreed on the need to free Americans from Obamacare's mandates, and policies contained in the discussion draft will repeal the individual mandate so Americans are no longer forced to buy insurance they don't need or can't afford; will repeal the employer mandate so Americans no longer see their hours and take-home pay cut by employers because of it," McConnell said on the floor of the Senate after releasing the bill. He also noted that the bill would help "stabilize the insurance markets that are collapsing under Obamacare as well."
As expected, Senate Minority Leader Chuck Schumer (D-N.Y.) assailed the bill, saying it would "strip away health care benefits and protections from Americans who need it most" through changes in Medicaid and the ACA's essential health benefits. "Even though much of the early reporting says the bill will keep certain protections for Americans with preexisting conditions," he added, "the truth is it may well not guarantee them the coverage they need. By allowing states to waive essential health benefits, what the bill is saying to those Americans is: Insurance still has to cover you, but it doesn't have to cover what you may actually need; it doesn't have to cover all or even most of your costs."
The White House had no immediate comment, but President Donald Trump has been pressuring Congress to pass a health bill quickly.
It is not clear that the bill will make it through the Senate, or that all of it will even make it to the Senate floor. The Senate (like the House) is operating under a special set of budget rules that allow it to pass this measure with only a simple majority vote and block Democrats from dragging out the debate by using a filibuster. But the “budget reconciliation” process comes with strict rules, including the requirement that every provision of the bill primarily impact the federal budget, either adding to or subtracting from federal spending.
For example, the legislation as released includes a one-year ban on Medicaid funding for Planned Parenthood. That is a key demand of anti-abortion groups and some congressional conservatives, because Planned Parenthood performs abortions with non-federal funding. But it is not yet clear that the Senate parliamentarian will allow that provision to be included in the bill.
Also still in question is a provision of the Senate bill that would allow states to waive insurance regulations in the Affordable Care Act. Many budget experts say that runs afoul of Senate budget rules because the federal funding impact is “merely incidental” to the policy.
Drafting the Senate bill has been a delicate dance for McConnell. With only 52 Republicans in the chamber and Democrats united in opposition to the unraveling of the health law, McConnell can afford to lose only two votes and still pass the bill with a tie-breaking vote from Vice President Mike Pence.
Sen. Tim Scott (R-S.C.) told reporters that he is "open to moving forward on the bill" but expects negotiations will result in more changes. "We have a lot of time now, seven days, to figure out what we like, what parts we plan to keep. This is only draft legislation."
McConnell has been leading a small working group of senators - all men - but even some of those have complained they were not able to take part in much of the shaping of the measure, which seems to have been largely written by McConnell’s own staff.
So far, McConnell has been fielding complaints from the more moderate and more conservative wings of his party. And the draft that has emerged appears to try to placate both.
For example, as sought by moderates, the bill would phase down the Medicaid expansion from 2020 to 2024, somewhat more slowly than the House bill does. But it would still end eventually. The Senate bill also departs from the House bill’s flat tax credits to help pay for insurance, which would have added thousands of dollars to the premiums of poorer and older people not yet eligible for Medicare.
A Congressional Budget Office report estimating the Senate bill’s impact on individuals and the federal budget is expected early next week. The House bill, according to the CBO, would result in 23 million fewer Americans having health insurance over 10 years.
For conservatives, however, the Senate bill would clamp down even harder on Medicaid in later years. The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s. That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs.
Defenders of the health law were quick to react.
Sen. Ron Wyden (D-Ore.) complained about changes to coverage guarantees in the ACA.
“I also want to make special note of the state waiver provision. Republicans have twisted and abused a part of the Affordable Care Act I wrote to promote state innovation, and they’re using it to give insurance companies the power to run roughshod over individuals,” he said in a statement issued shortly after the bill was released. “This amounts to hiding an attack on basic health care guarantees behind state waivers, and I will fight it at every turn.”
Tony Brooks, 42, of Philadelphia, was one of the about 60 people with disabilities who crowded the hallway around Senate Majority Leader Mitch McConnell’s office on Capitol Hill Thursday. Brooks said he wasn’t there to protest, he was there to ask for his rights and ask senators to keep Medicaid funding. (Rachel Bluth/KHN)
“The heartless Senate health care repeal bill makes health care worse for everyone - it raises costs, cuts coverage, weakens protections and cuts even more from Medicaid than the mean House bill,” said a statement from Protect Our Care, an umbrella advocacy group opposing GOP changes to the health law. “They wrote their plan in secret and are rushing forward with a vote next week because they know how much harm their bill does to millions of people.”
Tony Brooks, 42, from Philadelphia, was one was of the 60 or so people with disabilities who crowded the hallway around McConnell’s office to lobby the senators to not cut Medicaid funding. Without Medicaid, Brooks, who uses a wheelchair, said he wouldn’t be able to afford his medication, his rent and his medical care. Brooks got choked up when he talked about a friend who had to stay in a nursing home until his death because insurance wouldn’t cover the care he needed to go home. Without Medicaid, Brooks said he was afraid he would end up in a nursing home or shelter too.
“We are people with disabilities, we are human beings. Don’t look at us as garbage,” Brooks said.
Staff writers Rachel Bluth and Carmen Heredia Rodriguez contributed to this article.
“A lot of hospitals like [ours] could get hurt,” says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.
For the hundreds of rural U.S. hospitals struggling to stay in business, health policy decisions made in Washington, D.C., this summer could make survival a lot tougher.
Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding.
"A lot of hospitals like [ours] could get hurt," says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.
The GOP's repeal of the Affordable Care Act calls for deep cuts to Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities. The House version of the repeal law cuts Medicaid by $834 billion over 10 years, and the Senate revision of that bill cuts the program even more on a different timetable. The Congressional Budget Office has not yet scored the Senate version of the bill, but it said the House version would result in 23 million more people being uninsured in the next 10 years.
Loss of coverage is a problem for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for most health indicators, including premature deaths, quality of life and adult smoking rates. Closing the county's hospital could make those much worse.
And a rural hospital closure goes beyond people losing health care. Jobs, property values and even schools can suffer. Pemiscot County already has the state's highest unemployment rate. Losing the hospital would mean losing the county's largest employer.
"It would be devastating economically," Noble said. "Our annual payrolls are around $20 million a year."
All of that weighs on Noble's mind when he ponders the hospital's future. Pemiscot's story is a lesson in how decisions made by state and federal lawmakers have put these small hospitals on the edge of collapse.
Back in 2005, things were very different. The hospital was doing well, and Noble commissioned a $16 million plan to completely overhaul the facility, which was built in 1951.
"We were going to pay for the first phase of that in cash. We didn't even need to borrow any money for it," Noble said, while thumbing through the old blueprints in his office at the hospital.
But those renovations never happened. In 2005, the Missouri legislature passed sweeping cuts to Medicaid. More than 100,000 Missourians lost their health coverage, and this had an immediate impact on Pemiscot Memorial's bottom line. About 40 percent of their patients were enrolled in Medicaid at the time, and nearly half of them lost their insurance in the cuts.
Pemiscot Memorial had plans for expansion and improvements that the county hospital was ready to make — and pay for — in 2005, before the state legislature slashed Medicaid rolls. (Bram Sable-Smith/Side Effects Public Media)
Those now-uninsured patients still needed care, though, and as a public hospital, Pemiscot Memorial had to take them in.
"So we're still providing care, but we're no longer being compensated," Noble said.
And as the cost of treating the uninsured went up, the hospital's already slim margins shrunk, and it went into survival mode.
The Affordable Care Act was supposed to help with the problem of uncompensated care. It offered rural hospitals a potential lifeline by giving states the option to expand Medicaid to a larger segment of their populations. In Missouri, that would have covered about 300,000 people.
"It was the fundamental building block [of the ACA] that was supposed to cover low-income Americans," said Sidney Watson, a St. Louis University health law professor.
In Missouri, Kerry Noble and Pemiscot Memorial became the poster children for Medicaid expansion. In 2013, Noble went to the state Capitol to make the case for expansion on behalf of the hospital.
"Our facility will no longer be in existence if this expansion does not occur," Noble told a crowd at a press conference.
"Medicaid cuts are always hard to rural hospitals," Watson said. "People have less employer-sponsored coverage in rural areas and people are relying more on Medicaid and on Medicare."
But the Missouri legislature voted against expansion.
For now, the doors of Pemiscot Memorial are still open. The hospital has cut some costly programs — like obstetrics — outsourced its ambulance service and has skipped upgrades.
"People might look at us and say, ‘See, you didn't need Medicaid expansion. You're still there,'" Noble said. "But how long are we going to be here if we don't get some relief?"
This story is part of a partnership that includes KBIA, NPR and Kaiser Health News.
The Association of Health Care Journalists and The Commonwealth Fund are supporting a yearlong series of stories on rural health care by Side Effects Public Media and KBIA.
Built into the Senate ACA replacement bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.
Senate Republicans praised the Affordable Care Act replacement bill they presented Thursday as preserving coverage for people with cancer, mental illness and other chronic illness.
But the legislation may do no such thing, according to health law experts who have read it closely.
Built into the bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.
Depending on what states do, plans sold to individuals might exclude coverage for prescription drugs, mental health, addiction and other expensive benefits, lawyers said. Maternity coverage might also be dropped.
Somebody with cancer might be able to buy insurance but find it doesn’t cover expensive chemotherapy. A plan might pay for opioids to control pain but not recovery if a patient became addicted. People planning families might find it hard to get childbirth coverage.
“The protection your insurance provides could depend a lot on where you live,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. In some states, “over time, [patients with chronic illness] might find it increasingly difficult to find insurance companies that will offer plans that cover their needs.”
The Senate provisions aren’t expected to affect job-based health plans or Medicare for seniors. It would mainly affect the kind of insurance sold to individuals through the Affordable Care Act’s online exchanges, which cover about 10 million people.
Obamacare overhauls in both the House and Senate would also limit spending on Medicaid for low-income people, which analysts say would cause coverage losses for millions.
The Senate legislation, expected to be voted on next week, follows a widely criticized House bill that would also overhaul the Affordable Care Act, in its case giving states the option of denying coverage or raising premiums for those with preexisting illness.
On Thursday Republican Senators touted their bill as avoiding those features.
“I feel comfortable that no one is going to be denied coverage because they’ve been sick before,” said Sen. Lindsey Graham (R-S.C.) The bill “doesn’t change [protections for] preexisting illnesses, which is good,” he said.
Not explicitly. But it still gives insurers a potential way to shrink coverage for the chronically ill, albeit less obviously, said health law scholars.
“There’s nothing in the Senate bill that specifically would allow withdrawal of coverage for a person with a preexisting condition,” said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform. “What it does do is allow states to get waivers” allowing exceptions to rules requiring comprehensive coverage, he said.
The Affordable Care Act required carriers to offer “essential health benefits” covering a wide range of services including hospitalization, maternity, prescription drugs and mental health.
Both the Republican House bill and the Senate bill would let states change that rule. Under those measures, states could set their own standards that might not be as generous, allowing insurers to exclude benefits for those with preexisting illness.
Nurses are at the core of an anti-sepsis initiative at St. Joseph Hoag Health in California. From 2015 to 2016, the death rate for all of its hospitals dropped from 15 percent to 12 percent for severe sepsis/shock, and from 12 percent to 9 percent for all sepsis cases.
Dawn Nagel, a nurse at St. Joseph Hospital in Orange, Calif., knew she was going to have a busy day, with more than a dozen patients showing signs of sepsis. They included a 61-year-old mechanic with diabetes. An elderly man recovering from pneumonia. A new mom whose white blood cell count had shot up after she gave birth.
Nagel is among a new breed of nurses devoted to caring for patients with sepsis, a life-threatening condition that occurs when the body’s attempt to fight an infection causes widespread inflammation. She has a clear mission: identify and treat those patients quickly to minimize their chance of death. Nagel administers antibiotics, draws blood for testing, gives fluids and closely monitors her charges — all on a very tight timetable.
“We are the last line of defense,” Nagel said. “We’re here to save lives. If we are not closely monitoring them, they might get sicker and go into organ failure before you know it.”
Sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, a nationwide advocacy group based in San Diego. More than 1 million people get severe sepsis each year in the U.S, and up to 50 percent of them die from it. It is also one of the most expensive conditions for hospitals to treat, costing $24 billion annually.
Most hospitals in the U.S. have programs aimed at reducing sepsis, but few have designated sepsis nurses and coordinators like St. Joseph’s. That needs to change, said Tom Ahrens, who sits on the advisory board of Sepsis Alliance.
“From a clinical point of view, from a cost point of view, they make a huge impact,” said Ahrens, a research scientist at Barnes-Jewish Hospital in St. Louis.
A patient finds out she has sepsis at St. Joseph Hoag Health. Sepsis is a life-threatening condition caused by the body’s response to infection. (Heidi de Marco/KHN)
Recent federal rules could help foster such a change: The Centers for Medicare & Medicaid Services began requiring hospitals in 2015 to measure and report on their sepsis treatment efforts. They must make sure certain steps are completed within the first three hours after sepsis is identified, including getting blood cultures, giving intravenous fluids and starting patients on a broad-spectrum antibiotic.
Sepsis is difficult to diagnose, but if it’s caught early enough it can be treated effectively. If not, patients are at risk of septic shock, which can lead to organ failure and death.
St. Joseph Hoag Health, an integrated medical system in Orange County, Calif., that operates St. Joseph and six other hospitals, began employing dedicated sepsis nurses throughout the system in 2015. Hoag Hospital in Newport Beach and its namesake sister facility in Irvine were the first to try out the nurses about seven years ago, and four other hospitals have since followed.
The hospitals in the St. Joseph Hoag Health system treat about 8,000 cases of sepsis each year, at a cost of $130 million, according to Andre Vovan, a critical care physician who oversees St. Joseph Hoag’s anti-sepsis programs.
The health system also created sepsis care checklists and a mobile app to help coordinate care for patients at risk. But the nurses are at the core of the initiative. They know how to treat sepsis like “the back of their hands,” Vovan said. “Their familiarity allows them to do it faster.”
Speed is critical in sepsis: evidence shows that patients who get treatment quickly are more likely to survive.
Nagel has worked as a nurse at St. Joseph Hospital for 18 years and as part of the hospital’s sepsis unit since 2015. She tracks patients and starts antibiotics, takes labs, gives fluids and checks on patients, all on a strict timetable to reduce patients’ chances of going into septic shock. (Heidi de Marco/KHN)
“It’s so much easier to give someone salt water and antibiotics. It’s a lot harder when they are in the ICU and you are trying to get them off a ventilator,” said Cecille Lamorena, who is in charge of the sepsis nurses at St. Joseph Hospital.
Sepsis nurses give families an idea of what to expect — both during the patients’ hospital stay and after their discharge, Vovan said.
“We want the families to understand that just because you survive sepsis, it doesn’t mean you can get home and run a marathon,” Vovan said. “It can take weeks to months to recover.”
Sepsis nurses and coordinators also serve as on-site experts to ensure that required standards are followed by others, said Dr. David Carlbom, medical director at Harborview Medical Center in Seattle. The sepsis nurse coordinator there, Rosemary Mitchell Grant, educates staff and tracks data collected through the medical records. She also carries out projects to improve outcomes and helps organize an annual sepsis conference.
Nagel tracks patients’ progress, orders antibiotics and gives fluids to reduce patients’ chances of going into septic shock. (Heidi de Marco/KHN)
“Hospitals that don’t have a systematic approach could have a delay in recognition of sepsis,” Carlbom said, noting that busy acute care nurses might miss its subtle signs.
The St. Joseph Hoag Health effort seems to be working. From 2015 to 2016, the death rate for all of its hospitals dropped from 15 percent to 12 percent for severe sepsis/shock, and from 12 percent to 9 percent for all sepsis cases, Vovan said. The length of time patients stay in the health system’s hospitals is also dropping, he said. At St. Joseph Hospital in Orange, the number of patients who went into septic shock dropped 50 percent in the same two-year period, Lamorena said.
The sepsis program has support from doctors, including Dr. Matthew Mullarky, an emergency room physician at St. Joseph. He said he relies on the hospital’s sepsis nurses to help find and follow patients who are at risk. “With the knowledge they have, they ensure we are moving in the right direction quickly,” Mullarky said. “These patients are so overwhelmingly sick.”
At the hospitals in the St. Joseph Hoag network, there is always a dedicated sepsis nurse on duty. Dawn Nagel said that at St. Joseph Hospital, where she works, “sometimes I feel there should be three of us.”
Nagel weighs several factors as she tries to identify patients at risk. She scouts for signs they are worsening — a drop in blood pressure, confusion, increased heart rate, a high white-blood-cell count. And since sepsis is a response to infection, she wants to know if there is one. Pneumonia and urinary tract infections are the most common.
Nagel, who has worked as a nurse at St. Joseph for 18 years, seems to know everyone she passes in the halls. She spends the day bouncing between the emergency room, the maternity ward and the medical-surgical floor. She pitches in wherever needed, grabbing a pillow for one patient, starting an IV for another.
She carries a binder with tracking sheets for each patient. All potential sepsis patients are followed for at least 24 hours, during which they get visits from the sepsis nurse. Nagel’s phone rings constantly — nurses and doctors asking if she can check on patients. She also receives alerts on the in-house sepsis app embedded in her phone. When she meets with patients, she hands them a brochure on sepsis and explains more about it.
Nagel checks up on Scott Steffens. (Heidi de Marco/KHN)
One afternoon in May, Nagel checked up on Donald Hammock, 82. He already was being treated for sepsis with fluids and antibiotics, and Nagel wanted to ensure they were working. “I’m just another set of eyes to make sure you’re getting better, not worse,” she told him. “I’m like your infection babysitter.”
Hammock said he was glad for the extra attention. He had been treated for severe sepsis in 2011 after spiking a fever, and his blood pressure had dropped precipitously. At the time, Hammock said, he didn’t know anything about the illness. “I could have died right there.”
“I’m glad you got in here,” Nagel replied. “As you know, you can get really sick with sepsis.”
After a quick exam, Nagel told Hammock his vitals looked stable, he seemed alert, and his lungs sounded clear. “You are looking good to me,” she said.
She crossed him off her list and headed to the next room.