A colonoscopy might cost you or your insurer a few hundred dollars — or several thousand, depending on which hospital or insurer you use.
Long hidden, such price variations are supposed to be available in stark black and white under a Trump administration price transparency rule that took effect at the start of this year. It requires hospitals to post a range of actual prices — everything from the rates they offer cash-paying customers to costs negotiated with insurers.
Many have complied.
But some hospitals bury the data deep on their websites or have not included all the categories of prices required, according to industry analysts. A sizable minority of hospitals have not disclosed the information at all.
While imperfect and potentially of limited use right now to the average consumer, this trove is, nonetheless, eye-opening as an illustration of the huge differences in prices — nationally, regionally and within the same hospital. It's challenging for consumers and employers to use, giving a boost to a cottage industry that analyzes the data, which in turn could be weaponized for use in negotiations among hospitals, employers and insurers. Ultimately, the unanswered question is whether price transparency will lead to overall lower prices.
In theory, releasing prices may prompt consumers to shop around, weighing cost and quality. Perhaps they could save a few hundred dollars by getting their surgery or imaging test across town instead of at the nearby clinic or hospital. But, typically, consumers don't comparison-shop, preferring to choose convenience or the provider their doctor recommends. A recent Peterson-KFF Health System Tracker brief, for instance, found that 85% of adults said they had not researched online the price of a hospital treatment.
And hospitals say the transparency push alone won't help consumers much, because each patient is different — and individual deductibles and insurance plans complicate matters.
Under the Trump-era rule, hospitals must post what they accept from all insurers for thousands of line items, including each drug, procedure or treatment they provide. In addition, hospitals must present this in a format easily readable by computers and include a consumer-friendly separate listing of 300 "shoppable" services, bundling the full price a hospital accepts for a given treatment, such as having a baby or getting a hip replacement.
The negotiated rates now being posted publicly often show an individual hospital accepting a wide range of prices for the same service, depending on the insurer, often based on how much negotiating power each has in a market.
In some cases, the cash-only price is less than what insurers pay. And prices may vary widely within the same city or region.
In Virginia, for example, the average price of a diagnostic colonoscopy is $2,763, but the range across the state is from $208 to $10,563, according to a database aggregated by San Diego-based Turquoise Health, one of the new firms looking to market the data to businesses while offering some information free of charge to patients. Another is Health Cost Labs, which will have pricing information for 2,300 hospitals in its database when it goes live July 1.
Patients can try to find the price information themselves by searching hospital websites, but even locating the correct tab on a hospital's website is tricky.
Here's one tip: "You can Google the hospital name and the words 'price transparency' and see where that takes you," said Caitlin Sheetz, director and head of analytics at the consulting firm ADVI Health in the Washington, D.C., area.
Typing in "MedStar Health hospital transparency," for example, likely points to MedStar Washington Hospital Center's "price transparency disclosure" page, with a link to its full list of prices, as well as its separate list of 300 shoppable services.
By clicking on the list of shoppable services, consumers can download an Excel file. Searching it for "colonoscopy" pulls up several variations of the procedure, along with prices for different insurers, such as Aetna and Cigna, but a "not available" designation for the cash-only price. The file explains that MedStar does not have a standard cash price but makes determinations case by case.
Performing the same Google search for the nearby Inova health system results in less useful information.
Inova's website links to a long list of thousands of charges, which are not the discounts negotiated by insurers, and the list is not easily searchable. The website advises those who are not Inova patients or who would like to create their own estimate to log into the hospitals' "My Chart" system, but a search on that for "colonoscopy" failed to produce any data.
Because of the difficulty of navigating these websites — or locating the negotiated prices once there — some consumers may turn to sites like Turquoise. Doing a similar search on that site shows the prices of a colonoscopy at MedStar by insurer, but the process is still complicated. First, a consumer must select the "health system" button from the website's menu of options, click on "surgical procedures," then click again on "digestive" to get to it.
There is no similar information for Inova because the hospital system has not yet made its data accessible in a computer-friendly format, said Chris Severn, CEO of Turquoise.
Inova spokesperson Tracy Connell said in a written statement that the health system will create personalized estimates for patients and is "currently working to post information on negotiated prices and discounts on services."
For consumers who go the distance and can find price data from their hospitals, it may prove helpful in certain situations:
Patients who are paying cash or who have unmet deductibles may want to compare prices among hospitals to see if driving farther could save them money.
Uninsured patients could ask the hospital for the cash price or attempt to negotiate for the lowest amount the facility accepts from insurers.
Insured patients who get a bill for out-of-network care may find the information helpful because it could empower them to negotiate a discount off the hospitals' gross charges for that care.
While there's no guarantee of success, "if you are uninsured or out of network, you could point to some of those prices and say, 'That's what I want,'" said Barak Richman, a contract law expert and professor of law at Duke University School of Law.
But the data may not help insured patients who notice their prices are higher than those negotiated by other insurers.
In those cases, legal experts said, the insured patients are unlikely to get a bill changed because they have a contract with that insurer, which has negotiated the price with their contracted hospitals.
"Legally, a contract is a contract," said Mark Hall, a health law professor at Wake Forest University.
Richman agrees.
"You can't say, 'Well, you charged that person less,'" he noted, but neither can they say they'll charge you more.
Getting the data, however, relies on the hospital having posted it.
As for compliance, "we're seeing the range of the spectrum," said Jeffrey Leibach, a partner at the consulting firm Guidehouse, which found earlier this year that about 60% of 1,000 hospitals surveyed had posted at least some data, but 30% had reported nothing at all.
Many in the hospital industry have long fought transparency efforts, even filing a lawsuit seeking to block the new rule. The suit was dismissed by a federal judge last year.
They argue the rule is unclear and overly burdensome. Additionally, hospitals haven't wanted their prices exposed, knowing that competitors might then adjust theirs, or health plans could demand lower rates. Conversely, lower-cost hospitals might decide to raise prices to match competitors.
The rule stems from requirements in the Affordable Care Act. The Obama administration required hospitals to post their chargemaster rates, which are less useful because they are generally inflated, hospital-set amounts that are almost never what is actually paid.
Insurers and hospitals are also bracing for next year, when even more data is set to come online. Insurers will be required to post negotiated prices for medical care across a broader range of facilities, including clinics and doctors' offices.
In May, the Centers for Medicare & Medicaid Services sent letters to some of the hospitals that have not complied, giving them 90 days to do so or potentially face penalties, including a $300-a-day fine.
"A lot of members say until hospitals are fully compliant, our ability to use the data is limited," said Shawn Gremminger, director of health policy at the Purchaser Business Group on Health, a coalition of large employers.
His group and others have called for increasing the penalty for noncomplying hospitals from $300 a day to $300 a bed per day, so "the fine would be bigger as the hospital gets bigger," Gremminger said. "That's the kind of thing they take seriously."
Already, though, employers or insurers are eyeing the hospital data as leverage in negotiations, said Severn, Turquoise's CEO. Conversely, some employers may use it to fire their insurers if the rates they're paying are substantially more than those agreed to by other carriers.
"It will piss off anyone who is overpaying for healthcare, which happens for various reasons," he said.
Before the pandemic, 16-year-old Na'ryen Cayou had everything he needed. He had his own room. A partial scholarship to a boys' prep school. A spot playing trombone in the marching band, performing in parades all over New Orleans.
Then COVID-19 blew through the Big Easy like a hurricane, washing away nearly everything that helped him feel safe and secure. Schools shut down. His mom lost her job and couldn't make the rent. Their landlord evicted them.
Na'ryen and his mom now live with his grandmother. His mom sleeps on one couch; he sleeps on the other. He spent half the school year in virtual learning rather than in class with friends. Although he has struggled with math and chemistry, his mother, Nakia Lewis, said there's no money for a tutor.
"He went through a real deep depression," said Lewis, 45, a single mother with two older daughters living on their own. "This is nothing anyone could have prepared them for."Bottom of Form
As Americans crowd into restaurants, line up at movie theaters and pack their bags for summer travel, people are understandably eager to put the pandemic behind them. Yet kids like Na'ryen won't rebound quickly. Some won't recover at all.
"This could affect a whole generation for the rest of their lives," said Dr. Jack Shonkoff, a pediatrician and director of the Center for the Developing Child at Harvard University. "All kids will be affected. Some will get through this and be fine. They will learn from it and grow. But lots of kids are going to be in big trouble."
More than 5 million Americans lost a loved one to COVID, and the ripple effects could lead to serious illness down the road.
The pandemic will undermine Americans' health for years. Even those not infected by the coronavirus could suffer health problems related to poverty, job loss, eviction — or all of the above.
Many kids will go back to school this fall without having mastered the previous year's curriculum. Some kids have disappeared from school altogether, and educators worry that more students will drop out. Between school closures and reduced instructional time, the average U.S. child has lost the equivalent of five to nine months of learning during the pandemic, according to a report from McKinsey & Co.
Educational losses have been even greater for some minorities. Black and Hispanic students — whose parents are more likely to have lost jobs and whose schools were less likely to reopen for in-person instruction — missed six to 12 months of learning, according to the McKinsey report.
Missing educational opportunities doesn't just deprive kids of better careers; it can also cost them years of life. In study after study, researchers have found that people with less education die younger than those with more.
Schools across the country were closed for an average of 54 days in spring 2020, and many provided little to no virtual instruction, said Dr. Dimitri Christakis, director of the Center for Child Health, Behavior and Development at the Seattle Children's Research Institute. A study he co-authored found the learning that kids missed during that time could shorten an elementary school boy's life by eight months and a girl's by more than five months.
The total loss of life would be even larger when factoring in the loss of instructional time in the school year that just ended, Christakis said. "We've interrupted children's education, and it's going to have a significant impact on their health and longevity," he said. "The effects will linger a very long time."
Assaulted on All Sides
The double hit from the pandemic, which has impoverished millions of children and deprived them of classroom time, will be too much for some to overcome.
"Living in poverty, even as a child, has health consequences for decades to come," said Dr. Hilary Seligman, a professor at the University of California-San Francisco. "Children in poverty will have higher risk of obesity, cardiovascular disease and diabetes."
"Adversity literally shapes the developing brain," said Shonkoff, of Harvard. "It affects your memory, your ability to organize information, to control impulses."
Chronic stress in children can lead to persistent inflammation that damages the immune system, raises blood sugar and accelerates hardening of the arteries. The heart disease that kills someone in midlife can actually begin in childhood, Shonkoff said.
"What happens to children early on doesn't just affect early language and school readiness, but the early foundations of lifelong health," he said.
More Kids Going Hungry
The pandemic has deprived millions of children of school-related services that normally blunt the harm caused by poverty.
Children who experience even occasional "food insecurity" suffer two to four times as many health problems as other kids at the same income level, said Dr. Deborah Frank, director of the Grow Clinic for Children at Boston Medical Center.
Kids who don't consistently eat nutritious meals are more likely to develop anemia, more likely to be hospitalized and more susceptible to lead poisoning, Frank said. They also are more likely to behave aggressively and suffer from hyperactivity, depression and anxiety.
The consequences of food insecurity last well into adulthood, she said, increasing the risk of substance abuse, arrest and suicidal thoughts. "There's going to be educational and emotional fallout that won't disappear right away," Frank said. "These kids have endured a year and a half of deprivation. You can't sweep all that under the rug."
Kids at the Breaking Point
Young people are already showing signs of strain.
The proportion of emergency room visits related to mental health among kids 12 to 17 increased 31% from 2019 to 2020, according to the Centers for Disease Control and Prevention.
Although overall suicide deaths haven't increased during the pandemic, as many feared, teens are making more attempts. ERs treated 50% more adolescent girls and 4% more boys for suspected suicide attempts in February and March 2021 than in those months the year before.
Diagnoses of obsessive-compulsive disorder have soared 41% among girls 12 to 18, according to a June report from Epic Health Research Network. Diagnoses of eating disorders have jumped 38% among girls and 5% among boys.
Many children separated from their peers during the pandemic have been depressed and anxious, said Dr. Lisa Tuchman, chief of adolescent and young adult medicine at Children's National Medical Center in Washington, D.C.
"Mental illness thrives in isolation," Tuchman said. "The longer the behaviors and thoughts persist, the more entrenched they become and the harder they are to interrupt."
Falling Behind in School
The loss of educational opportunities has been far more extensive than many realize. Although the majority of students were back in classrooms by the end of the last school year, most spent a large part of the year in virtual learning.
And while some students thrive in virtual classes, studies generally find they provide an inferior education to in-person instruction, partly because students are less engaged. Just 60% of students consistently participated in distance learning, recent surveys found.
Test scores show students have fallen behind in math and reading. And those scores likely underestimate the damage, given that some of the most vulnerable kids weren't able to report to school for the exams.
An estimated 3 million marginalized students — including those who are homeless or in foster care — received no instruction during the past school year, either because they had no computer or internet access, had to leave school to work or faced other challenges, according to Bellwether Education Partners, a nonprofit that focuses on disadvantaged students.
Less-educated students can expect to earn less after they leave school.
Lost educational time will cost the average child $61,000 to $82,000 in lifetime earnings, McKinsey concluded. Lifetime earning losses are predicted to be twice as great for Black and Hispanic students as for whites.
"Many of the teens I see have given up on school and are working instead," said Dr. Sara Bode, a pediatrician at Nationwide Children's Hospital in Columbus, Ohio. "It's helping their families in the short term, but what does it mean for their future?"
Katrina left 80% of the city under water. Although New Orleans students missed an average of five weeks of learning, children wound up two years behind peers not affected by the hurricane, said Douglas Harris, professor and chair of economics at Tulane University.
Na'ryen Cayou was just 2 months old when Katrina submerged his house, leaving the family homeless. He contracted whooping cough in an emergency shelter, the first of four moves in eight months. His sister, O're'ion Lewis, then 4, didn't attend school at all that year. When she finally began prekindergarten at age 5, the other kids "were already ahead of her," mom Nakia Lewis said. For a time, teachers even mislabeled O're'ion as having dyslexia. It took five years — from prekindergarten until fourth grade — before she finally caught up with her peers, Lewis said.
It will be years before researchers know how far behind the pandemic will have left American kids.
After Katrina, 14% to 20% of students never returned to school, according to the McKinsey report. "As kids fall further behind, they feel hopeless; they don't engage," said Sarakatsannis, one of its authors.
Under normal circumstances, high school students who miss more than 10 days of school are 36% more likely to drop out. Based on the number of absences during the pandemic, dropout rates could increase by 2% to 9%, with up to 1.1 million kids quitting school, Sarakatsannis said.
Communities need to find ways to repair the damage children have suffered, said Dr. Gabrielle Shapiro, chair of the American Psychiatric Association's Council on Children, Adolescents and their Families. "How we behave as a society now will determine the depth of the impact on the younger generation."
Nakia Lewis is hoping for better days.
O're'ion is now 20 and studying nursing at community college. Although her classes were virtual last year, she expects to attend class in person in the fall.
Lewis recently landed a job as a manager at a Shoney's restaurant and is looking for an affordable home. She looks forward to reclaiming her furniture, which went into storage — at $375 a month — when she was evicted.
She said she's relieved that Na'ryen's mood has improved. He found a summer job working part time at a food market and will begin marching band practice this summer.
"He is happy and I'm happy for him," Lewis said. "Now I just have to worry about everything else."
Walden, Colorado has suffered the fate of many small towns across the United States, as the economics of the pharmacy business have made it difficult for community drugstores to survive.
This article was published on Thursday, July 1, 2021 in Kaiser Health News.
WALDEN, Colo. — The building that once housed the last drugstore in this town of fewer than 600 is now a barbecue restaurant, where pit boss Larry Holtman dishes out smoked brisket and pulled pork across the same counter where pharmacists dispensed vital medications more than 30 years ago.
It's an hourlong drive over treacherous mountain passes to Laramie, Wyoming, or Granby or Steamboat Springs, Colorado — and the nearest pharmacies. The routes out of the valley in which Walden lies are regularly closed by heavy winter snows, keeping residents in and medications out.
Walden has suffered the fate of many small towns across the United States, as the economics of the pharmacy business have made it difficult for community drugstores to survive. With large pharmacy chains buying up independent drugstores and increasingly controlling the supply chain, towns such as Walden have too few residents to attract a chain drugstore and no great appeal for pharmacists willing to strike out on their own.
With no local access to prescription drugs, the town of mainly cattle ranchers and hay farmers has crowdsourced a delivery system, taking advantage of anyone's trip to those bigger cities to pick up medications for the rest of the town.
"Really, it's a network of community and people reaching out and knowing that others have needs," said Tina Maddux, who runs a nonprofit that provides food and other assistance in Walden. "We're a community that pulls together for the wellness of everyone."
The system is just one of the creative ways that rural communities deal with a lack of healthcare. In Walden, the senior center runs a regular shuttle to the bigger locales so older residents don't have to drive to pick up groceries, visit doctors or refill their meds. In October, a pharmacy in Steamboat Springs began delivering medications to Walden once a week. Mail-order pharmacies can help with medications for chronic conditions, but not for acute needs.
Yet these solutions can't replace a bricks-and-mortar pharmacy, as pharmacists do much more than count pills. They can give flu or COVID shots and, in some states, such as Colorado, even prescribe contraceptives. Some run diabetes management or smoking cessation programs. Medications can be complicated, and without a live person to talk to, patients can struggle to take them correctly.
In Walden, locals are one snowstorm, one mishap, from being cut off from their meds.
That uncertainty leaves Whitney Milek with constant anxiety. Her younger son, 8-year-old Wade, relies on medications to control his seizures. She usually picks up his medicines in Laramie, where the family does its big grocery runs. But when she needs to refill in between trips, she turns to her neighbors for help.
The informal system runs primarily through a Facebook group created in 2013 as a sort of online garage sale. For years, people have been posting to ask if anybody is headed toward a pharmacy and can bring back a prescription. Neighbors deliver to neighbors, even during the pandemic, and no money is exchanged.
"There are times when nobody is going and you end up having to have them mailed, which is a whole other thing, especially with seizure meds," Milek said. "Some are controlled substances and they can't mail them."
Two winters ago, Milek called in one of her son's prescriptions to a Steamboat Springs pharmacy. But when she arrived, the medication was out of stock. With road conditions rapidly worsening, she asked if the pharmacy would mail the medication but was told she lived too close for mail delivery. She turned to a pharmacy in Laramie, which eventually agreed to mail it to her — but also didn't have it in stock.
"So, he ended up going five days without," Milek said. "It's not a big deal if you miss a dose here or there. But when you miss that many over a period of time, your tolerance level goes down."
That medication must be carefully managed to build up gradually in Wade's blood to avoid a severe allergic reaction. It took three weeks to scale up to his daily dose when he started taking the drug two years ago.
"When he went five days without it, he had to basically start all over again. It was over Christmas break, so he wasn't in school. I brought him to work with me because I didn't feel comfortable leaving him with anybody else," said Milek, a bookkeeper. "I didn't know what was going to happen."
Wade was fortunate to avoid complications that time. But having a local pharmacy mail medications comes with added costs — $26, in their case, for a prescription last month — an extra tax on those who cannot get to a pharmacy. Mail-order pharmacies typically don't charge for shipping yet can run into snags, too. Last year, some of Wade's mailed medications got stuck in a Denver processing facility for three weeks. The Mileks had to pay $1,600 out-of-pocket to get replacements.
Walden has no hospital, only a small clinic where Dr. Lynnette Telck and a nurse practitioner care for residents. The clinic stocks some basic medications to handle routine acute needs — antibiotics for strep throat, inhalers for asthma — and they can mix up liquid suspensions for those who can't swallow pills.
"It's a small town, so we all wear many hats," Telck said.
Studies show that, without a drugstore nearby, patients aren't as likely to keep up with their medications and their chronic conditions can worsen. Without readily available medications, Telck said, patients can end up taking an ambulance to an emergency room.
"It's just so darn expensive to the system," she said.
Walden touts itself as the moose-viewing capital of Colorado and is a recreation mecca for hunting, fishing and snowmobiling. But Telck said it could be hard to attract a pharmacist because the town lacks amenities like movie theaters and shopping malls.
"It's pristine and wonderful in its own quirky way and we love it," she said. "But not a lot of people want to come to rural areas. The wages aren't as high as in the big cities."
Middle Park Health, the Granby-based hospital system that operates the Walden clinic, had looked at putting a more complete pharmacy in the clinic but couldn't find a technician to staff it.
"The days of that being a profitable, desirable business? It's a lot tougher than it was a decade or two ago," said Gina Moore, an associate dean at the University of Colorado's School of Pharmacy. "You come out of eight years of college — four years of undergraduate and four years of pharmacy school — with pretty significant student loan debt. It's very hard to go to a rural community where you don't make any money."
In towns without an ER or a clinic open late, pharmacists often become the health provider of last resort. They tell patients whether they need to make the long trek to a hospital late at night or can wait until morning.
"A patient will often come to the pharmacy as the first point of access for healthcare," Moore said. "Our pharmacists are taught to understand and to be able to advise people on what can be self-treated with over-the-counter medications versus when you need to see a higher-level provider or an urgent care."
Researchers from the Rural Policy Research Institute at the University of Iowa have documented how the deck is increasingly stacked against community pharmacies.
"It's just not a really attractive business model anymore," said Keith Mueller, the institute's director.
In 2013, they found that new Medicare Part D drug plans resulted in low and late reimbursements, replacing direct out-of-pocket payments from customers. That left many pharmacies unable to turn a profit. By 2018, surveys showed pharmacies were struggling more with the narrowing margin between what they paid for the drugs and what they were being reimbursed by health plans.
Towns of more than 10,000 people are often served by at least a Walmart or a supermarket pharmacy, Mueller said.
"But you get out into smaller communities, the predominant modality had been the corner drugstore," he said. "We're not seeing that replacement of the closed independents by a CVS, Rite Aid or Walgreens."
The Mileks have talked about whether they should move near her family in Wyoming to be closer to a hospital and pharmacy.
"When you can't get to a pharmacy, it's scary, because things can happen so fast," Milek said. "People just have no concept of what it's like out here."
CASTINE, Maine — For years, Louise Shackett has had trouble walking or standing for long periods, making it difficult for her to clean her house in southeastern Maine or do laundry. Shackett, 80, no longer drives, which makes it hard to get to the grocery store or doctor.
Her low income, though, qualifies her for a state program that pays for a personal aide 10 hours a week to help with chores and errands.
"It helps to keep me independent," she said.
But the visits have been inconsistent because of the high turnover and shortage of aides, sometimes leaving her without assistance for months at a time, although a cousin does help look after her. "I should be getting the help that I need and am eligible for," said Shackett, who has not had an aide since late March.
The Maine home-based care program, which helps Shackett and more than 800 others in the state, has a waitlist 925 people long; those applicants sometimes lack help for months or years, according to officials in Maine, which has the country's oldest population. This leaves many people at an increased risk of falls or not getting medical care and other dangers.
The problem is simple: Here and in much of the rest of the country there are too few workers. Yet, the solution is anything but easy.
Katie Smith Sloan, CEO of Leading Age, which represents nonprofit aging services providers, says the workforce shortage is a nationwide dilemma. "Millions of older adults are unable to access the affordable care and services that they so desperately need," she said at a recent press event. State and federal reimbursement rates to elder care agencies are inadequate to cover the cost of quality care and services or to pay a living wage to caregivers, she added.
President Joe Biden allotted $400 billion in his infrastructure plan to expand home and community-based long-term care services to help people remain in their homes and out of nursing homes. Republicans pushed back, noting that elder care didn't fit the traditional definition of infrastructure, which generally refers to physical projects such as bridges, roads and such, and the bipartisan deal reached last week among centrist senators dealt only with those traditional projects. But Democrats say they will insist on funding some of Biden's "human infrastructure" programs in another bill.
As lawmakers tussle over the proposal, many elder care advocates worry that this $400 billion will be greatly reduced or eliminated.
But the need is undeniable, underlined by the math, especially in places like Maine, where 21% of residents are 65 and older.
Betsy Sawyer-Manter, CEO of SeniorsPlus in Maine, one of two companies that operate that assistance program, said, "We are looking all the time for workers because we have over 10,000 hours a week of personal care we can't find workers to cover."
For at least 20 years, national experts have warned about the dire consequences of a shortage of nursing assistants and home aides as tens of millions of baby boomers hit their senior years.
"Low wages and benefits, hard working conditions, heavy workloads, and a job that has been stigmatized by society make worker recruitment and retention difficult," concluded a 2001 report from the Urban Institute and Robert Wood Johnson Foundation.
Robyn Stone , a co-author of that report and senior vice president of Leading Age, says many of the worker shortage problems identified in 2001 have only worsened. The risks and obstacles that seniors faced during the pandemic highlighted some of these problems. "COVID uncovered the challenges of older adults and how vulnerable they were in this pandemic and the importance of front-line care professionals who are being paid low wages," she says.
Michael Stair, CEO of Care & Comfort, a Waterville, Maine-based agency, said the worker shortage is the worst he's seen in 20 years in the business.
"The bottom line is it all comes down to dollars — dollars for the home care benefit, dollars to pay people competitively," he said. Agencies like his are in a tough position competing for workers who can take other jobs that don't require a background check, special training or driving to people's homes in bad weather.
"Workers in Maine can get paid more to do other jobs that are less challenging and more appealing," he added.
His company, which provides services to 1,500 clients — most of whom are enrolled in Medicaid, the federal-state health program for people with low incomes — has about 300 staffers but could use 100 more. He said it's most difficult to find workers in urban areas such as Portland and Bangor, where there are more employment opportunities. Most of his jobs pay between $13 and $15 an hour, about what McDonald's restaurants in Maine advertise for entry-level workers.
The state's minimum wage is $12.15 an hour.
Stair said half his workers quit within the first year, a little better than the industry's average 60% turnover rate. To help retain employees, he allows them to set their own schedules, offers paid training and provides vacation pay.
"I worry there are folks going without care and folks whose conditions are declining because they are not getting the care they need," Stair said.
Medicare does not cover long-term home care.
Medicaid requires states to cover nursing home care for those who qualify, but it has limited entitlement for home-based services, and eligibility and benefits vary by state. Still, in the past decade, states including Maine have increased funding to groups providing Medicaid home and community services — anything from medical assistance to housekeeping help — because people prefer those services and they cost much less than a nursing home.
The states also are funding home care programs like Maine's for those same services for people who don't qualify for Medicaid in hopes of preventing seniors from needing Medicaid coverage later.
But elder care advocates say the demand for home care far outweighs supply.
Bills in the Maine legislature would increase reimbursement rates for thousands of home care workers to ensure they are being paid more than the state's minimum wage.
The state does not set worker pay, only reimbursement rates.
It's not just low pay and lack of benefits that hobbles the hiring of workers, according to experts who study the issue. In addition, home care providers struggle to recruit and retain workers who don't want the stress of caring for people with physical disabilities and, often, mental health issues, such as dementia and depression, said Sawyer-Manter of SeniorsPlus.
"It's backbreaking work," said Kathleen McAuliffe, a home care worker in Biddeford, Maine, who formerly worked as a Navy medic and served in the Peace Corps. She provides homemaker services for a state-funded program run by Catholic Charities. She usually visits two clients a day to help them with chores like cleaning and scrubbing floors, wiping down bathrooms, vacuuming, preparing meals, food shopping, organizing medicines and getting them to the doctor.
Her clients range in age from 45 to 85. "When I walk in, the laundry is piled up, the dishes are piled up, and everything needs to be put in order. It's hard work and very taxing," said McAuliffe, 68.
She makes about $14 an hour. Though the job of taking care of the frail elderly requires broad skills — and training in things like safe bathing — it is generally classified as "unskilled" labor. Working part time, she gets no vacation benefits. "Calling us homemakers sounds like we are coming in to bake brownies," she said.
The homemaker program serves 2,100 Maine residents and has more than 1,100 on a waitlist, according to Catholic Charities Maine. "We can't find the labor," said Donald Harden, a spokesperson for the organization.
The federal government is giving states more dollars for home care — at least temporarily.
The money, which must be spent by March 2024, can be used to provide personal protective equipment to home care workers, train workers or help states reduce waiting lists for people to receive services.
For Maine, the bump in funding from the American Rescue Plan will provide a $75 million increase in funding. But Paul Saucier, aging and disability director at the Maine Department of Health and Human Services, said the money will not make the waitlists disappear, because it will not solve the problem of too few workers.
Joanne Spetz, director of the Health Workforce Research Center on Long-Term Care at the University of California-San Francisco, said throwing more money into home care will work only if the money is targeted for recruiting, training and retaining workers, as well as providing benefits and opportunities for career growth. She doubts significant improvements will occur "if we just put money out there to hire more workers."
"The problem is the people who are in these jobs always get the same amount of pay and the same low level of respect no matter how many years they are in the job," Spetz said.
Under pressure to rein in skyrocketing prescription drug costs, states are targeting companies that serve as conduits for drug manufacturers, health insurers and pharmacies.
More than 100 separate bills regulating those companies, known as pharmacy benefit managers, have been introduced in 42 states this year, according to the National Academy for State Health Policy, which crafts model legislation on the topic. The flood of bills comes after a U.S. Supreme Court ruling late last year backed Arkansas' right to enforce rules on the companies. At least 12 of the states have adopted new oversight laws. But it's not yet clear how much money consumers will save immediately, if at all.
The companies are powerful, together administering medication plans for more than 266 million Americans. A handful of the companies, CVS Caremark, Express Scripts and OptumRX, control the vast majority of the market while also operating national pharmacy chains. PBMs say they use all that power to negotiate lower prescription prices. But the inner workings of the deals — and how much of the savings the companies pocket — happen largely behind a curtain that lawmakers are trying to pull back.
Montana is one testing ground for whether more transparency leads to lower drug prices with a new law that places those businesses under state oversight. The legislature unanimously passed a measure in April that, beginning next year, requires pharmacy benefit managers to get a state license and publicly report how much money they receive. It also dictates what information PBMs must provide to other companies amid negotiations.
"This was kind of the low-hanging fruit in terms of something where we thought we could get some meaningful policy out there," said Troy Downing, Montana's Republican commissioner of securities and insurance. "At least turn the light on in that black box."
New York lawmakers also passed legislation requiring PBMs to get a state license and submit an annual report that details the financial benefits they collect. Some efforts go broader, such as one in Wisconsin that brought PBMs under state oversight and required pharmacies to tell customers about less expensive generic prescription options.
PBMs pit drug manufacturers against one another to get lower drug prices on behalf of clients such as health insurers or large employers offering prescription drug benefits. They influence what prescription plans cover, and they help set pharmacy reimbursement rates for medications bought under PBM-managed plans. They can make money by pocketing some of the cash saved in negotiations and through the rebates that drug manufacturers offer for a sought-after spot on the list of prescriptions covered by health plans.
PBMs are accustomed to negative attention, though they often counter it's pointed in the wrong direction.
"The main focus for state policymakers should be to examine brand drug manufacturers' pricing strategies," emailed Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, a national trade group. "Drug manufacturers are solely responsible for setting and raising drug prices."
One in 10 U.S. adults ration prescriptions they can't afford, according to the National Center for Health Statistics. And as prices climb, every industry touchpoint for pharmaceutical drugs — manufacturers, distributors, insurers and more — blames the others. Policymakers have said each plays a role, though PBMs have become easy targets for politicians across political parties.
While PBM regulation is often pitched as a way to lower drug costs, patients shouldn't expect lower prices at pharmacy counters immediately, said Elizabeth Seeley, an expert in healthcare payment systems at the Harvard T.H. Chan School of Public Health.
"There's really not a clear answer on what types of policies will necessarily bring down spending," Seeley said. "Because you have to also ask the question of 'spending for who?'"
The changes could mean savings for patients or savings for just another part of the health industry, such as insurers. Seeley said she welcomes the recent spate of legislation to get more transparency into the system. But to get more affordable prescriptions on a wide scale, she said, lawmakers need a broad set of policies that sweep in players such as drug manufacturers. That would most likely have to happen on a national level.
Last year, bills died in Congress that sought to penalize drugmakers for raising prices above inflation rates and to cap some Medicare enrollees' out-of-pocket costs. Drug-pricing proposals are back on the table this year, with some zeroing in on specific industry players — including pharmacy benefit managers.
Montana's Democratic senator, Jon Tester, recently introduced bipartisan legislation that aims to prevent pharmacy benefit managers from extracting fees from pharmacies after they're already reimbursed. He has proposed similar efforts before. Tester said local rules help, but national policy forces the companies to play by the same rules in every state.
"This isn't going to solve the problem of high prescription drug prices, but it will help," Tester said.
Independent pharmacies are often in the background, lauding such efforts to regulate PBMs.
"They're squeezing us out of the market," said Josh Morris, who owns several rural Montana pharmacies.
Morris said that, when it came time to sign a new PBM contract last year to stay in an insurers' preferred network, reimbursement rates were too low to cover the pharmacies' costs to supply the prescriptions. So, he rejected the offer from the company, which he declined to name out of concern it would hurt their future interactions. As a result, Morris said, many of his customers' prescription copays rose, but they have few other pharmacies nearby. His patients in West Yellowstone, for example, faced a 90-mile trek to Bozeman as the next-closest option for more affordable medicine.
"How is that better for patients?" Morris said. "Pharmacies are stuck in the middle with no power; we're told, 'Here are the rates — either sign it or don't sign it.'"
While Morris hopes to see more rules like Tester's legislation become reality, for now he thinks Montana's new law could help. The rules call for PBMs to have adequate networks, which Morris said he hopes will help remote pharmacies like his.
David Root — vice president of government affairs for Prime Therapeutics, one of Montana's larger PBMs, which represents more than 30 million people nationwide — said the increased legislative scrutiny is a classic case of shooting the messenger.
"In some cases, we're the deliverer of bad news," he said.
Root said some of the changes taking place in Montana and elsewhere aren't an issue, such as being licensed through the state and establishing rules on what PBMs communicate to insurers. But he said bills like Montana's go wrong by making numbers public, potentially stripping some of the companies' power to negotiate among other players, which he said could result in higher drug prices.
Downing, the Montana insurance commissioner, said the state rules aren't saying PBMs must drastically change how they operate — they just have to show some of their work along the way.
"Best-case scenario is, through this transparency and through this regulatory authority, we start to see market forces improving consumer costs," Downing said. "Worst-case scenario is, in two years, we know what we don't know now, and we can make better decisions on how to better attack this problem."
The Newsom administration is hampered by an outreach campaign that relies too heavily on advertising firms and companies such as Blue Shield of California.
This article was published on Tuesday, June 29, 2021 in Kaiser Health News.
SACRAMENTO — Gov. Gavin Newsom routinely boasts that California has "one of the highest vaccination rates in the United States of America."
But Newsom, facing a recall election this fall, rarely mentions that the state's COVID vaccine uptake has largely stagnated in Black and Latino neighborhoods hardest hit by the coronavirus, and in rural outposts where opposition to vaccines runs rampant. In these communities, deep distrust of government and the U.S. healthcare system has collided with the state's high-stakes effort to finish vaccinating its 34 million vaccine-eligible residents.
These are places where state health officials believe they can change a significant number of minds. But the Newsom administration is struggling to do so, public health experts say, hampered by its inconsistent and hastily developed public messaging and outreach campaign that relies too heavily on private advertising firms and companies such as Google and Blue Shield of California.
"Many people don't trust information being put out about vaccines because it's coming from private companies that have profit-seeking motives," said Dr. Tony Iton, a senior vice president at the California Endowment, which focuses on expanding healthcare access for Californians. Iton served as Alameda County's public health officer from 2003 to 2009.
What actually works, Iton and other public health experts say, are well-funded, locally designed operations led by organizations that have built trust with residents and are capable of going door to door to dispel vaccine mythology, such as local nonprofits, county health departments and community clinics.Bottom of Form
But California's 61 local public health departments have been stunted by years of declining revenue, budget cuts and staff reductions that have stymied their ability to conduct the expensive and time-consuming public health outreach campaigns necessary to combat vaccine skepticism and hesitancy.
"When something like COVID-19 comes along, local knowledge is absolutely invaluable in reaching every pocket of that community, particularly in building trust in vulnerable populations," Iton said. "The state doesn't have that, Google doesn't have that, and certainly Blue Shield doesn't have that."
Even the Newsom administration's internal polling shows its efforts are faltering.
"The resounding barrier to vaccination," state officials wrote in the latest survey published in June, "has been confusion as a result of inconsistent, contradictory or insufficient messaging from government and public health officials."
Statewide, nearly 60% of Californians are fully vaccinated, but progress is uneven. Just 39% of eligible Black residents and 40% of Latinos had been vaccinated as of Friday, and local public health officials are intensely worried about regions like the Central Valley, where vaccination rates have stalled, especially given the threat of COVID's dangerous delta variant. Similar disparities exist by geography, across regions and even among neighborhoods.
The state's vaccine holdouts make up a cohort that cuts across political and geographic ideologies and is dominated by Latinos, African Americans, rural residents and young people. Unlike outright vaccine "rejecters," who lean Republican, undecideds align with Democrats, according to state polling.
State officials are trying to change the minds of both "undecideds" and "rejecters," and are relying primarily on vaccine lotteries with giveaways totaling $116.5 million or vacation packages, and glitzy advertising campaigns featuring paid social media influencers. The state has awarded two $40 million contracts to high-dollar ad agencies for vaccine outreach and education.
Companies including Facebook, Google, Comcast and TikTok are providing free advertising on social media, radio and TV, and making charitable contributions to help the state fund its public education campaigns, state records show.
Lackluster vaccination uptake drove the Newsom administration to pursue the more personal approach that public health experts favor, but the still-nascent campaign leaves out large swaths of the state. The administration launched its "Get Out the Vax" campaign in April, enlisting 70 community-based organizations and 2,000 community canvassers, now focused on Los Angeles and Central Valley neighborhoods where vaccinations have plateaued or declined.
But county public health officials say the campaign isn't big enough to combat the vaccine misinformation that has infiltrated regions such as California's rural north.
"It's terrible," said Placer County's health officer, Dr. Rob Oldham, who said misinformation is driving vaccines down. "Unfortunately, the lottery didn't really help us. We're working so much harder to get a dozen people vaccinated, whereas before we were doing close to 1,500 shots a day."
State Health and Human Services Secretary Mark Ghaly acknowledged that the state must boost its presence on the ground and said it "needs to do better and more." At the same time, he and other state officials argue that the vaccine lottery is working and that they are seeing progress in hard-hit neighborhoods.
This month the state debuted pop-up vaccine clinics at McDonald's restaurants in 11 counties, and state-funded outreach workers have fanned out in neighborhoods such as South Los Angeles to sign people up for appointments or vaccinate takers from a roving van. Vaccine canvassers report that the people who don't want the vaccines say they're concerned about safety or repeat sometimes outrageous rumors, such as the false assertion that vaccines turn people into zombies.
"We're seeing lots of disinformation and lack of a sense of urgency," said Yolanda Richardson, secretary of the California Government Operations Agency and Newsom's "vaccination czar." "The work that we have left to do is really finding out what each individual person needs to make that jump."
Carnella Marks of Oroville, in Butte County, offers a telling case of how hard public health officials must work to cut through the thick swamp of misinformation and confusion.
Marks, 51, who is Black, has deep misgivings about the safety of the vaccines that are rooted in the country's racist history and her personal experience: When she was pregnant with her second child, her doctor suggested she get a hysterectomy even though she wasn't ready to stop having kids and had no health complications. She wonders if the U.S. government is experimenting on Black people, as it did on African American men in the Tuskegee syphilis study from the 1930s into the 1970s.
"Why do they want us to take the vaccine so bad?" Marks asked. "We've never been first in line for anything, but now all of a sudden you want to make sure that the African American community gets the vaccine?"
She had considered getting vaccinated because she thought it might be required for work — until government officials paused the single-dose Johnson & Johnson shot over concerns it caused blood clots.
"I don't care what kind of money the governor is shelling out to get me to take the vaccine," said Marks, who wants to discuss the safety of the vaccines with someone who knows. But "nobody's knocking on my door to talk to me or answer my questions."
Public health experts say it could be possible to change the minds of people like Marks with targeted and relentless outreach by trusted members of the community who acknowledge their fears and mistrust of the medical system. A knock on the door or phone call from an epidemiologist who can explain the science behind vaccinations couldn't hurt, they added.
"So many of these people really aren't vaccine hesitant; they're just trying to figure out the facts for themselves and get their questions answered," said Oldham of Placer County.
But the county can't afford its own campaign, so Oldham said it "Placerizes" state material, adapting messaging for its residents.
"What we've seen from the state, frankly, is a lack of investment and interest in public health," he said. "I think it builds trust when you have the resources to call people back and tailor a message, but honestly we don't really have that capacity."
Some counties have committed scarce funds to develop ads targeting populations among whom distrust runs rampant, an effort they say has helped boost vaccination rates. Santa Clara County, for instance, has plowed at least $8.6 million into an outreach campaign and public service announcements related to COVID since March 2020, including Spanish-language ads targeting the county's large Latino population.
Health officer Dr. Sara Cody said the county has also enlisted the help of local health clinics, nonprofit groups and county employees of various ethnicities to develop messages that might persuade people to get vaccinated.
"We are extraordinarily fortunate," Cody said. "That investment turned out to be one of the most useful. People do have fears, and we want to hear them."
About 73% of the county's population is fully vaccinated, while other counties with fewer public health resources, like Placer, have struggled to mount effective campaigns. There, about 48% of residents are fully vaccinated.
Vaccine canvassers say they are making progress by using personal stories and discussing the science behind the vaccines.
Ricardo Márquez, a state-funded vaccine outreach worker in South Los Angeles, said he has changed minds.
"Sometimes facts and science work, but sometimes people who don't believe change their minds when I tell them people are dying, like my sweet grandma," Márquez said.
Early in this century, post-SARS, and in a period when China started allowing more students and scientists to study abroad, collaboration and exchange between American and Chinese scientists blossomed.
Many of China's top scientists today were educated in the West. These include George Gao, the head of China's Center for Disease Control and Prevention, who trained and taught at Oxford and Harvard, and Shi Zhengli, who directs the Center for Emerging Infectious Diseases at the Wuhan Institute of Virology and received her Ph.D. in France.
Many, like Gao, spent more than a decade abroad before returning to China for top jobs and, often, prestigious positions and big salaries. They were great at their bench work, their science was well respected, and top American scientists got to know them well. They became friends with their American counterparts, as is clear from Anthony Fauci's email correspondence with Gao as the pandemic emerged, recently released through a Freedom of Information Act request.
But early on in what became a global crisis, when limited and reassuring information was coming out of China about the transmissibility of the novel coronavirus and the extent of its domestic outbreak, misplaced trust among America's top scientists led some to think the spread of the virus probably wouldn't be so bad.
Here's the problem: Chinese scientists are great scientists, but they work for an authoritarian government where politics, not facts, always comes first. If information they know or discover makes China look bad, it is dangerous to say it — especially to foreign colleagues, especially publicly, and, often, even to their friends or family.
That may sound familiar after the presidency of Donald Trump, during which he often mocked and sidelined experts like Fauci. But the risk for scientists in China is far worse: loss of your job and your kids' career prospects, visits by the police, false accusations, even prison.
As the country's leader, Xi Jinping, reminded his scientists in a speech last year: "Science has no borders, but scientists have a motherland."
Every Chinese citizen knows how to interpret that statement, and I learned, too: When I was a reporter in Beijing, I got to know Dr. Gao Yaojie, who exposed an epidemic of HIV/AIDS in rural China that had resulted from unsanitary blood collection practices, some state-run.
She was a valued source for a series of articles I wrote on the unfolding tragedy, in which nearly the entire adult population of poor farming villages was dying, without any treatment and leaving AIDS orphans behind. Dr. Gao (no relation to George Gao) was feted by Bill and Hillary Clinton and won international human rights awards for saving perhaps tens of thousands of lives and ending dangerous practices. But in China, that very same work meant Gao spent her retirement under house arrest, often followed and threatened by local officials for embarrassing China. She fled China in 2009 and obtained political asylum in the U.S. And that was at a time when China was less autocratic and more open than it is today.
President Joe Biden had instructed security agencies to investigate the lab leak theory — to figure out whether SARS-CoV-2, the virus that causes COVID-19, emerged from the Wuhan lab or from nature. But if international scientific sleuths are hoping to see a lab log or find a whistleblower, that very likely won't happen. That kind of information won't be revealed, even to Chinese scientists' many American friends and scientific partners, which include the U.S. The Wuhan lab has received more than half a million dollars of funding that originated from the National Institutes of Health and has worked with many American scientists.
Mistakes happen in science. Pathogens leak out of good containment labs, and not because people are evil. It's because, for example, the technician performing the bench work forgets an important step or, in a rush to go home, gets sloppy — it takes only a second. Or, for example, if scientists gathering bat samples in remote caves get a bit too comfortable in a dangerous environment — because they've been there dozens of times before with no problem and the biohazard suits and masks are suffocating. So, they pull off the face mask a bit too early as they exit.
When that happens, you have to acknowledge the error right away to contain the damage. But Chinese scientists can't do that, at least publicly. When, in late December 2019, Dr. Li Wenliang, an ophthalmologist working at one of Wuhan's major hospitals, raised his concerns to colleagues about patients dying from a strange new virus, he was punished and told by police to "stop making false comments" and investigated for "spreading rumours." He died of COVID just a few weeks later.
In China today, it is dangerous to say what you know if it challenges the official government narrative. People who participated in the protests on June 4, 1989, in Tiananmen Square, which were violently put down by the Chinese army, don't even tell their children about that bloody day when many hundreds, and possibly thousands, were killed.
Kai Strittmatter, a longtime China correspondent for one of Germany's largest newspapers, told NPR's Terry Gross: "Of course, this generation, they all know, but they were afraid to tell their children. Because, you know, what do you do when your child in school suddenly tells the teacher and asks the teacher about Tiananmen massacre?"
We may never know if the novel coronavirus leaked from a lab or from animal-to-human transmission from a wild animal at one of Wuhan's live animal markets, as the Chinese first suggested. And that's exactly the knowledge we desperately need to prevent the next pandemic, because the solutions are so different.
If the former hypothesis proved true, U.S. scientists would need to ensure that collaborations with their Chinese partners involve full transparency — access to log books, internal reports, and all. If the latter, China must fully enforce its ban on the sale of exotic animals (the "intermediate hosts" that carry the virus) at its wet markets, a ban it promised after the original SARS virus emerged there from a civet cat nearly two decades ago. But the Chinese government's control over its scientists makes it unlikely we will learn the truth now — or ever.
As hospitals disaggregate charges for services, there has been a proliferation of newfangled fees to increase billing. In the field, this is called "unbundling."
This article was published on Monday, June 28, 2021 in Kaiser Health News.
Claire Lang-Ree was in a lab coat taking a college chemistry class remotely in the kitchen of her Colorado Springs, Colorado, home when a profound pain twisted into her lower abdomen. She called her mom, Jen Lang-Ree, a nurse practitioner who worried it was appendicitis and found a nearby hospital in the family's health insurance network.
After a long wait in the emergency room of Penrose Hospital, Claire received morphine and an anti-nausea medication delivered through an IV. She also underwent a CT scan of the abdomen and a series of tests.
Hospital staffers ruled out appendicitis and surmised Claire was suffering from a ruptured ovarian cyst, which can be a harmless part of the menstrual cycle but can also be problematic and painful. After a few days — and a chemistry exam taken through gritted teeth — the pain went away.
Then the bill came.
Patient: Claire Lang-Ree, a 21-year-old Stanford University student who was living in Colorado for a few months while taking classes remotely. She's insured by Anthem Blue Cross through her mom's work as a pediatric nurse practitioner in Northern California.
Total Bill: $18,735.93, including two $722.50 fees for a nurse to "push" drugs into her IV, a process that takes seconds. Anthem's negotiated charges were $6,999 for the total treatment. Anthem paid $5,578.30, and the Lang-Rees owed $1,270 to the hospital, plus additional bills for radiologists and other care. (Claire also anted up a $150 copay at the ER.)
Service Provider: Penrose Hospital in Colorado Springs, part of the regional healthcare network Centura Health.
What Gives: As hospitals disaggregate charges for services once included in an ER visit, a hospitalization or a surgical procedure, there has been a proliferation of newfangled fees to increase billing. In the field, this is called "unbundling." It's analogous to the airlines now charging extra for each checked bag or for an exit row seat. Over time, in the health industry, this has led to separate fees for ever-smaller components of care. A charge to put medicine into a patient's IV line — a "push fee" — is one of them.
Though the biggest charge on Claire's bill, $9,885.73, was for a CT scan, in many ways Claire and her mom found the push fees most galling. (Note to readers: Scans often are significantly more expensive when ordered in an ER than in other settings.)
"That was so ridiculous," said Claire, who added she had previously taken the anti-nausea drug they gave her; it's available in tablet form for the price of a soda, no IV necessary. "It works really well. Why wasn't that an option?"
In Colorado, the average charge for the code corresponding to Claire's first IV push has nearly tripled since 2014, and the dollars hospitals actually get for it has doubled. In Colorado Springs specifically, the cost for IV pushes rose even more sharply than it did statewide.
A typical nurse in Colorado Springs makes about $35 an hour. At that rate, it would take nearly 21 hours to earn the amount of money Penrose charged for a push of plunger that likely took seconds or at most minutes.
The hospital's charge for just one "IV push" was more than Claire's portion of the monthly rent in the home she shared with roommates. In the end, Anthem did not pay the push fees in its negotiated payment. But claims data shows that in 2020 Penrose typically received upward of $1,000 for the first IV push. And patients who didn't have an insurer to dismiss such charges would be stuck with them. Colorado hospitals on average received $723 for the same code, according to the claims database.
"It's insane the variation that we see in prices, and there's no rhyme or reason," said Cari Frank with the Center for Improving Value in Healthcare, a Colorado nonprofit that runs a statewide healthcare claims database. "It's just that they've been able to negotiate those prices with the insurance company and the insurance company has decided to pay it."
Penrose initially charged more money for Claire's visit than the typical Colorado hospital would have charged for live birth, according to data published by the Colorado Division of Insurance.
Even with the negotiated rate, "it was only $1,000 less than an average payment for having a baby," Frank said.
In an emailed statement, Centura said it had "conducted a thorough review and determined all charges were accurate" and went on to explain that "an Emergency Room (ER) must be prepared for anything and everything that comes through the doors," requiring highly trained staff, plus equipment and supplies. "All of this adds up to large operating costs and can translate into patient responsibility."
Do you have an exorbitant or baffling medical bill? Join the KHN and NPR 'Bill of the Month' Club and tell us about your experience. We'll feature a new one each month.
As researchers have found, little stands in the way of hospitals charging through the roof, especially in a place like an emergency room, where a patient has no choice. A report from National Nurses United found that hospital markups have more than doubled since 1999, according to data from the United States Bureau of Labor Statistics. In an email, Anthem called the trend of increasing hospital prices "alarming" and "unsustainable."
But Ge Bai, an associate professor of accounting and health policy at Johns Hopkins University, said that when patients see big bills it isn't only the hospital's doing — a lot depends on the insurer, too. For one, the negotiated price depends on the negotiating power of the payer, in this case, Anthem.
"Most insurance companies don't have comparable negotiating or bargaining power with the hospital," said Bai. Prices in a state like Michigan, where Bai said the autoworkers union covers a big portion of patients, will look very different from those in Colorado.
Also, insurers are not the wallet defenders patients might assume them to be.
"In many cases, insurance companies don't negotiate as aggressively as they can, because they earn profit from the percentage of the claims," she said. The more expensive the actual payment is, the more money they get to extract.
Though Anthem negotiated away the push fees, it paid the hospital 30% more than the average Level IV emergency department visit in Colorado that year, and it paid quadruple what Medicare would allow for her CT scan.
Resolution: Claire and her mom decided to fight the bill, writing letters to the hospital and searching for information on what the procedures should have cost. The prices of the IV pushes and the CT scan infuriated them — the hospital wanted more than double what top-rated hospitals typically charged in 2019.
But the threat of collections wore them out and ultimately they paid their assigned share of the bill, $1,420.45, which was mostly coinsurance.
"Eventually it got to the point where I was like, 'I don't really want to go to collections, because this might ruin my credit score,'" said Claire, who didn't want to graduate from college with dinged credit.
Bai and Frank said Maryland can be a useful benchmark for medical bills, since the state sets the prices that hospitals can charge for each procedure. Data provided by the Maryland Healthcare Commission shows that Anthem and Claire paid seven times what she likely would have paid for the CT scan there, and nearly 10 times what they likely would have paid for the Level IV ER visit. In Maryland, IV pushes typically cost about $200 apiece in 2019. A typical Maryland hospital would have received only about $1,350 from a visit like Claire's, and the Lang-Rees would have been on the hook for about $270.
Claire's pain has come back a few times but never as bad as that night in Colorado. After visiting multiple specialists back home in California, she learned it might have been a condition called ovarian torsion. Claire has avoided reentering an emergency room.
The Takeaway: Even at an in-network facility and with good insurance, patients can get hurt financially by visiting the ER. A few helpful documents can help guide the way to fighting such charges. The first is an itemized bill.
"I just think it's wrong in the U.S. to charge so much," said Jen Lang-Ree. "It's just a little side passion of mine to look at those and make sure I'm not being scammed."
Bai, of Johns Hopkins, suggests asking for an itemized explanation of benefits from the insurance company, too. That will show what the hospital actually received for each procedure.
Vincent Plymell with the Colorado Division of Insurance encourages patients to reach out if something looks sketchy. "Even if it's not a plan we regulate," he wrote in an email, such departments "can always arm the consumer with info."
Finally, make it fun. Claire and Jen made bill-fighting their mother-daughter hobby for the winter. They recommend pretzel chips and cocktails to boost the mood.
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
The week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for COVID-19. What he thought at first was a head cold had morphed into shortness of breath and chest congestion coupled with profound fatigue and loss of balance.
Now, seven months have passed and Colvin, 44, is still waiting to feel well enough for surgery. His surgeon is concerned about risking anesthesia with his ongoing respiratory problems, while Colvin worries he'll lose his balance and fall on his shoulder before it heals.
"When I last spoke with the surgeon, he said to let him know when I'm ready," Colvin said. "But with all the symptoms, I've never felt ready for surgery."
As the number of people who have had COVID grows, medical experts are trying to determine when it's safe for them to have elective surgery. In addition to concerns about respiratory complications from anesthesia, COVID may affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent study compared the mortality rate in the 30 days following surgery in patients who had a COVID infection and in those who did not. It found that waiting to undergo surgery for at least seven weeks after a COVID infection reduced the risk of death to that of people who hadn't been infected in the first place. Patients with lingering COVID symptoms should wait even longer, the study suggested.
But, as Colvin's experience illustrates, such guideposts may be of limited use with a virus whose effect on individual patients is so unpredictable.
"We know that COVID has lingering effects even in people who had relatively mild disease," said Dr. Don Goldmann, a professor at Harvard Medical School who is a senior fellow and chief scientific officer emeritus at the Institute for Healthcare Improvement. "We don't know why that is. But it's reasonable to assume, when we decide how long we should wait before performing elective surgery, that someone's respiratory or other systems may still be affected."
The study, published in the journal Anaesthesia in March, examined the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October. Researchers found that patients who had surgery within two weeks of their COVID diagnosis had a 4.1% adjusted mortality rate at 30 days; the rate decreased to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery occurred at least seven weeks after their COVID diagnosis had a mortality rate of 1.5% 30 days after surgery, the same as for patients who were never diagnosed with the virus.
Even after seven weeks, however, patients who still had COVID symptoms were more than twice as likely to die after surgery than people whose symptoms had resolved or who never had symptoms.
Some experts said seven weeks is too arbitrary a threshold for scheduling surgery for patients who have had COVID. In addition to patients' recovery status from the virus, the calculus will be different for an older patient with chronic conditions who needs major heart surgery, for example, than for a generally healthy person in their 20s who needs a straightforward hernia repair.
"COVID is just one of the things to be taken into account," said Dr. Kenneth Sharp, a member of the Board of Regents of the American College of Surgeons and vice chair of the Department of Surgery at Vanderbilt University Medical Center.
In December, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation issued these guidelines for timing surgery for former COVID patients:
• Four weeks if a patient was asymptomatic or had mild, non-respiratory symptoms.
• Six weeks for a symptomatic patient who wasn't hospitalized.
• Eight to 10 weeks for a symptomatic patient who has diabetes, is immunocompromised or was hospitalized.
• Twelve weeks for a patient who spent time in an intensive care unit.
Those guidelines are not definitive, according to the groups. The operation to be performed, patients' medical conditions and the risk of delaying surgery should all be factored in.
"Long COVID" patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require a more thorough evaluation before surgery, said Dr. Beverly Philip, president of the society.
Now that COVID has been brought to heel in many areas and vaccines are widely available, hospital operating rooms are bustling again.
"In talking to surgical colleagues, hospitals are really busy now," said Dr. Avital O'Glasser, medical director of the outpatient preoperative clinic at Oregon Health and Sciences University in Portland. "I've seen patients with delayed knee replacements, bariatric surgery, more advanced cancer."
At the beginning of the pandemic, surgical volumes dropped dramatically as many hospitals canceled nonessential procedures and patients avoided facilities packed with COVID patients.
From March to June 2020, the number of inpatient and outpatient surgeries at U.S. hospitals was 30% lower than in the same period the year before, according to McKinsey & Company's quarterly Health System Volumes Survey. By May 2021, surgical volumes had mostly rebounded, and were just 2% lower than their May 2019 totals, according to the May survey.
Oregon Health and Sciences University clinicians developed a protocol a year ago for clearing any patient who had COVID for elective surgery. When obtaining patients' medical history and conducting physical exams, clinicians look for signs of COVID complications that aren't readily identifiable and determine whether patients have returned to their pre-COVID level of health.
The pre-op exam also includes lab and other tests that evaluate cardiopulmonary function, coagulation status, inflammation markers and nutrition, all of which can be disrupted by COVID.
If the assessment raises no red flags, patients can be cleared for surgery once they have waited the minimum seven weeks since their COVID diagnosis.
Originally, the minimum wait for surgery was four weeks, but clinicians pushed it back to seven after the international study was published, O'Glasser said.
"We are still learning about COVID, and uncertainty in medicine is one of the biggest challenges we face," said O'Glasser. "Right now, our team is erring on the side of caution."
At Memorial Sloan Kettering Cancer Center in New York, doctors don't follow a specific protocol. "We're taking every patient one at a time. There are no hard-and-fast rules at this institution," said Dr. Jeffrey Drebin, chair of surgery.
Clinicians work to find a balance between the urgency of the cancer surgery and the need to allow enough time to ensure COVID recovery, he said.
For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and may worsen the tear. But the rest of his life is on hold, too. A sales representative for an auto parts company, he hasn't been able to work since he got sick. His balance problems make him reluctant to stray far from his home in Crest Hill, Illinois, the Chicago suburb where he lives with his wife and 15-year-old son.
Some days he has more energy and isn't as short of breath as others. Colvin hopes it's a sign he's slowly improving. But at this point, it's hard to be optimistic about the virus.
SACRAMENTO, Calif. — The board that licenses and disciplines doctors in California is failing to hold bad actors accountable, endangering patients in the process.
That's the verdict of state lawmakers and patient advocates who have been working for years to reform the Medical Board of California.
But an attempt this year to give the board more money and power to investigate complaints of fraud, gross negligence, sexual misconduct and other misbehavior is under attack from one of the most politically potent forces in California's Capitol: doctors themselves.
And so far, it seems, the doctors are winning.
The California Medical Association (CMA), whose top lobbyist sat next to Gov. Gavin Newsom at the infamous French Laundry dinner last fall, swooped in to slash a proposed hike on physicians' licensing fees even though the board, which relies on those fees, is teetering on insolvency. It also beat back a proposal to put more non-physician members of the public on the board, which would have diminished the influence of the doctors who represent a majority.
"The strength and the power of the CMA is that they are able to deflect and obstruct the beneficial and necessary legislation to protect the consumer and to ensure the success of the medical board," said former state Sen. Jerry Hill, who four years ago lost his push to overhaul the board. "That's what I found, and that's what I see occurring this year."
This year's bill was approved by the state Senate after it was amended under pressure from the doctors' group. The measure is now before the state Assembly, where it remains a target of the California Medical Association. As currently written, SB 806 would authorize a smaller licensing fee increase, restore the board's authority to recoup investigative costs from doctors who have been disciplined and create an independent monitor to evaluate the board's complaint and disciplinary processes.
The mission of the medical board, composed of eight physicians and seven members of the public, is to license and discipline doctors. But critics say the board has allowed some doctors who have committed wrongdoing to keep their licenses, despite reports of egregious behavior, while families complain they've been left in the dark for years.
The board received 10,868 complaints in the 2019-20 fiscal year. During that period, it initiated 1,956 investigations, revoked 35 physician licenses, put 170 doctors on probation and reprimanded 108 doctors, according to the board's 2019-2020 Annual Report. An additional 96 physicians surrendered their licenses.
In his independent review of cases that came before the panel last year, board member Eserick "TJ" Watkins told lawmakers the board had settled 84% of complaints, with a bias toward allowing doctors to continue to practice without real rehabilitation.
"This board's value is we protect the doctors, and we'll go over and above in order to do so," said Watkins, one of the board's members representing the public.
Earlier this year, the board's executive director told lawmakers the board is taking longer to investigate complex cases than it did six years ago, in part because of more complaints and vacancies among the board's support staff. In fiscal year 2019-20, those cases took an average of 548 days from start to end, he said, compared with 310 in fiscal year 2013-14.
Patients and their families who have testified at legislative hearings describe an unresponsive and uncommunicative board that usually allows doctors accused of negligence or malpractice to continue to practice.
"I thought there would be a lot of integrity and thoroughness to the investigation process, and I didn't get a sense that the medical board really looked at the matter," said Alka Airy, who in 2019 filed a complaint of unprofessional conduct and potential negligence against the University of California-San Francisco's Lung Transplant Program after her sister, Shilpa Airy, died the year before.
According to the complaint, doctors who treated Shilpa Airy between 2015 and 2018 failed to evaluate how her lung failure affected her heart or refer her to a cardiologist. She died of end-stage heart failure while waiting for a lung transplant. Airy said the board closed the complaint without taking action. The board declined to comment.
By comparison, when Alka Airy filed a complaint with the California Board of Registered Nursing, she said, she was interviewed by an investigator who requested additional records beyond what the doctors or hospital may have provided. Airy said she is still waiting to learn the outcome of the case.
A UCSF spokesperson said its clinicians have fully cooperated with all investigators and could not comment on pending investigations.
"I think my experience was very similar to thousands of other folks who sent in complaints to the medical board," Airy said. "It's not a transparent process. So much happens behind closed doors."
Board spokesperson Carlos Villatoro said the board bases its disciplinary decisions "on the facts and circumstances of each case" to determine whether revoking a physician's license is necessary.
"The board does not have the authority to punish a licensee by imposing a level of discipline that goes beyond what is necessary to protect the public," Villatoro said via email.
Advocates for patients and even some board members believe that tipping the board's balance of power to public members could regain some of the public's trust. But that provision was removed from this year's bill after the California Medical Association argued the panel — like other comparable state boards — needed the expertise of people in the profession it regulates.
Dr. Howard Krauss, himself a former trustee of the CMA, has been on the board for eight years. In that time, he said, he's never witnessed a decision that pitted physicians on the board against public members.
"The optics of having a board with one more public member than a physician might be of benefit," Krauss said at an emergency hearing this month.
Critics say the board also lacks the resources and the ability to pursue timely investigations, hamstrung by a legislature beholden to the CMA, whose 50,000 pediatricians, surgeons and other physicians are influential members of every lawmaker's district.
The California Medical Association is one of the most prolific campaign contributors in Sacramento and has given to Newsom and all but one of the 119 lawmakers currently serving in the state legislature.
In addition to making campaign contributions directly to lawmakers, the association spent $18.6 million between Jan. 1, 2011, and March 30, 2021, lobbying lawmakers and state agencies on a variety of issues, from flavored tobacco to medical malpractice caps, according to records filed with the California secretary of state's office. It employs its own lobbyists and hires outside lobbying firms.
The group routinely scores access to the state's top leaders. Among the movers and shakers at the French Laundry dinner party in Napa Valley in November were the association's top lobbyist, Janus Norman, and CEO, Dustin Corcoran.
CMA spokesperson Anthony York said the organization is "like any other group in the Capitol" that advocates for its members. He said the $367 increase in licensing fees that lawmakers initially proposed — from $783 to $1,150 — would have been too big a burden on doctors who fought to stay open during the pandemic.
Family medicine physicians in California earned an average annual wage of $220,240 as of the first quarter of this year, according to the state Employment Development Department. "A lot of physician practices are struggling to keep their doors open," York said. "Now is not the time for a fee increase."
After state Sen. Richard Roth (D-Riverside) introduced the legislature's must-pass bill to reauthorize the medical board in May, the CMA issued an "action alert" to its members, urging doctors to call, text and email their senators to voice their opposition. Eight days later, it declared a partial victory when Roth amended his bill to lower the fee increase to $863 and eliminate a requirement that the board be controlled by public members, a provision that had been backed by Senate leader Toni Atkins.
"While the bill is not perfect," the association wrote on its website, the removal of those provisions "was a major victory."
Despite repeated requests from the medical board, lawmakers haven't approved a licensing fee increase in 16 years, even though the fees are the board's primary source of income. The CMA agreed to the last fee increase in 2005 as part of a deal that also took away the board's ability to recover legal and investigative costs for cases in which doctors had been disciplined.
York said the association remains opposed to the provision that would restore the board's ability to recoup investigative costs and has concerns about the role of the independent monitor.
In its report to the legislature, the medical board projected it would be insolvent by the end of 2021-22 without an increase in licensing fees.
Doctors "just don't want to pay for it," said Bridget Gramme, an attorney at the Center for Public Interest Law at the University of San Diego School of Law. "What is the money going for? It's going for a stronger discipline system, which they don't want."
Roth, who chairs the Senate Business, Professions and Economic Development Committee, said the CMA's influence wasn't the reason he amended the bill to reduce the fee increase. Rather, he said the board hadn't justified the large fee increase — even though he included it in the original version of the bill — and could make do with a modest fee increase combined with better money management.
"Everybody had an opportunity to voice their perspective," Roth said, pointing out that the bill still includes provisions that doctors oppose. "The goal is to make sure that we have a medical board that is functioning effectively and efficiently, that the enforcement process does the right thing at the right time for the right reasons, and that we squeeze every bit of operational efficiency that we can afford."
As he watches from afar, Hill, the former legislator, said he doesn't think the California Medical Association will give up until it kills every provision it opposes.
"This whole thing is part of CMA's playbook. It's how they operate," Hill said. "They hire just about every available lobbyist in Sacramento to remove the rest of what was in the bill."