KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Supreme Court Declines To Hear Military Medical Malpractice Case

KFF Health News, May 21, 2019

Justices won’t alter the rule that prevents active-duty military members from suing the government for negligence. The challenge came from the family of Navy nurse Lt. Rebekah 'Moani' Daniel, who died in 2014 after bleeding to death following childbirth.

This article was published May 20, 2019, by Kaiser Health News.

By JoNel Aleccia, Kaiser Health News

The family of a young Navy nurse who died after military doctors allegedly failed to halt massive bleeding following childbirth won't get a hearing in the nation's highest court.

The Supreme Court on Monday denied a petition that sought to change what's known as the Feres doctrine, a long-standing rule that bars active-duty military members from suing the federal government for injuries, including medical malpractice.

The justices declined to discuss the case of Navy Lt. Rebekah "Moani" Daniel, who was 33 in 2014 when she died following a massive postpartum hemorrhage at the Naval Hospital Bremerton, within hours of the birth of her daughter, Victoria.

In court documents, Justice Ruth Bader Ginsburg said she would have granted the petition. Justice Clarence Thomas dissented from the decision, arguing that it was up to the court to reconsider the rule in the absence of a decision by Congress. He noted that the court in recent rulings "twisted traditional tort principles" to allow certain veterans to seek damages for negligence.

"Such unfortunate repercussions—denial of relief to military personnel and distortions of other areas of law to compensate—will continue to ripple through our jurisprudence as long as the Court refuses to reconsider Feres," he wrote.

Through a lawyer, the nurse's widower, Walter Daniel, and her daughter, Victoria, now 4, argued that the court should amend the 1950 ruling to allow service members to sue for medical malpractice the same way civilians can.

"Sadly, the justice system remains closed to our family, our colleagues and the families who commit their lives to military service," Daniel, 39, said in a statement Monday. "Victoria and I won’t have the opportunity to learn what led to Moani's death, and to ensure others don't experience the same tragedy."

Andrew Hoyal, Daniel's lawyer, said he was "clearly disappointed" at the decision but heartened at the responses from Thomas and Ginsburg.

"We knew from the beginning that this would be a long journey with even longer odds," he said.

Rebekah Daniel died on March 9, 2014, at the Washington state facility. In a 2015 wrongful death lawsuit, her husband claimed that she died from botched medical care that failed to halt hemorrhaging of nearly a third of the blood in her body.

Daniel, a former Coast Guard officer, disputed the findings of a Navy autopsy that concluded Rebekah Daniel died of "natural" causes possibly linked to a rare, hard-to-prove complication of childbirth.

But that lawsuit and subsequent appeals were dismissed not based on the facts of the case but because of the Feres doctrine, which holds that active-duty members of the military can't sue under the Federal Tort Claims Act for harm that they incur "incident to service."

The ruling was last challenged in the high court more than 30 years ago when the justices voted 5-4 to uphold it. That decision drew a scathing dissent from Justice Antonin Scalia, who declared the rule should be scrapped. More recently, Justice Thomas also argued it should be amended.

Since then, however, the court has refused to accept two previous petitions that would have allowed reconsideration. The Daniel request beat the odds. Of the 7,000 to 8,000 cases submitted to the Supreme Court each term, only about 80 are accepted.

Congress has considered amending the Feres rule in the past but stopped short of action. In April, Rep. Jackie Speier (D-Calif.) introduced H.R. 2422, which would allow active-duty service members to sue the government for damages caused by medical malpractice. The bill has been referred to the House judiciary committee.

Daniel said he would continue to work with lawmakers and advocates to change the rule.

"Our case and our fight is over—but it continues for other service members. Moani's story has generated a groundswell of momentum to correct the injustice of Feres, and now this issue is going all the way to Capitol Hill," the statement said.

Why Missouri's The Last Holdout On A Statewide Rx Monitoring Program

KFF Health News, May 20, 2019

Because of ongoing fears about privacy violations tangled up with gun control, the bill never got a full vote in the Missouri Senate.

This article was first published on Monday, May 20, 2019 in Kaiser Health News.

By Lauren Weber

Missouri retained its lonely title as the only state without a statewide prescription drug monitoring program — for the seventh year in a row — after the legislative session ended Friday.

Patient advocates, politicians, experts and members of the medical community had hoped this would finally be the year Missouri would create a statewide electronic database designed to help spot the abuse of prescription drugs. After all, Republican Gov. Mike Parson had pushed for it and, more important, its longtime opponent was no longer in office to block it.

But, because of ongoing fears about privacy violations tangled up with gun control, the bill never got a full Senate vote. And finance site WalletHub last week ranked Missouri third worst in the country for its drug use based on a review of arrests, overdose rates, opioid prescriptions and other measures.

Katie Reichard, a lobbyist with Missouri Primary Care Association who has been working in and around the Missouri legislature for almost 15 years and previously pushed for the issue, said this proposal has bedeviled the state capital as none other while the opioid crisis continues to rage nationwide.

"I've never seen anything take seven years to get anywhere, and especially something that's going to be put into place to save lives."

Missouri's cities, neighboring states and the federal government have been forced to create a patchwork of incomplete workarounds. Those include a voluntary program tracking patients' prescriptions run by St. Louis County that receives federal funding and a statewide monitoring system put into place by former Republican Gov. Eric Greitens that tracks physicians' prescriptions.

And yet, the state cannot seem to legislate a complete fix. "It's frustrating to watch the rest of the country get this done and watch Missouri be the last one," said Dr. Sam Page, the St. Louis County prescription drug monitoring program architect and current St. Louis County Executive.

To be sure, the databases don't eliminate the ability of drug abusers to acquire prescription opioids. But the federal Centers for Disease Control and Prevention has called such statewide patient monitoring databases "among the most promising state-level interventions" to improve opioid prescribing and protect at-risk patients.

It's an embarrassment Missouri can't figure out its own statewide system, often referred to as a PDMP, according to St. Joseph pharmacist JulieMarie Nickelson. "No one in the pharmacy or medical world really understands it," she said.

Privacy, Guns And Opposition

While a PDMP bill has been introduced every year in the Missouri legislature since 2005, it was initially championed by the minority Democratic Party, which meant it didn't have much of a shot at passing until 2012.

Then New Hampshire approved a statewide program in 2012, leaving Missouri as the sole holdout. That pressure, combined with an uptick in awareness of drug abuse, led to a swell of bipartisan agreement.

A statewide PDMP bill passed the Missouri House handily that year, then met its biggest adversary: Republican state Sen. Robert Schaaf, whose district stretched from Kansas City to St. Joseph along Missouri's western border.

Since then, Schaaf — who is also a family physician — filibustered or insisted on kill clauses that would never pass the House, citing his concerns over privacy and personal liberty issues along with his belief it was an ineffective tool. Year after year, his efforts would defeat PDMP bills.

Schaaf has said the risk of a database of patient information being hacked — and the government having access to the information — far outweighed the potential benefits. He also tapped into underlying fears of privacy violations, driven in part by a 2013 scandal over the Missouri Highway Patrol turning over a database of concealed weapons permit holders to a federal agent.

"I've always been opposed to taking private citizens' information and putting it on a government database to which many, many people have access," he told Kaiser Health News. "My understanding is there is no computer information to which the NSA is not privy. How long is it going to be 'til this is used to pare down the number of people with concealed weapons or weapons at all?"

By stoking privacy fears and connecting them to gun rights, Schaaf also helped tap into grassroots far-right opposition that lives on to this day. A YouTube video tweeted by this year's anti-PDMP supporters details how the St. Louis County monitoring system could be used in "passing your personal information on to the federal government, which could use it to infringe on your right to bear arms."

To date, the only reported hack has been of Virginia's PDMP database, though it is unclear if the hackers were able to access medical records.

Over the years, Missouri's PDMP advocates, led by Republican Rep. Holly Rehder, unsuccessfully tried to assuage such concerns by offering amendments to delete records older than three years and ensure medical information could not be tied to buying a gun. And while Schaaf did an about-face in 2017 and agreed to stop filibustering the proposal, he effectively killed it with his only stipulation: that all physicians be required to use it. That measure, which took away the inherent voluntary aspect of the PDMP, failed in the House.

"If they're going to take our liberty away for something that's never been proven to work, doctors have to use it," Schaaf told Kaiser Health News.

The former head of the St. Louis County Health Department, Faisal Khan, who in 2017 helped start the voluntary county-based PDMP program that now covers other portions of the state, claims the opposition goes deeper than what he called "totally unfounded" privacy concerns.

"They view St. Louis County and St. Louis City and St. Louis, in general, as this liberal Democratic bastion that they don't want anything to do with," he said. "It's the usual nonsense that we're seeing around the country at the moment, and it's stymying progress in the parts of the state where we need it the most."

But this year, Schaaf had hit his term limit of eight years in office and did not return to the Missouri Senate. Finally becoming like every other state seemed within reach — until a group of six Republican state senators formed a new conservative caucus and filibustered yet again over the issue, citing the same privacy issues and civil liberties.

"The conservative caucus has carried his torch on," Reichard said.

A Series Of Workarounds

Now, because the legislature has refused to move on the issue, cities, states and the federal government must continue to rely on the stopgaps they created to help address the opioid problem ravaging Missouri.

Today, 72 jurisdictions have opted into St. Louis County's voluntary prescription drug monitoring system so pharmacists and doctors could check a patient's other prescriptions. It now covers 84% of the state's population.

Even St. Joseph, one of the areas hardest hit by the opioid epidemic and where Schaaf lives, joined last year.

For Nickelson, a pharmacist at Rogers Pharmacy in the city of about 76,000 people, the voluntary database means she no longer has to spend upward of 30 minutes on the phone tracking down whether a patient had prescriptions for drugs elsewhere.

"It's really helpful to us as it makes it so we can make sure that patients aren't taking medications that interact and can increase risk for an overdose," she said. "We just want to make sure our patients are safe, and we want to make sure medication that's not necessary doesn't get into the community."

Since her city's voluntary PDMP has been in effect, she estimates she sees a handful fewer people each week who were doctor-shopping, a particular risk considering the pharmacy is less than 5 miles from the Kansas border.

Missouri was a premier destination for pill-shopping, Page said, but that's changed.

"Our PDMP is first-class, as any in the country," Page said. "We have gaps, but those will continue to fill in. If the state continues to not move forward with this, then St. Louis County will continue to do the right thing."

And while St. Louis County built its voluntary database in part with $200,000 from the U.S. Department of Justice, interstate sharing of the data with neighboring Illinois, Kansas and Oklahoma didn't happen until February. Eight states border Missouri and more states are expected to collaborate with St. Louis County's system this year. But data-sharing can occur only among states that have managed to bend or rewrite their regulations to accommodate the one state in the nation without a statewide program.

Tennessee even created and passed legislation to allow it to communicate with the St. Louis County program while Missouri was still haggling over its PDMP bill, according to Spring Schmidt, acting head of the St. Louis County Department of Public Health.

The system that Greitens created when governor, along with Express Scripts, to monitor physicians' prescriptions for unusual patterns led to 50 referrals to the Missouri Healing Arts Board — the disciplinary board for medical practitioners in Missouri — for prescribing issues since March 2018, according to Missouri's head of Health and Senior Services, Dr. Randall Williams.

Ideally, Williams said, he would love to combine a statewide version of the voluntary PDMP system with Greitens' physician-monitoring one, but he's waiting on the legislation.

Reichard can't help but wonder why the state won't join the rest of the nation in passing it.

"I'm not saying do what everyone else is doing," she said. "But if 49 other legislatures are saying 'This is important, we need to save lives,' I don't understand why Missouri can't find a way to compromise and do what's best for its citizens."

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Escalating Workplace Violence Rocks Hospitals

KFF Health News, May 20, 2019

Many healthcare workers say the physical and verbal abuse come primarily from patients, some of whom are disoriented because of illness or from medication.

This article was first published on Monday, May 20, 2019 in Kaiser Health News.

By Marlene Harris-Taylor, Ideastream

Across the country, many doctors, nurses and other healthcare workers have remained silent about what is being called an epidemic of violence against them.

The violent outbursts come from patients and patients' families. And for years, it has been considered part of the job.

When you visit the Cleveland Clinic emergency department — whether as a patient, family member or friend — a large sign directs you toward a metal detector.

An officer inspects all bags and then instructs you to walk through the metal detector. In some cases, a metal wand is used — even on patients who come in on stretchers. Cleveland Clinic officials say they confiscate thousands of weapons like knives, pepper spray and guns each year. The metal detectors were installed in response to what CEO Tom Mihaljevic calls an epidemic.

"There is a very fundamental problem in U.S. healthcare that very few people speak about," he said, "and that's the violence against healthcare workers. Daily — literally, daily — we are exposed to violent outbursts, in particular in emergency rooms."

Many healthcare workers say the physical and verbal abuse come primarily from patients, some of whom are disoriented because of illness or from medication. Sometimes nurses and doctors are abused by family members who are on edge because their loved one is so ill.

Cleveland Clinic has introduced other safety measures — such as wireless panic buttons incorporated into ID badges and more safety cameras and plainclothes officers in ERs.

But these incidents aren't limited to emergency rooms.

Allysha Shin works as a registered nurse in neuroscience intensive care at the University of Southern California's Keck Hospital in Los Angeles. One of the most violent incidents she has experienced happened when she was caring for a patient who was bleeding inside her brain.

The woman had already lashed out at other staff, so she had been tied to the bed, Shin said. She broke free of the restraints and then kicked and punched Shin in the chest — before throwing a punch at her face.

"There was this one point where she swung, and she had just glanced off the side of my chin. If I hadn't dodged that punch, she could have knocked me out," Shin said. "And she very well could have killed me."

The encounter left Shin shaken and anxious when she returned to work days later. She still has flashbacks.

She used to be afraid to speak about these types of attacks, she said, because of what she calls a culture of accepting violence in most hospitals. "It is expected that you are going to get beat up from time to time," Shin said.

According to the Occupational Safety and Health Administration, incidents of serious workplace violence are four times more common in healthcare than in private industry. And a poll conducted by the American College of Emergency Physicians in August found nearly half of emergency physician respondents reported having been physically assaulted. More than 60% of them said the assault occurred within the previous year.

Groups representing doctors and nurses say that, while the voluntary safety improvements that some hospitals have enacted are a good first step, more needs to be done.

There is still a code of silence in healthcare, said Michelle Mahon, a representative of the labor group National Nurses United. "What happens if they do report it?" she said. "In some cases, unfortunately, they are treated as if they are the ones who don't know how to do their job. Or that it's their fault that this happened."

"There's a lot of focus on de-escalation techniques," Mahon added. "Those are helpful tools, but oftentimes they are used to blame workers."

In California, the nurses' labor union pushed for a law giving OSHA more authority to monitor hospital safety. The group is now backing a national effort to do the same thing. "The standard that we are recommending federally holds the employer responsible," Mahon said. "It mandates reporting of incidents and transparency."

The Workplace Violence Prevention for Healthcare and Social Service Workers Act, introduced last fall in Congress, would require hospitals to implement plans to prevent violence. And any hospital could face fines for not reporting incidents to OSHA, Mahon said.

The goal of the legislation — and of the union — is to hold administrators more accountable for acts of violence in their hospitals.

This story is part of a partnership that includes Ideastream, NPR and Kaiser Health News.

'Sham' Sharing Ministries Test Faith Of Patients And Insurance Regulators

KFF Health News, May 17, 2019

Insurance regulators in Washington and other states are taking a hard look at healthcare sharing ministry — faith-based co-ops in which members agree to pay one another's medical bills.

This article was first published on Friday, May 17, 2019 in Kaiser Health News.

By JoNel Aleccia

Sheri Lewis, 59, of Seattle, needed a hip transplant. Bradley Fuller, 63, of nearby Kirkland, needed chemotherapy and radiation when the pain in his jaw turned out to be throat cancer. And Kim Bruzas, 55, of Waitsburg, hundreds of miles away, needed emergency care to stop sudden —and severe — rectal bleeding.

Each of these Washington state residents required medical treatment during the past few years, and each thought they had purchased health insurance through an online site.

But when it was time to pay the bills, they learned that the products they bought through Aliera Healthcare Inc. weren't insurance at all — and that the cost of their care wasn't covered.

Lewis and the others had enrolled in what Aliera officials claimed was a healthcare sharing ministry (HCSM) — faith-based co-ops in which members agree to pay one another's medical bills.

But Washington insurance officials this week said the firm doesn't meet the definition of a sharing ministry and described Aliera's products as a "sham" aimed at misleading consumers. Other states, including Texas and New Hampshire, are poised to take similar action.

Insurance Commissioner Mike Kreidler on Monday ordered Aliera, which operates Trinity Healthshare Inc., both of Delaware, to halt operations in Washington, alleging the firm was selling health insurance illegally and engaging in deceptive business practices.

Aliera falsely represented itself as a sharing ministry, which would be exempt from insurance regulations, an investigation found. Though he wouldn't name them, Kreidler said he's investigating two additional firms over similar concerns.

"They don't have the direct affiliation with a particular religious group, a church, a pastor," Kreidler said.

In a statement, Aliera officials disputed Kreidler's conclusions. The company has 90 days to request a hearing.

"Aliera has never misled consumer and sales agents about its health plans," the statement said. "For example, our website, marketing materials and other communications clearly state that Trinity's health sharing products are not insurance. Most importantly, they have never been represented as insurance."

The Washington order followed complaints from nearly two dozen people, including Lewis, a dance teacher who was told her planned hip surgery wouldn't be covered.

Across the U.S., several state insurance regulators report similar concerns.

Texas insurance officials have scheduled a hearing to consider a similar order against Aliera, which has 100,000 members nationwide and reported revenue of $180 million in 2018, documents showed.

New Hampshire insurance officials on Tuesday warned consumers about Aliera, saying they were concerned about "potential fraudulent or criminal activity." Officials in at least five other states told Kaiser Health News they are reviewing firms operating as "illegitimate" healthcare sharing ministries.

Aliera is operated by Shelley Steele of Marietta, Ga., and her husband, Timothy Moses, who was convicted in 2006 of federal securities fraud and perjury. He was sentenced to 6½ years in prison and ordered to repay more than $1 million to victims.

Nationwide, nearly 1 million people are enrolled in more than 100 sharing ministries in at least 29 states, according to the Alliance of Healthcare Sharing Ministries. But that's just an estimate, said James Lansberry, executive vice president of Samaritan Ministries International of Peoria, Ill. No comprehensive data is available.

"We try to track what's going on out there," Lansberry said. "Anyone claiming to be a healthcare sharing ministry could spill over onto our reputation."

Samaritan is among what have been the three top players in the sharing ministries field. The oldest, founded in 1993, is the Medi-Share program of Melbourne, Fla., operated by Christian Care Ministry. The third is Christian Healthcare Ministries of Barberton, Ohio. All are explicitly religious and emphasize faith as the basis for members to share medical burdens.

Those groups originally were certified by the Centers for Medicare & Medicaid Services and required to meet specific criteria. Consumers who enrolled were shielded from the Affordable Care Act's individual mandate that required they show proof of insurance or pay a fine.

But CMS no longer certifies HCSMs and, since Congress zeroed out the mandate's penalty in 2017, a new crop of companies, including Aliera, has sprung up. That worries some of the traditional ministries.

"HCSMs must operate with integrity, transparency, full compliance with the law, and enforcement of the law," officials with Medi-Share, which has 415,000 members nationwide, said in a statement. "Anything outside of that violates the true spirit of the HCSM community."

Washington investigators found that Aliera's marketing materials rarely mention religious or ethical motivations, and they don't meet government requirements.

Many of these entities mimic the marketing, structure and language of ACA-compliant health insurance plans — but offer none of the protections, said JoAnn Volk and Justin Giovannelli, researchers at the Georgetown University Center on Health Insurance Reforms, who wrote about the issue last summer.

"The way they advertise and the services they are providing, it sounds a heck of a lot like health insurance," Giovannelli said. "They're letting folks believe they have a product that has a promise to pay."

That's exactly what Lewis thought.

"It looked like Aliera was health insurance to me," she said.

When Aliera denied her surgery, she had to resort to a GoFundMe site organized by friends to raise nearly $13,000 and then travel to Tijuana, Mexico, to get a hip transplant she could afford.

Fuller, who was diagnosed with throat cancer, said he was stuck with $81,000 in bills for his first month of treatment.

"They started checking my insurance and it didn't cover nothing," said the retired commercial electrician.

Fuller, his voice still raspy after radiation, said he had insurance through his union for years, but when the premiums spiked, he went online to find something else.

The person he talked to from Aliera said he could get insurance, no problem, Fuller said. The premium would be $350 a month, rather than the $1,300 fee for a gold plan on the state insurance exchange. "And that was with dental, too," he added.

Low premiums also attracted Bruzas, who left her well-paid government job in Tacoma, and the insurance it provided, after her husband died in 2015. She moved to a small town in southeastern Washington to care for her parents and went online to find health insurance.

"I just sat down and Googled 'Obamacare,'" she said. "I got a call back from a lady who said she could help me find coverage." Bruzas was charged $219 for the first month.

Four days later, she was in the local emergency room with massive rectal bleeding. As she was discharged, hospital officials said they had "never heard of Aliera Healthcare," she said.

The $10,000 bill was not covered. Bruzas, who works part time at a hardware store, filed for charity care and the debt was reduced to $6,500. She is paying it off slowly, $50 each month.

The Washington patients recalled mentions of "sharing" and vague references to spirituality. But none realized they were signing up for a religious cost-sharing ministry, they said.

"I would have hung up the phone if she would have said, 'We're a group, and we'll review your records and pray for you,'" Bruzas said.

Aliera officials said they make the nature of their products clear.

"Aliera disagrees that Trinity's inclusive and specific statement of beliefs misleads consumers or violates the applicable regulations governing healthcare sharing ministries," the statement said.

It's not clear how states can curb the new sharing ministries. If Aliera ignores his order, Kreidler said, he'll seek a court injunction to force the groups to cease operations. But several states contacted by KHN said that because the ministries are not health insurance, state insurance officials don't review or regulate them.

Some users of sharing ministries say the lower-priced products should be available for consumers who understand and accept the risks involved.

But consumers need to pay close attention to details when they sign up for any health plans, said Colorado Insurance Commissioner Michael Conway, who is investigating sharing ministries operating in his state.

"Ask if it's actually insurance," he advised. "Ask if there's a guarantee of coverage. Get into the policy documents. Read the contract they're agreeing to."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Editor's note: This story has been updated to include a link from Aliera.

As ER Wait Times Grow, More Patients Leave Against Medical Advice

KFF Health News, May 17, 2019

The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters.

This story was first published on Friday, May 17, 2019 in Kaiser Health News.

By Phillip Reese

Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.

About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That's up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.

Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.

Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.

Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.

California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.

The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended with patients leaving the ER against medical advice or abruptly discontinuing care after seeing a doctor, compared with 1.8% in 2012.

"Most patients are sick but not critically ill," said Dr. Steven Polevoi, medical director of the emergency department at UCSF Helen Diller Medical Center at Parnassus Heights. "Emergency care doesn't equal fast care all of the time."

When a patient leaves the ER after seeing a doctor but before the doctor clears them to leave, the Office of Statewide Health Planning and Development classifies that encounter as "leaving against medical advice or discontinued care." The definition includes encounters in which a doctor carefully explains the risks to the patient and has the patient sign a form, but also instances in which the patient simply discontinues care and bolts out the door.

Patients leaving the emergency room too soon "are deliberately putting themselves at more risk for morbidity and even mortality," Polevoi said — a point echoed by other physicians.

Dr. Veronica Vasquez-Montez, emergency room medical director at Good Samaritan Hospital in Los Angeles, said she sometimes finds herself having "tough conversations" with sick patients intent on leaving the ER, often citing pressing responsibilities.

"If you die from this," she tells them, "you are good to no one you are caring for."

One of her recent patients was at high risk for a major stroke but insisted he needed to leave the ER to take care of his pet.

"Guess what he came back for? A major stroke," said Vasquez-Montez, also a clinical assistant professor at the University of Southern California's Keck School of Medicine.

Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.

Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the highest proportion of ER encounters in 2017 that ended with patients leaving against medical advice or abruptly discontinuing care. Each of those counties recorded more than 4% of ER patients leaving too soon, state figures show.

From 2012 to 2017, the number of emergency room encounters in Fresno County increased by almost 95,000, or 37%. At Fresno's Community Regional Medical Center, about 9% of ER encounters ended with a patient leaving too soon, more than three times the statewide rate.

Community Regional Medical Center is one of the busiest hospitals in the state. It recently instituted a "Provider at Triage" program that puts caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the hospital's chief medical and quality officer. The hospital's internal data now show fewer than 2% of patients leaving against medical advice or abruptly discontinuing care.

"When patients bring themselves into the ED, they are seen in about 5 minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival," Thomas said in a statement.

When a sick patient is about to leave the emergency room, doctors should determine why he or she wants to go, make sure the patient is capable of making a sound decision, involve friends and family, explain the course of treatment and, if nothing works, arrange for speedy follow-up care, said Dr. Jay Brenner, emergency department medical director at Upstate University Hospital-Community Campus in New York and co-author of several studies about patients leaving against medical advice.

"When someone requests to leave," Brenner said, "it needs to be a priority that ranks just below a cardiac arrest."

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

This KHN story first published on California Healthline, a service of the California Healthcare Foundation.

Walmart Charts New Course By Steering Workers To High-Quality Imaging Centers

KFF Health News, May 15, 2019

The retail giant is believed to be the first to prod workers to use imaging providers based on diagnostic accuracy — not price.

This article was first published on Wednesday, May 15, 2019 in Kaiser Health News.

By Phil Galewitz

Walmart Inc., the nation's largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company's workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only non-surgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended since March that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City-based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy — not price, said employer health experts.

"A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery," said Woods. "The goal is to give associates the best chance to get better, and that starts with the right diagnosis."

Walmart employees are not required to use those 800 centers, but if they don't use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Studies show a 3% to 5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

"There's no question that there are a lot of errors that occur," said Dr. Vijay Rao, chairwoman of radiology at the Thomas Jefferson University Hospital in Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Rao said. The average radiologist typically has only seconds to read each image, she said. "It's just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen," she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use free-standing outpatient centers rather than those based in hospitals, which tend to be more expensive.

Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. "Unfortunately, it is all over the country. It's everywhere," she said.

Walmart's new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants and certain cancers.

As part of its "Centers of Excellence" program, the Bentonville, Ark.-based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company's health insurance plan, including a caregiver.

Sampling Imaging Centers' Work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers' compensation field.

"Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients," said Dan Elgort, Covera's chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities' error rates. It uses statistical modeling along with information on each center's equipment, physicians and use of industry-accepted patient protocols to determine the facilities' rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year's end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients' images and reports to Covera.

Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images — like those of the brain or bones — and sometimes radiologists read images from exams they have less experience with, he said.

Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. "Most people think of diagnostic imaging as a commodity, and that's a mistake," he said.

Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. "I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this," she said.

Few Guides For Consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

"We would love to have more robust … measurements" than what is currently available, said Dr. Geraldine McGinty, chair of the college's board of chancellors.

Facilities typically conduct peer reviews of their radiologists' patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly two years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees' health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

"Walmart is on the leading edge of focusing on quality of diagnostic imaging," said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led healthcare think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles-based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. "This would be the first time," he said, "I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price."

Woods said that even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

"It's been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better," she said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?

KFF Health News, May 14, 2019

After depending on the local hospital for more than a century, Fort Scott residents now are trying to cope with life without it.

This article was first published on Tuesday, May 14, 2019 in Kaiser Health News.

By Sarah Jane Tribble

FORT SCOTT, Kan. — A slight drizzle had begun in the gray December sky outside Community Christian Church as Reta Baker, president of the local hospital, stepped through the doors to join a weekly morning coffee organized by Fort Scott's chamber of commerce.

The town manager was there, along with the franchisee of the local McDonald's, an insurance agency owner and the receptionist from the big auto sales lot. Baker, who grew up on a farm south of town, knew them all.

Still, she paused in the doorway with her chin up to take in the scene. Then, lowering her voice, she admitted: "Nobody talked to me after the announcement."

Just a few months before, Baker — joining with the hospital's owner, St. Louis-based Mercy — announced the 132-year-old hospital would close. Baker carefully orchestrated face-to-face meetings with doctors, nurses, city leaders and staff members in the final days of September and on Oct. 1. Afterward, she sent written notices to the staff and local newspaper.

For the 7,800 people of Fort Scott, about 90 miles south of Kansas City, the hospital's closure was a loss they never imagined possible, sparking anger and fear.

"Babies are going to be dying," said longtime resident Darlene Doherty, who was at the coffee. "This is a disaster."

Bourbon County Sheriff Bill Martin stopped before leaving the gathering to say the closure has "a dark side." And Dusty Drake, the lead minister at Community Christian Church, diplomatically said people have "lots of questions," adding that members of his congregation will lose their jobs.

Yet, even as this town deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small communities like this one need a traditional hospital at all? And, if not, what health care do they need?

Sisters of Mercy nuns first opened Fort Scott's 10-bed frontier hospital in 1886 — a time when traveling 30 miles to see a doctor was unfathomable and when most medical treatments were so primitive they could be dispensed almost anywhere.

Now, driving the four-lane highway north to Kansas City or crossing the state line to Joplin, Mo., is a day trip that includes shopping and a stop at your favorite restaurant. The bigger hospitals there offer the latest sophisticated treatments and equipment.

And when patients here get sick, many simply go elsewhere. An average of nine patients stayed in Mercy Hospital Fort Scott's more than 40 beds each day from July 2017 through June 2018. And these numbers are not uncommon: Forty-five Kansas hospitals report an average daily census of fewer than two patients.

James Cosgrove, who directed a recent U.S. Government Accountability Office study about rural hospital closures, said the nation needs a better understanding of what the closures mean to the health of people in rural America, where the burden of disease — from diabetes to cancer — is often greater than in urban areas.

What happens when a 70-year-old grandfather falls on ice and must choose between staying home and driving to the closest emergency department, 30 miles away? Where does the sheriff's deputy who picks up an injured suspect take his charge for medical clearance before going to jail? And how does a young mother whose toddler fell against the coffee table and now has a gaping head wound cope?

There is also the economic question of how the hospital closure will affect the town's demographic makeup since, as is often the case in rural America, Fort Scott's hospital is a primary source of well-paying jobs and attracts professionals to the community.

The GAO plans to complete a follow-up study later this year on the fallout from rural hospital closures. "We want to know more," Cosgrove said. The report was originally requested in 2017 by then-Sen. Claire McCaskill (D-Mo.) and then-Rep. Tim Walz (D-Minn.), and has been picked up by Sen. Gary Peters (D-Mich.). Here in Fort Scott, the questions are being answered — painfully — in real time.

At the end of December, Mercy closed Fort Scott's hospital but decided to keep the building open to lease portions to house an emergency department, outpatient clinic and other services.

Mercy Hospital Fort Scott joined a growing list of more than 100 rural hospitals that have closed nationwide since 2010, according to data from the University of North Carolina's Cecil G. Sheps Center for Health Services Research. How the town copes is a window into what comes next.

'We Were Naive'

Over time, Mercy became so much a part of the community that parents expected to see the hospital's ambulance standing guard at the high school's Friday night football games.

Mercy's name was seemingly everywhere, actively promoting population health initiatives by working with the school district to lower children's obesity rates as well as local employers on diabetes prevention and healthy eating programs — worthy but, often, not revenue generators for the hospital.

"You cannot take for granted that your hospital is as committed to your community as you are," said Fort Scott City Manager Dave Martin. "We were naive."

Indeed, in 2002 when Mercy decided to build the then-69-bed hospital, residents raised $1 million out of their own pockets for construction. Another million was given by residents to the hospital's foundation for upgrading and replacing the hospital's equipment.

"Nobody donated to Mercy just for it to be Mercy's," said Bill Brittain, a former city and county commissioner. The point was to have a hospital for Fort Scott.

Today Mercy is a major health care conglomerate, with more than 40 acute care and specialty hospitals, as well as 900 physician practices and outpatient facilities. Fort Scott is the second Kansas hospital Mercy has closed.

Tom Mathews, vice president of finance for Mercy's southwestern Missouri and Kansas region, said Fort Scott's steady decline in patients, combined with lack of reimbursement — as well as the increasing cost of expenses such as drugs and salaries — "created an unsustainable situation for the ministry."

But Fort Scott is a place that needs health care: One out of every four children in Bourbon County live in poverty. People die much younger here than the rest of the state and rates for teen births, adult smoking, unemployment and violent crime are all higher in Bourbon County than the state average, according to data collected by the Kansas Health Institute and the Robert Wood Johnson Foundation. Ten percent of Bourbon County's more than 14,000 residents, about half of whom live in Fort Scott, lack health insurance. Kansas is one of 14 states that have not expanded Medicaid under the Affordable Care Act and, while many factors cause a rural closing, the GAO report found states that had expanded Medicaid had fewer closures.

The GAO report also found that residents of rural areas generally have lower household incomes than their counterparts in bigger cities, and are more likely to have limitations because of chronic health conditions, like high blood pressure, diabetes or obesity, that affect their daily activities.

The county's premature birth rate is also higher than the 9.9% nationwide, a number that worries Dr. Katrina Burke, a local family care doctor who also delivers babies. "Some of my patients don't have cars," she said, "or they have one car and their husband or boyfriend is out working with the car."

By nearly any social and economic measure, southeastern Kansas is "arguably the most troubled part of the entire state," said Dr. Gianfranco Pezzino, senior fellow at the Kansas Health Institute. While the health needs are great, it's not clear how to pay for them.

Health Care's 'Very Startling' Evolution

Reta Baker describes the farm she grew up on, south of town, as "a little wide place in the road." She applied to the Mercy school of nursing in 1974, left after getting married and came back in 1981 to take a job as staff nurse at the hospital. She has "been here ever since," 37 years — the past decade as the hospital president.

It has been "very startling" to watch the way health care has evolved, Baker said. Patients once stayed in the hospital for weeks after surgery and now, she said, "they come in and they have their gallbladder out and go home the same day."

With that, payments and reimbursement practices from government and health insurers changed too, valuing procedures rather than time spent in the hospital. Rural hospitals nationwide have struggled under that formula, the GAO report found.

Acknowledging the challenge, the federal government established some programs to help hospitals that serve poorer populations survive: Through a program called 340B, some hospitals get reduced prices on expensive drugs. Rural hospitals that qualified for a "critical access" designation because of their remote locations got higher payments for some long stays. About 3,000 hospitals nationwide get federal "disproportionate share payments" to reflect the fact that their patients tend to have poor or no insurance.

Fort Scott took part in the 340B discount drug program as well as the disproportionate share payments. But, though Baker tried, it could not gain critical access status.

When Medicare reimbursement dropped 2% because of sequestration after the Budget Control Act of 2011, it proved traumatic, since the federal insurer was a major source of income and, for many rural hospitals, the best payer.

Then, in 2013, when the federal government began financially penalizing most hospitals for having too many patients returning within 30 days, hospitals like Fort Scott's lost thousands of dollars in one year. It contributed to Fort Scott's "financial fall," Baker said.

Baker did her best to set things right. To reduce the number of bounce-back admissions, patients would get a call from the physician's office within 72 hours of their hospital stay to schedule an office visit within two weeks. "We worked really, really hard," Baker said. Five years ago, the number of patients returning to Fort Scott's hospital was 21%; in 2018 it was 5.5%.

Meanwhile, patients were also "out-migrating" and choosing to go to Ascension Via Christi in Pittsburg — which is two times larger than Fort Scott — because it offered cardiology and orthopedic services, Baker said. Patients also frequently drove 90 miles north to the Kansas City area for specialty care and the children's hospital.

"Anybody who is having a big surgery done, a bowel resection or a mastectomy, they want to go where people do it all the time," Baker said. Mercy's Fort Scott hospital had no cardiologists and only two surgeons doing less complicated procedures, such as hernia repair or removing an appendix.

Last year, only 13% of the people in Bourbon County and the surrounding area who needed hospital care chose to stay in Fort Scott, according to industry data shared by Baker.

There were no patients in the hospital's beds during one weekend in December, Baker said, adding: "I look at the report every day. It bounces between zero and seven." The hospital employed 500 to 600 people a decade ago, but by the time the closure was announced fewer than 300 were left.

That logic — the financial need — for the closing didn't sit well with residents, and Mercy executives knew it. They knew in June they would be closing Fort Scott but waited until October to announce it to the staff and the city. City Manager Martin responded by quickly assembling a health task force, insisting it was "critical" to send the right message about the closure.

Relations between Mercy and the city grew so tense that attorneys were needed just to talk to Mercy. In all, Fort Scott had spent more than $7,500 on Mercy Closure Project legal fees by the end of 2018, according to city records.

Will Fort Scott Sink With No Mercy?

When Darlene Doherty graduated from Fort Scott High School in 1962, there were two things to do in town: "Work at Mercy or work at Western Insurance." The insurance company, though, was sold in the 1980s, and the employer disappeared, along with nearly a thousand jobs.

Yet, even as the community's population slowly declined, Martin and other community leaders have kept Fort Scott vibrant. There's the new Smallville CrossFit studio, which Martin attends; a new microbrewery; two new gas stations; a Sleep Inn hotel, an assisted living center; and a Dairy Queen franchise. And the McDonald's that opened in 2012 just completed renovation.

The town's largest employer, Peerless Architectural Windows and Doors, which provides about 400 jobs, bought 25 more acres and plans to expand. There's state money promised to expand local highways, and Fort Scott has applied for federal grants to expand its airport.

Baker and some of the physicians on Mercy's staff have been busy trying to ensure that essential health care services survive, too.

Baker found buyers for the hospital's hospice, home health services and primary care clinics so they could continue operating.

Burke, the family care doctor, signed on to be part of the Community Health Center of Southeast Kansas, a federally qualified nonprofit that is taking over four health clinics operated by Mercy Hospital Fort Scott. She will have to deliver babies in Pittsburg, which is nearly 30 miles away on a mostly two-lane highway that has construction workers slowing traffic as they work to expand it to four lanes.

Burke said her practice is full, and she wants her patients to be taken care of: "If we don't do it, who's going to?"

Mercy donated its ambulances and transferred emergency medical staff to the county and city.

And, in a tense, last-minute save, Baker negotiated a two-year deal with Ascension Via Christi hospital in Pittsburg to operate the emergency department — which was closed for two weeks in February before reopening under the new management.

But she knows that too may be just a patch. If no buyer is found, Mercy will close the building by 2021.

This is the first installment in KHN's year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community's health care, economy and equilibrium.

Sarah Jane Tribble: sjtribble@kff.org, @SJTribble

How Obamacare, Medicare And 'Medicare For All' Muddy The Campaign Trail

KFF Health News, May 13, 2019

As the debate continues, one point should be clear: Medicare for All would not look like the ACA or like Medicare today.

This article was first published on Monay, May 13 in Kaiser Health News.

By Shefali Luthra

The healthcare debate has Democrats on Capitol Hill and the presidential campaign trail facing renewed pressure to make clear where they stand: Are they for "Medicare for All"? Or will they take up the push to protect the Affordable Care Act?

Obamacare advocates have found a powerful ally in House Speaker Nancy Pelosi, who in a recent "60 Minutes" appearance said that concentrating on the health law is preferable to Medicare for All. She argued that since the ACA's "benefits are better" than those of the existing Medicare program, implementing Medicare for All would mean changing major provisions of current Medicare, which covers people 65 and up as well as those with disabilities.

This talking point — one Pelosi has used before — seems tailor-made for the party's establishment. It's politically palatable among moderates who believe that defending the ACA's popular provisions, such as protecting coverage for those with preexisting conditions, fueled the Democrats' House takeover in 2018.

Progressive Democrats argue that the time has come to advance a far more disruptive policy, one that guarantees healthcare to all Americans. Those dynamics were on full display on Capitol Hill, as recently as an April 30 Medicare for All hearing.

But this binary view — Medicare (and, for argument's sake, Medicare for All) versus Obamacare — oversimplifies the issues and distracts from the policy proposals.

"It's sort of a silly argument," said Robert Berenson, a health policy analyst at the Urban Institute, of Pelosi's talking point. "She's trying to argue the Affordable Care Act needs to be defended, and Medicare for All is a diversion."

As the debate continues, one point should be clear: Medicare for All would not look like the ACA or like Medicare today. Instead, it — or any other single-payer system — would drastically change how Americans get healthcare.

Medicare for All is complicated, analysts noted, and the phrase is often deployed to mean different things, depending on who is speaking.

What's clear is that the "Medicare" described in Sen. Bernie Sanders' (I-Vt.) legislation — the flagship Medicare for All proposal — would create a health program far more generous than traditional Medicare's current benefit, or even the vast majority of health plans made available through the ACA.

Sanders relied heavily on this concept during his 2016 Democratic presidential primary run and recently introduced an updated version in the Senate.

To be fair, though, Sanders also sometimes blurs the lines between the programs. In a May 5 appearance on ABC's "This Week with George Stephanopoulos," he used existing Medicare as part of his sales pitch: "Medicare right now is the most popular health insurance program in the country," he said. "But it only applies to people 65 years of age or older. All that I want to do is expand Medicare over a four-year period to cover every man, woman and child in this country."

As counterintuitive as it sounds, understanding Medicare as it works today isn't helpful in envisioning a Medicare for All plan. Unlike with existing Medicare, the proposed health plan would cover things like nursing home care, vision care and dental services. It would get rid of cost sharing — meaning no premiums, deductibles or copays. (Sanders has acknowledged that financing the program would mean raising taxes.)

"It's not Medicare. It's something different," said Ellen Meara, a health economist at the Dartmouth Institute for Health Policy and Clinical Practice.

But voters may not grasp the differences between the existing Medicare program for seniors and the hypothetical one being discussed. Pelosi's comments may add to that confusion. Pelosi's office did not respond to a request for comment.

Prioritizing efforts to bolster the ACA based on Medicare's current benefit package "is convenient and not necessarily compelling," Berenson said, adding: "No one is proposing the Medicare benefit package would be taken and applied nationally."

That said, many of the presidential candidates have advanced far less sweeping healthcare options that would lower the Medicare age to 55 or allow people to buy in to the current Medicare program — an approach often referred to as a "public option." Those would keep the program essentially structured as it is today.

Every analyst interviewed for this story floated some kind of concern regarding a Medicare for All system. There's the issue of how people would respond to losing the option of private insurance — a likely consequence of Sanders' proposal — and the question of what level of tax hikes would be necessary to finance such a system, particularly if it covers a big-ticket item such as long-term care. There are also concerns about the financial impact for hospitals, often large employers in a community, or for the private insurance industry jobs that would likely disappear.

Focusing on current Medicare benefits misses the point, suggested Sherry Glied, a health economist and dean at New York University. When debating the merits of the ACA versus Medicare for All, Medicare's current generosity is kind of a red herring, she said.

Plus, making Obamacare or Medicare for All an either-or debate ignores a sizable political bloc: Democrats who say they support the ACA and see single-payer as a next step. That tension is at play with presidential candidates like Kamala Harris, who frame Medicare for All as an ultimate goal, while also backing incremental reforms.

The problem is that both Medicare and Obamacare are vast programs. Depending on your income, health needs and the version you sign up for, either one could prove the better choice.

"It's impossible to say the ACA as a concept has more or less generous benefits," Berenson said.

Broadly, the ACA has protections in place that traditional Medicare doesn't. It caps how much patients pay out-of-pocket, and it has more generous coverage of mental healthcare and substance abuse treatment. But, in practice, those benefits have proved elusive for many since Medicare generally has a more robust network of participating physicians than many of the ACA's cheaper plans, which restrict patients to a narrower coverage network.

Also, most beneficiaries don't solely have traditional Medicare.

About a third use Medicare Advantage, in which private insurance companies construct Medicare plans with benefits and protections based on factors like company, tier and geography. They, too, are often restricted to narrower networks.

More than 1 in 5 traditional Medicare beneficiaries also receive Medicaid coverage, according to figures kept by the Kaiser Family Foundation, and about a third of them buy so-called Medigap plans, which are sold by private insurance and are meant to supplement gaps in coverage.

The ACA also encompasses an array of coverage options. Which plans are available in an area and whether earnings qualify a consumer for a government subsidy— a tax break meant to make an ACA plan more affordable — make a significant difference in evaluating whether Medicare or an ACA plan offers better benefits for a particular person or family.

Suggesting that one is clearly better than the other, Meara said, is a "gross oversimplification."

But that kind of oversimplification may be hard to avoid, especially in a primary season where healthcare is a top issue.

"The Affordable Care Act is also not one thing, the way Medicare is not one thing," said Katherine Baicker, dean of the Harris School of Public Policy at the University of Chicago. "So much of healthcare is more complicated than we can explain in a sound bite."

Shefali Luthra: ShefaliL@kff.org, @Shefalil

'John Doe' Patients Sometimes Force Hospital Staff To Play Detective

KFF Health News, May 13, 2019

Establishing identity helps avoid the treatment risks that come with not knowing a patient's medical history.

This article was first published on Monday, May 13, 2019 in Kaiser Health News.

By Susan Abram and Heidi de Marco

The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: no wallet, no cellphone, not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient's medical history. And they strive to find next of kin to help make medical decisions.

"We're looking for a surrogate decision-maker, a person who can help us," said Jan Crary, supervising clinical social worker at L.A. County+USC, whose team is frequently called on to identify unidentified patients.

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient's identity challenging for staff members at hospitals nationwide.

At L.A. County+USC, social workers pick through personal bags and clothing, scroll through cellphones that are not password-protected for names and numbers of family or friends, and scour receipts or crumpled pieces of paper for any trace of a patient's identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings, and even try to track down dental records. It's more difficult to check fingerprints, because that's done through law enforcement, which will get involved only if the case has a criminal aspect, Crary said.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, said Crary. They might also be people with severe cognitive impairment, such as Alzheimer's, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the past three years, the number of patients who arrived unidentified at L.A. County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, the staff at the hospital will make up an ID, usually beginning with the letter "M" or "F" for gender, followed by a number and a random name, Crary said.

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a "trauma alias," said Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals who sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs. On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands. Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, said Lake. But it was a struggle, especially for smaller hospitals, he said.

The Health Insurance Portability and Accountability Act, a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer's disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name "Trauma XXX."

Police and family members inquired about him at the hospital several times but were told he was not there. After a week — during which hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the unidentified patient.

Hospital officials later told the man's son that because he had not explicitly asked for "Trauma XXX," they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing persons from police or family members. The guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing persons.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, "the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient's next-of-kin, if doing so is in the best interest of the patient."

At L.A. County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary said.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays at L.A. County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary said she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, delirious with what was later diagnosed as encephalitis and unable to speak.

Acting on a gut instinct that the well-groomed man must have a loved one who had reported him missing, Crary checked with police stations in the area. She learned instead that this John Doe was wanted in several states for sexual assault.

"He was done in by a mosquito," Crary mused.

"It is a case that I will never forget," she added. "The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification rather than finding a felon."

This KHN story first published on California Healthline, a service of the California Healthcare Foundation.

Heidi de Marco: heidid@kff.org, @Heidi_deMarco

Surprise! Fixing Out-Of-Network Bills Means Someone Must Pay

KFF Health News, May 10, 2019

Insurers and healthcare providers each oppose the other side's preferred solution to end surprise bills.

This article was first published on Thursday, May 9, 2019 in Kaiser Health News.

By Julie Rovner

President Donald Trump called on Republicans and Democrats to pass legislation this year to end surprise medical bills, in remarks made in the White House's Roosevelt Room on Thursday. "We're determined to end surprise medical billing for American patients," Trump said.

Bills like those have been featured in the NPR-Kaiser Health News series launched in February 2018. Two patients whose medical bills were part of the series attended the event.

Austin, Texas, teacher Drew Calver talked about the six-figure bill he received after having a heart attack. "I felt like I was exploited at the most vulnerable time in my life," he said. His bill was reduced to $332 after the NPR-KHN story was published.

A bipartisan group of senators has been working to come up with a plan for the past several months. They said Thursday that they hope to have a bill to the president by July.

But will bipartisanship be enough? Even political will might not overcome divisions within the health industry.

Specifically, lawmakers aim to address the often-exorbitant amounts patients are asked to pay out-of-pocket when they receive care at health facilities that are part of their insurance network but are treated by out-of-network practitioners. Legislators are also looking to address bills for emergency care at a facility that doesn't have a contract with patients' insurers.

"We're getting really close to an approach that we'll be able to unveil pretty soon," Sen. Maggie Hassan (D-N.H.) told reporters on a conference call Thursday with Sen. Bill Cassidy (R-La.).

And it's not just politicians and patients: Out-of-network doctors, insurance companies and hospital groups say they want the problem for consumers fixed, too.

Despite that broad agreement, a hurdle remains. Insurers and healthcare providers each oppose the other side's preferred solution to end surprise bills. That conflict makes it almost impossible for lawmakers to come up with a fix that won't leave one of the influential groups unhappy.

"It's a different axis than the partisan [conflicts] we're used to," said Loren Adler, who has been studying the surprise-bill problem for the USC-Brookings Schaeffer Initiative for Health Policy. The fight over how to fix it is less likely "to break down between Republicans and Democrats and more likely to break down to where the money is" and which group will have to take less of it.

"I don't see a coalescence around a solution," said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit facilities.

The divide is wide, despite the overall interest in protecting consumers.

"What we'd most like to see is clarity for the patients," said Bob Kneeley, a senior vice president for Envision Healthcare, which employs physicians to staff a variety of hospital departments, such as emergency rooms, neonatal units and anesthesiology. "This is a system that's just not working well for the patient, and we need to establish some appropriate guardrails."

"We want this to be solved. We know it needs federal legislation," agreed Molly Smith, a vice president at the American Hospital Association. She said hospitals believe that patients should "not have to be involved in any process if there's a dispute between the payer and the provider."

States have been working on the problem for several years. Nine now have programs aimed at protecting patients from surprise bills. But state laws cannot reach those with employer-provided insurance — more than half of all Americans — because those plans are regulated by a federal law called the Employee Retirement Income Security Act, or ERISA. That means only Congress can fix it for everyone.

Patients and groups that represent them say the problem is more urgent than ever.

"We are talking about situations in which families — despite enrolling in health insurance, paying premiums, doing their homework and trying to work within the system — are being left with completely unanticipated and sometimes financially devastating bills," Frederick Isasi, executive director of the consumer group Families USA, told a House Education and Labor subcommittee hearing in April. "This is inexcusable behavior on the part of hospitals, doctors and insurers. They each know — or should know — that patients have no real way to understand the financial trap they have just walked into."

Dr. Paul Davis, whose daughter received a bill for a $17,850 for a urine test after back surgery, also spoke at the White House on Thursday: "The situation is terrible. It is a national disgrace, and I think a lot of people would support me on that," Davis told a reporter. Their story was the first featured in the "Bill of the Month" project.

Still, it's not clear where compromise might be found.

By and large, doctors favor some sort of negotiated-fee system when there is a dispute about a bill, such as binding arbitration, in which an independent third party makes the ultimate payment decision.

"That's consistent with what's working in some states," said Envision's Kneeley.

Among those frequently cited by doctors' groups is New York, which has one of the strongest state laws on surprise billing. There patients are not required to pay more than they would for an in-network doctor or hospital. For the remaining bill, an independent arbitrator settles any dispute between the provider and insurer.

But the insurance industry worries about that approach. "Our larger concern with arbitration is that it still relies on bill charges," said Adam Beck, a vice president for America's Health Insurance Plans, an insurance industry trade group. And insurers think those charges are too high.

A senior administration official also said on Thursday that the administration does not favor the arbitration approach, either.

Insurers — and many consumer groups — "believe if you have a clear benchmark pegged to reasonable rates, that will really solve this problem," Beck said, because insurers would be more likely to cover charges they found more in line with what they consider reasonable.

A "benchmark" payment might correspond to what Medicare pays for the same service, for instance.

But doctors don't like that idea one bit. "Even if [the benchmark] is on the high side, it's still rate-setting," said Kneeley.

Hospitals don't like it, either.

"We can't get behind any sort of rate-setting in statute," said Smith of the AHA. "We have too many concerns about getting that wrong." For example, she said, if the rate is set too low, hospitals might have trouble finding doctors willing to provide care.

Meanwhile, insurers and hospitals want to ban out-of-network providers from billing patients for whatever part of the charge the insurer won't cover, a practice called "balance billing."

Such bans are anathema to doctors, who instead believe insurers bear responsibility for doctors not being in their networks because they "don't have an incentive to offer fair rates," said Kneeley. Although insurers often feel they must contract with specific high-profile hospitals, he explained, the doctors who work there are often "invisible providers."

Addressing the underlying causes of high health costs, however, will be difficult, said Adler of USC-Brookings.

Doctors want to be paid more than insurers typically offer, he said, which is why some do not join insurance networks. And insurers "want the problems [with surprise bills to patients] to go away." The question for them, he said, is, "How much are insurers willing to pay to have their patients not get surprise bills?"

In the end, a settlement that eliminates surprise bills but builds the excess into everyone's premiums doesn't truly address healthcare's spending problem.

"I think there's a good chance it gets solved," Adler said, and that lawmakers will eventually agree on a plan. "But I'm pessimistic it gets solved in a way" that deals with healthcare's high costs.

KHN senior correspondent Fred Schulte contributed to this report.

Julie Rovner: jrovner@kff.org, @jrovner

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