After baby Dorian Bennett arrived two months early and spent more than 50 days in the neonatal ICU, his parents received a bill of more than $550,000—despite having insurance.
Close to midnight on Nov. 12, 2020, Bisi Bennett was sitting on the couch in her pajamas and feeling uncomfortable. She was about seven months pregnant with her first child, Dorian, and the thought that she could be in labor didn’t even cross her mind.
Then, she felt a contraction so strong it knocked her off the couch. She shouted to her husband, Chris, and they ran to the car to start the 15-minute drive to AdventHealth hospital in Orlando, Florida. About halfway through the trip, Bennett gave birth to Dorian in her family’s Mitsubishi Outlander. Her husband kept one hand on his newborn son’s back and one hand on the wheel.
Born breech, meaning his head emerged last, Dorian wasn’t crying at first, and the terrified new parents feared something was wrong. Chris Bennett turned on the SUV’s flashers and flagged down a passing emergency vehicle. The EMS team escorted the family to the hospital.
“He was still connected to me with the umbilical cord when they rolled the two of us together into the hospital,” Bisi said. “They cut the cord, and the last thing I heard was, ‘He has a pulse,’ before they wheeled me away.”
“I just cried tears of relief,” she said.
Dorian stayed in the neonatal intensive care unit until Jan. 7, 2021, for almost two full months. While Dorian was in the hospital, Bisi wasn’t worried about the cost. She works in the insurance industry and had carefully chosen AdventHealth Orlando because the hospital was close to her house and in her insurance network.
Then the bills came.
The Patient: Dorian Bennett, an infant born two months premature. He has health insurance through his mother’s employer, AssuredPartners, where she works as a licensed property insurance agent.
Medical Service: A neonatal intensive care unit stay of 56 days. Dorian needed highly technical, lifesaving respiratory and nutritional care until his organs matured. He also received laboratory, radiology, surgery, cardiology and audiology services and treatments.
Service Provider:AdventHealth Orlando in Orlando, Florida. It is a part of the AdventHealth system, a large nonprofit and faith-based group of health care providers with locations across Florida and several other states.
Total Bill: AdventHealth Orlando billed $660,553 for Dorian’s NICU care. Because of an insurance snafu, the “patient responsibility” portion of the bill sent to the Bennetts was $550,124. They were offered an installment payment plan of $45,843 a month for 12 months.
What Gives: Under the 2010 health law, nonprofit hospitals are required to provide financial assistance to help patients pay their bills, and payment plans can be part of that assistance. But the Bennett family’s experience shows the system is still far from friendly to patients.
The installment amount offered to the Bennetts — $45,843 — resembles an annual salary more than a reasonable monthly payment. The laughably unrealistic plan was apparently automatically generated by the hospital’s billing system. A spokesperson for the hospital, David Breen of AdventHealth, did not answer KHN’s questions about its billing software or why a five-digit monthly payment was not flagged by the hospital as a problem that might need extra attention.
The size of the Bennetts’ bill stems from two overlapping issues: Baby Dorian was born in 2020 and needed hospital care into 2021, and Bisi Bennett’s employer shifted its health plan to a different company in January 2021. She informed AdventHealth about the change.
As someone who works in the insurance industry, Bennett was pretty sure that she understood the mix-up and that the charge of more than half a million dollars was unjustified.
But as Dorian turned a year old last month, the family still had bills pending and a tangle of red tape to fight.
AdventHealth bundled the 2020 and 2021 dates of Dorian’s NICU stay and then billed both insurance plans for the whole stay. Both insurance plans said the bill contained dates of care when Dorian was not covered, so neither paid the hospital. The shift from one year to the next flummoxed three large business entities, which seemed unmotivated to resolve the problem quickly.
“A bill this large is a huge crisis for the family, but it’s not a huge crisis for the insurance company or for the hospital,” said Erin Fuse Brown, an associate professor of law at Georgia State University who studies health care policy.
In 2020, Dorian was covered under a UnitedHealthcare plan, which for in-network providers had a $6,000 deductible and $6,000 out-of-pocket maximum for the family.
In 2021, Bisi Bennett’s employer switched its third-party administrator of its self-funded plan from UnitedHealthcare to UMR. The deductible and out-of-pocket maximum did not change.
Although UMR is owned by UnitedHealthcare, the two companies did not communicate well about the case.
“It’s indicative of all the ways the system fails the patient,” Fuse Brown said. “Even the one who does everything right.”
Through the nearly yearlong fight over the bill, the Bennetts were also caring for Dorian, who left the hospital with lingering gastrointestinal issues, and managing Chris’ treatment for stage 4 neuroendocrine cancer, which was diagnosed in April. At one point, Bisi said, she felt she was going crazy.
“They’re in charge of billing, and I shouldn’t be the one having to tell them, ‘Bill my one insurance for dates in 2020 and bill my other insurance for dates in 2021,’ but I did,” she said. “I kept having the same conversation over and over.”
Resolution: Bisi Bennett immediately noticed and understood the calendar issue when she received the billing statements in spring 2021. She started by calling the hospital and was told the problem would be corrected in March. Yet, in September, she got the same half-a-million-dollar bill.
UnitedHealthcare spokesperson Maria Gordon Shydlo, who also fielded KHN’s questions for UMR, said the insurance company told AdventHealth to revise the bill with correct dates in the spring.
Breen, the spokesperson for AdventHealth Orlando, confirmed to KHN that the billing error stemmed from the change in insurers from 2020 to 2021. In a statement, Breen said medical billing can be a complex process and the hospital “understand[s] this has been a confusing and challenging experience for Ms. Bennett, and we apologize for the frustration this has caused.”
AdventHealth Orlando did not submit a revised bill with corrected dates until KHN contacted the hospital in October 2021.
After UHC and UMR reprocessed the 2020 and 2021 claims, the original bill of more than $550,000 was knocked down to $300.
In his statement, Breen said that the Bennetts’ case sparked AdventHealth to identify and address issues in its system and that the hospital plans to improve the billing and communications process for future patients, particularly when there is a change in insurance.
The Takeaway: Much of our fragmented health care system is on autopilot, with billing software that generates confusing or, in this case, absurd bills and payment plans.
Bisi Bennett did everything right: She chose an in-network hospital and informed it of the changes to her health insurance. She followed up when she saw there was an error. But her case didn’t reach a resolution until a reporter called on her behalf.
If you are fighting a bill that you believe contains an error, call all the entities involved — the hospital, insurers, other providers — and don’t forget about your company’s human resources department. It may be able to pressure insurers to resolve an error faster than you can.
Most states have a department of consumer services that can help you file a complaint with the appropriate oversight entity. Staff members at state agencies can help you figure out what is going on. Tell the medical providers you are reporting them to the state.
Still, it is a frustrating, uphill battle, especially when patients have improper bills hanging over their heads for many months and are at risk of having the bills sent to a collection agency or having their credit score dinged. There should be far more transparency in billing and a set time limit for dispute resolution, experts say.
“This shows how little leverage or power a patient has in this situation,” Fuse Brown said. “You almost have to go outside the system and put external pressure.”
Since the start of the pandemic, Luz Gallegos and her team of 56 advocates for immigrants have battled the scorching sun, illiteracy and deadly propaganda in the fields and fruit groves of the Coachella Valley.
As they fanned out to educate farmworkers on how to protect themselves from covid-19, they quickly learned that rumors and disinformation often account for most of the news farmworkers in the area are getting about the disease. The need for boosters and the looming threat of the omicron variant have made covid communication extra challenging.
Gallegos and her team huddle in the mornings to discuss a strategy on how to diffuse misinformation before it spreads. “Once we start hearing rumors, we try to get ahead of them and create messaging to debunk it before they start penetrating the fields like they did when we first started vaccinating in January.”
In January, the word in the fields was that covid vaccination would make you sterile. Now, people hear from friends and social media that the vaccines can turn you into a monkey, change your gender or clone you.
Gallegos and Riverside County health workers managed earlier in the year to get vaccines into the arms of most farmworkers in the valley, where dates, citrus and grapes are the dominant crops. That has eased the sales job for some of her crew of TODEC employees and volunteers.
“People that got vaccinated, they feel like they’re still here, they’re still alive,” she said. “People see science now.”
But equity issues that were evident in the first round of vaccines are more evident now, including access to health care, language barriers and misinformation, Gallegos said. Some workers don’t understand why they need a follow-up shot. Others are newcomer migrants who haven’t been vaccinated against covid at all.
Community health organizations have struggled to provide booster shots for the Latino community — whose members account for more than half of covid cases in California. By September, about 80% of eligible Latinos had received at least one shot, the same rate as whites. But of the 23.4 million people 65 and older who had received a booster dose by Dec. 13, only 7.8% were Latinos (who make up nearly 10% of that age group), according to the Centers for Disease Control and Prevention. Latinos of other ages were also relatively unboosted.
“Latinos don’t know who to turn to for accurate information,” said Gilberto Lopez, an assistant professor at Arizona State University who has been working on vaccine communication. “The government hasn’t been doing the best job, the big national TV channels haven’t been doing that good of a job, and community organizations are working at a hyper-local level.”
One basic problem: Credible vaccine information and the science that supports it is not readily available in Spanish or other languages, said Dr. Yelba Castellon-Lopez, an assistant clinical professor in family medicine at UCLA Health. “People are afraid to contract the virus in health care settings. Many avoided seeking care even when they were sick for fear of being put on ventilators, afraid they would never make it out of the hospital.”
The county has partnered with TODEC to send health care providers out to the fields and hold open vaccination and booster clinics on Fridays. This answers immigrants’ fears of going to the doctor and their concerns that side effects from the shot will cause them to miss work.
“Fridays gives them the opportunity to actually recover,” said Gallegos.
Castellon-Lopez has been conducting webinars for patients and community members to dispel myths and explain the shifting reality of the covid epidemic. “What we’re learning about covid is changing every day and that makes it difficult,” she said. “I think people appreciate having access to doctors who look like them and speak the language.”
Disinformation on Spanish AM radio, social media and messaging apps like WhatsApp is fueling continued vaccine hesitancy among Latinos, according to a recent survey conducted by Change Research and the Latino Anti-Disinformation Lab. It found that almost 4 in 10 respondents had seen information that made them think the covid vaccines were not safe or effective.
Latino educators are seeking to smother misleading propaganda with culturally relevant, easy-to-understand, accurate information.
Lopez, at Arizona State University, created the Covid Health Animation Project, which makes cartoons that address covid misinformation. But he thinks health communicators need to inject some bawdiness into their scripts to get people’s attention.
“The type of comedy, the type of messaging, the wording we use, it’s G-rated,” said Lopez. He just published an animation that drops a few cuss words here and there. “That’s the way this population talks. We need to use some of the language that they use to reach out to the community that’s not getting vaccinated.”
Language barriers remain a consistent issue, especially for Indigenous-language speakers, said Odilia Romero, executive director of Comunidades Indígenas en Liderazgo (CIELO), a Los Angeles nonprofit.
Pablo Ek Oxte, a 52-year-old plumber from a small pueblo in Yucatán, Mexico, rolled up his sleeve for a booster shot on a recent Saturday morning after hearing about the vaccine clinic in a public service announcement produced by CIELO in his native Mayan language. The group has posted a series of vaccination cartoons in various Indigenous languages on social media sites.
“I relied on the information from CIELO,” said Oxte, who has asthma and diabetes. Although he speaks some Spanish, “I appreciate the information in my language,” he said.
In Oxnard, California, Francisco Didier Ulloa and Bernardino Almazán host a show on Radio Indígena in Spanish and Mixteco, an Indigenous Mexican language.
“A lot of our Indigenous brothers don’t speak Spanish, so it was necessary to convey the information in a way that they would listen and understand,” said Ulloa.
The Los Angeles County Department of Public Health has increased its social media memes and is testing strategies to narrow the vaccination gap between white and Latino residents. The state partnered with political cartoonist Lalo Alcaraz to create a series of cartoons and animations promoting vaccination and booster information.
“We want people to see themselves and their families reflected in these images and maybe do a double take and think twice about their own family’s situation,” said Alcaraz. “Maybe it changes their mind about the vaccine.”
Eleven months ago, President Joe Biden assumed office during one of the most critical moments of the covid-19 pandemic. Case counts and death rates were shockingly high. The vaccine rollout, which had started under former President Donald Trump, was disjointed. People were generally sequestered in their homes, and kids were relegated to remote learning.
Biden promised to change all that. He said he would differ from Trump in that he would listen to the scientists, encourage the use of masks and give the federal government a stronger role in addressing the pandemic. He also pledged to deliver the “most efficient mass vaccination plan in U.S. history” and to get 100 million covid shots administered in his first 100 days.
How well did Biden do? We asked four public health experts who said the president’s vaccine rollout, overall, was excellent, but his messaging was off at certain points, and other setbacks — both within and beyond his control — stymied progress against covid-19.
After all, cases in the U.S. are again surging, largely due to the delta and omicron variants. In some places, these numbers, as well as hospitalization tallies, are approaching the highest levels in months. This month, the U.S. surpassed 800,000 covid-related deaths since the pandemic started, and the 1 million mark is in view. The reopening of Broadway shows — something viewed by many as a sign that normalcy was returning — is facing interruptions as breakthrough cases among cast members cause intermittent performance cancellations. The sports world is facing its own covid-related disturbances. Colleges have announced they will hold final exams remotely and are canceling winter graduations.
All of this calls into question how much progress has been made against covid. Let’s take a look at what happened in 2021 and whether Biden’s efforts have made a difference.
Even before taking office, Biden set an initial target of getting 100 million doses of vaccine administered in his first 100 days. While there was initial uncertainty about this target, it turned out to be an easily achievable goal that took only 58 days.
Still, vaccine distribution unfolded by fits and starts. At first, only certain populations were eligible for shots. And when Biden announced he was ordering states to open up eligibility to all adults May 1, demand outstripped vaccine supply in many locations. By summer, though, most who wanted a vaccine could get one — free of charge.
That push “was extraordinary,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “The Biden administration increased the number of people to get shots, they increased the number of places to get shots, they reduced the number of disparities for those getting shots,” he said.
Indeed, getting almost half of the U.S. population fully vaccinated in the first six months of 2021 resulted in a huge drop in covid cases, hospitalizations and deaths by early summer. Recent data from the Commonwealth Fund indicates that the covid vaccination program in the U.S. prevented 1 million deaths and 10 million hospitalizations.
Yet, those two optimistic signs — high vaccine availability and low covid cases — led the Biden administration to prematurely assert triumph over the virus, said Dr. Leana Wen, a professor of health policy and management at George Washington University. This was just one of several messaging missteps made by Biden and his administration in 2021, said the experts.
“They had declared victory right when delta was starting to surge,” Wen said.
Wen pointed to the Centers for Disease Control and Prevention’s “confused” messaging, starting with an announcement in May that those who were fully vaccinated no longer needed to wear masks indoors or outdoors, or practice physical distancing, even though those strategies had proved useful in combating the virus.
The change in mask guidance came at a pivotal time. The dangerous delta variant was beginning to take hold throughout the U.S., and public health officials were only starting to understand that those who had been vaccinated could still spread the virus. As delta boosted case counts in midsummer, the CDC had to walk back its guidance to recommend that vaccinated people resume wearing masks indoors if they lived in an area with substantial or high transmission. This remains the recommendation. Yet, that initial announcement opened a door for many states and localities to repeal their mask requirements and never reinstate them, despite continued high levels of transmission nationwide.
“The unmasking order back in May was too hastily done,” Benjamin said. “That was a misstep.”
Also, Biden’s announcement in mid-August that booster shots would be available by Sept. 20 to all Americans preceded both the Food and Drug Administration’s recommendation and the CDC’s guidance on boosters for everyone — another stumble. The FDA didn’t authorize boosters for all adults until November.
“I think people saw that as him making a political statement,” Benjamin said. “He knew that was where we were going, where the science was taking us. He got ahead of it.”
Overall, though, Biden followed the science, said the experts. Plus, implementing regular covid media briefings with scientists and public health leaders, and allowing Dr. Anthony Fauci, his chief medical adviser, to be front and center and not contradicting his advice, represented a meaningful change from the previous administration, when daily briefings were held but speakers often dismissed scientific evidence in favor of untested treatments and the president, himself, would dismiss the pandemic’s severity.
Biden also used the power of his office to advance certain public health measures. He issued vaccine mandates for federal employees and contractors, health care workers and certain companies. This has increased the number of people vaccinated, though the mandates, except for the one aimed at government workers, are on hold while objections work their way through the court system.
And, despite state rollbacks of mask mandates, the president has continued to require masking in areas under his control, including within the interstate transportation and air travel industries and in federal buildings. He also signed a $1.9 trillion covid relief law in March that provided financial assistance to people in the form of stimulus checks, child tax credits and additional unemployment benefits, as well as aid to states and local governments.
However, one area in which government efforts have been severely lacking is covid testing, said every public health expert we consulted.
“We need more availability of at-home rapid tests. There shouldn’t be shortages,” said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, which represents state and local public health agencies.
The Biden administration has invoked the Defense Production Act to ramp up production of rapid tests, and is providing tests free of charge to community health clinics and requiring private insurance companies to reimburse consumers for tests they buy.
It could do more, said Jen Kates, director of global health and HIV policy at KFF.
“They still haven’t gone to the next step and bought tests and sent them to every household, to really blanket the country with tests,” Kates said. That would prove especially vital if the U.S. does indeed experience a winter surge due to delta and omicron as anticipated.
Variants, especially delta, have caused more serious disease symptoms than other forms of the covid virus, exacerbating the challenge of battling the pandemic this year. Still, data shows that covid-related death rates were far higher among the unvaccinated than the vaccinated. The volume of people unwilling to get the shot because of vaccine hesitancy or misinformation may have contributed to the high number of covid deaths in 2021, which have surpassed 2020, said Kates.
In addition, covid vaccines weren’t widely available to everyone in the U.S. until May. Plus, during 2020, much of the U.S. was locked down at home, while many activities have resumed in 2021, with increased opportunities for viral spread.
Still, under Biden, according to the latest metrics, more than 61% of the U.S. population — and 72% of adults — have been fully vaccinated against covid.
“I think we should really be celebrating the 70% more,” Plescia said. “For adult vaccinations, we never get anywhere close to that number with other vaccines, like influenza.”
Yet, as the nation stares down omicron, the country braces for increasing cases amid continued uncertainty over when the pandemic will finally end.
Experts agreed the U.S. has made positive gains in its efforts against covid this year, but there is more work to do. Testing, continuing to encourage vaccinations and boosters in the U.S., and providing shots to the world — to help prevent future variants — are the only ways to reach a point where covid becomes endemic, they said.
“We are in a different place. Last year we needed vaccines. Now we need to get to the point where testing is the norm,” Wen said. “This is how we’re going to live with covid in our lives in the future and is how we as America will be able to move on.”
Bill Mather, a pharmacist in the small Iowa city of Greenfield, wanted to make sure his neighbors could fill their prescriptions without driving long distances or enduring long wait times.
So when pharmacy chains and big-box stores began expanding into rural markets, he sold his drugstore in 2007 to Pamida, a grocery chain owned by the Shopko department store company, hoping that would keep his practice alive. Then, in 2019, when Shopko declared bankruptcy, shuttering more than 360 stores, he and another Shopko pharmacist helped open a new drugstore for the city of about 2,000 people.
Across the country, pharmacists like Mather are filling the voids left when large drugstore chains and big-box stores with pharmacies pull out of small communities. In some areas, pharmacists who were let go when big chains closed are now opening new drugstores, often in the same locations. In other areas, pharmacy owners from neighboring towns are opening new branches. Without them, numerous communities would have been left with no pharmacy.
It didn’t used to be this way. Big-box stores like Shopko started to move aggressively into the pharmacy market 30 years ago, hoping customers would fill their carts while the store filled their prescriptions. Large chains established beachheads in small towns by acquiring independent pharmacies or driving them out of business.
According to the Bureau of Labor Statistics, the number of pharmacists employed at big-box stores peaked at more than 31,800 in 2012. But as online sales and mail delivery of consumer goods and prescription drugs grew, the big-box stores had no reason to stay. By 2019, the number of big-box pharmacists had dropped to fewer than 18,000. (The bureau no longer reports the number.)
“The big-box stores came into smaller and smaller communities, and they, in essence, outcompeted all the other pharmacies in the area,” said David Zgarrick, a pharmacy professor at Northeastern University in Boston. “Now they’re completely gone and with them the pharmacy services and everything else they provided. They left a vacuum in a lot of these places.”
With CVS Health’s recent announcement that it will close 300 stores a year over the next three years, more towns could lose another tier of pharmacies: the big drugstore chains. CVS has not yet said which stores will close.
“We’re considering a number of factors when making these decisions, including local market dynamics, population shifts, store density, and the needs of underserved communities,” said Mike DeAngelis, a CVS Health spokesperson. “In fact, reaching underserved populations has been a priority for us all through the pandemic, such as the access to testing and vaccines we’ve provided.”
Kathleen Bashur, a spokesperson for the National Association of Chain Drug Stores, said chain pharmacies of all types and sizes play a significant role in meeting the health and wellness needs of communities throughout the nation. “The decision to close a store is a difficult one,” she said.
Zgarrick attributes much of the decline in big-box pharmacies to Amazon and other online merchants that undercut the profitability of their non-pharmacy sales. In the past, big-box stores could treat pharmacies as loss leaders and make up that revenue with sales of other goods. Now, Zgarrick said, big-box stores have to ask tough questions about how to allocate their space: “‘At the end of the day, how are we going to make the most money per square foot? Is it by having a pharmacy or by selling tires?’”
Nelson Lichtenstein, a University of California-Santa Barbara history professor who has chronicled the rise of Walmart, said big-box stores are constantly reevaluating their store locations, closing less profitable stores and opening new ones in places where they think they can make money.
“They just keep a kind of slow churn,” he said.
The cost of building a big-box store is about $10 million, Lichtenstein said, and such stores can net $200 million in annual revenue. Pulling out of a location is therefore not a huge loss for a big company if revenues falter.
“So they will shut down the stores and leave a devastated town because the Walmart put the other guys out of business,” he said.
Walmart did not answer questions about its closures.
The growth in online options for all kinds of items, spurred by people shopping from home during the covid-19 pandemic, has put further pressure on big-box stores.
“Now they’re less likely to do that roaming shopping than they were five years ago,” said Adam Hartung, a business strategy consultant with Spark Partners. “They’re not going to say, ‘Oh, let’s pick up a prescription and, while we’re at it, let’s walk through the store and look at vacuum cleaners.’ That doesn’t happen anymore.”
Hartung said that the U.S. retail market has an excess of shops, by as much as 40% compared with other countries, and that more big-box stores are likely to close in the coming years.
But closures provide opportunities for regional chains or pharmacists willing to strike out on their own.
In Orofino, Idaho, the mayor, the chamber of commerce and many residents appealed to pharmacist Rod Arnzen after Shopko pulled out. So Arnzen began delivering to Orofino from his store 23 miles away in Kamiah. He then opened a branch in Orofino in the building left behind by the pharmacy that had previously sold its business to Shopko.
Andy Pottenger, who owns a pharmacy 45 miles away in Lewiston, Idaho, added a second pharmacy in Orofino, population about 3,000, after receiving hundreds of responses to an ad he had placed in the local paper to gauge interest.
“It was overwhelming,” he said. “That kind of cemented the idea that we should do it.”
In Montana, Mike Matovich, a third-generation pharmacist, opened stores in Roundup and Hardin after Shopko closures there.
“It’s a pretty good-sized community and has a hospital and clinic in town,” Matovich said of Roundup, “and all of a sudden people are driving 50 miles one way to fill an antibiotic for a sick child.”
Matovich has seen what can happen when a rural community loses its only pharmacy.
“If there’s a hospital clinic and a pharmacy there, they’re going to do fairly well,” Matovich said. “Once you lose one or the other, the communities start to struggle because people start leaving to be closer to health care.”
For the residents of Greenfield, Iowa, Shopko’s decision meant they had to scramble. Shopko had sold the pharmacy records to a Walgreens 50 miles away. Some people turned to the Hy-Vee grocery stores in the nearby Iowa cities of Atlantic or Winterset, or to the Walmart in Creston — each at least a half-hour drive away. Others switched to mail order.
“It was sheer chaos,” former Shopko pharmacist Rachel Hall said. “People were trying to figure out what to do, where they should send their prescriptions.”
Mather, Hall and the rest of the Greenfield staff were given just one week’s notice after being told they had nothing to worry about. Their pharmacy had been among the chain’s fastest-growing locations.
“We literally had trophies from Shopko that we threw away when we left,” Hall said.
Former Shopko executives contacted by KHN declined interview requests. Shopko Optical, which operates in 11 states, said it is no longer affiliated in any way with Shopko Stores and declined to comment.
Mather and Hall didn’t want to give up on Greenfield. They reached out to NuCara, a chain with 30 retail pharmacies across five states, and it agreed to help them open a drugstore in their city.
NuCara opened pharmacies in two other communities that Shopko vacated. In the Minnesota cities of Cokato and North Branch, NuCara partnered with pharmacists who had previously sold their pharmacies to Shopko, said Brett Barker, vice president of pharmacies for NuCara.
In Greenfield, Hall and Mather were forbidden from telling customers about the new NuCara drugstore until Shopko officially closed its doors. Hall said Shopko management wanted to maintain the value of the customer files it was selling to Walgreens. So Hall and Mather asked the local chamber of commerce to get the word out.
They found temporary space at the local hospital, which relocated its billing office to accommodate them. A year later, they moved back into their former location in the old Shopko building, leasing the space from new owners, who were running a household goods store there.
After serving three generations of Greenfield customers, Mather was relieved the town still had a pharmacy. But he couldn’t get past how Shopko had ended things.
“The way they slammed the door, I was really unhappy about that,” Mather said. “It wasn’t fair to all the people at the Greenfield pharmacy and the people of Greenfield. Shopko couldn’t have cared less.”
Yet the move brought Mather full circle. Greenfield still has a pharmacy, just as when he started at Murdy Drug in 1968. It’s just a different storefront, with a new name on the sign.
In recent years, interfacility transports or transfers, also known as IFTs, have become increasingly common for GVH Paramedics, forcing the team to drive far outside its already vast zone.
GUNNISON, Colo. — The night after Thanksgiving, a small ambulance service that covers a huge swath of southwestern Colorado got a call that a patient needed an emergency transfer from the hospital in Gunnison to a larger one with an intensive care unit 65 miles away in Montrose.
The patient — a 78-year-old man — was experiencing atrial fibrillation, an irregular heartbeat that usually isn’t life-threatening. But for patients like this one with chronic health conditions, a history of cardiac issues and high blood pressure, the condition can cause a stroke or heart failure.
Workers from Gunnison Valley Health Paramedics rolled the patient, who was on a gurney, out of the hospital and into the frigid night air. AnnieGrace Haddorff, the emergency medical technician on call, helped load the patient into the ambulance and jumped into the driver’s seat. Paramedic Alec Newby got into the back and hooked the patient up to a blood pressure cuff; a pulse oximeter, which measures heart rate and blood oxygen saturation; and an electrocardiogram, which records the heart’s electrical activity.
“Your heart is obviously pissed off,” Newby told the man as the ECG confirmed the atrial fibrillation.
The ambulance pulled onto U.S. Highway 50 for the one-hour-and-15-minute drive past clusters of homes among rolling hills of sagebrush, the expansive Blue Mesa Reservoir and the gaping Black Canyon of the Gunnison, with its craggy spires.
The patient was stable enough for the long drive, which covered only a sliver of GVH Paramedics’ 4,400-square-mile service area. It is more than twice the size of Delaware and is the largest response zone for an ambulance service in all of Colorado. A typical fire or emergency medical service response area ranges from 100 to 400 square miles.
In recent years, interfacility transports or transfers, also known as IFTs, like this one have become increasingly common for GVH Paramedics, forcing the team to drive far outside its already vast zone. Before the pandemic, the number of transfers rose because the population of Gunnison County was steadily increasing, more tourists were being drawn to places like the popular Crested Butte ski resort, and GVH Paramedics had expanded its services to larger metropolitan hospitals outside Gunnison County.
But now the team is being called to move patients more frequently, and greater distances, because the hospital beds in the relatively close cities of Montrose and Grand Junction are filled with covid-19 patients. The team is regularly required to drive patients to Denver, which is around three hours and 40 minutes from Gunnison.
Officials from the ambulance service worry that they might find themselves unable to respond to an emergency because their resources, which include six ambulances but only enough staff to operate three of those vehicles, are tied up on a long-haul transfer.
What were once 2½- or three-hour trips to Montrose are now far longer excursions, “and that takes resources from this community,” said CJ Malcolm, chief of emergency services. “We were doing that pre-covid, but now the state is so impacted, it’s like a daily part of our lives.”
Before the pandemic, all the ambulances would be simultaneously out on 911 calls or IFTs less than 10 times a year. Now, Malcolm said, it is happening with greater frequency. In those cases, GVH Paramedics leans on the emergency response team in Crested Butte, about 28 miles from Gunnison, or the response to the patient is delayed.
In 2018, GVH Paramedics made 166 IFTs, requiring nearly 40,000 miles of travel and a total of 987 hours of ambulance operation, according to data collected by the team. Last year concluded with 260 IFTs, over 70,000 miles of travel and a total of 1,486 hours of ambulance operation. That’s a 50% increase in time on the road.
“Anytime we have one or two ambulances out on an IFT, this leaves a massive tract of land with only one ambulance to respond,” Malcolm said. “This is a moderately terrifying position to be put into when we can easily have two or three 911 calls in a row.”
In August, for example, Gunnison Valley Health hospital transferred more than 60 patients, 37 of whom were transported by GVH Paramedics. That means that at least once a day that month, a GVH Paramedics crew was taking a patient out of town, Malcolm said. And if crew members aren’t scheduled to be back in Gunnison by 1 a.m., they must spend the night in a hotel to avoid driving along treacherous mountain roads while overly tired.
GVH Paramedics’ service area covers almost all of Gunnison County, a large portion of Saguache County and sections of Montrose and Hinsdale counties. It contains mountain ranges, canyons and wide expanses of high desert. With around 6,600 full-time residents and a university, Gunnison is the largest town the team serves. The surrounding towns — including Tin Cup, Pitkin and Ohio City — are villages with a couple of hundred people or former mining towns where the artifacts from the boom times outnumber the residents.
GVH Paramedics’ 21 full-time staff members and 10 to 20 individuals who work as needed have certifications in wildland firefighting and backcountry medicine skills, including swift-water, ice and avalanche rescue. To deal with the increased demands from IFTs, they have added an extra staff member to each shift, and off-duty staffers are being called in to assist.
As the pandemic drags on, the number of IFTs will probably continue to increase. By mid-November, the number of people in the hospital with covid-19 in Colorado was staggeringly high, approaching the December 2020 peak of 1,847. Hospitalizations remained above 1,500 through the end of the month. As a result, 93% of the state’s acute care hospital beds and 94% of ICU beds were being used as of Nov. 30, according to data from the Colorado Department of Public Health and Environment.
“I don’t think we see the capacity concerns easing anytime soon,” said Cara Welch, senior director of communications at the Colorado Hospital Association.
Adding to the strain are people seeking care they delayed because of the pandemic and other respiratory viruses, such as respiratory syncytial virus, circulating in the state, Welch said.
Kelly Thompson, chief of operations of CareFlight of the Rockies, an air ambulance service that operates in Colorado and other parts of the West, agreed with this assessment. “We’ve already been transporting large numbers of kids with RSV that are sick, and you have covid on top of all of this,” Thompson said. “It’s a big concern. This is the time when we have a lot of sick people.”
In early November, to manage escalating concerns about hospital capacity, Colorado hospitals and health systems activated tier 3 of the state's patient transfer system — the highest level. That means covid and non-covid patients can be moved without their consent from a hospital that doesn’t have enough capacity to one with more space. Hospitals can also send sicker patients to medical centers with more specialized care.
As the GVH Paramedics crew members approached Montrose with their patient over the recent holiday weekend, Newby called the hospital to let the staff know they were arriving. They pulled up to the emergency room entrance, and Newby and Haddorff rolled the patient into a hospital room. The Montrose hospital staff took over, moving the patient from the gurney to a hospital bed as Newby updated them on the patient’s medical records.
Soon they were back in the ambulance, headed for home. “IFTs can be stressful,” said Haddorff as she maneuvered the twisty mountain road bathed in moonlight.
Pharmacies were once routinely bequeathed from one generation to the next, but, in interviews with more than a dozen pharmacists, many said the pressure of running an independent drugstore have them pushing their offspring toward other careers.
Ted Billinger Jr. liked to joke that he would work until he died. That turned out to be prophetic.
When Billinger died of a heart attack in 2019 at age 71, he was still running Teddy B’s, the pharmacy his father had started more than 65 years earlier in Cheyenne Wells, Colorado. With no other pharmacist to work at the store, prescriptions already counted out and sealed in bottles were suddenly locked away in a pharmacy that no one could enter. And Cheyenne Wells’ fewer than 800 residents were abruptly left without a drugstore.
Pharmacies were once routinely bequeathed from one generation to the next, but, in interviews with more than a dozen pharmacists, many said the pressure of running an independent drugstore have them pushing their offspring toward other careers. And when they search for a buyer, they often find that attracting new pharmacists, especially to rural settings, is difficult. With a large group of pharmacists nearing retirement age, more communities may lose their only drugstore.
“It’s going to be harder to attract people and to pay them,” said David Kreling, a professor emeritus at the University of Wisconsin-Madison School of Pharmacy. “If there’s not a generational thing where someone can sit down with their son or daughter and say that they could take the store over, there’s a good chance that pharmacy will evaporate.”
Tom Davis, Billinger’s friend and co-owner of Kiowa Drug in Eads, Colorado, stepped in to sort out the mess in Cheyenne Wells. With permission from the State Board of Pharmacy, the county sheriff let Davis into Teddy B’s in the eastern Colorado town to take an inventory of the remaining drugs. Customers who had dropped off their prescriptions before Billinger died were able to pick up their medications.
Davis then bought the pharmacy from Billinger’s estate. He runs it as a convenience store and six days a week delivers prescriptions to it from Eads, 44 miles away.
“By the time you paid a pharmacist, the location there was borderline unprofitable,” Davis said.
He has received numerous requests to open pharmacies in other eastern Colorado towns, but making that work financially would be difficult. Reimbursements from insurance plans have dwindled, and customer bases have eroded as health insurers push patients toward mail-order deliveries.
“I fill prescriptions every day where my reimbursement is less than the cost of the drug,” Davis said. “In other settings, you might tell a patient, ‘We don’t have that in stock,’ or ‘Why don’t you go down the street to the chain?’ But down here, we just take care of our patients, and we just eat it.”
He can survive, he said, because, after 48 years, he no longer has any business debt.
“I look at my bottom line,” Davis said. “With the amount of profit that I had at the end of the year, that would not have been enough if I was having to pay a mortgage.”
Studies have found the number of pharmacists nationally to be sufficient, even more than enough, to meet current needs, although supply and demand don’t always line up. Finding pharmacists is more difficult in rural areas.
“Once they get a taste of the big city,” Kreling said, “it’s hard to get them back to the farm.”
Workforce data also shows worrisome trends. Concerns about a shortage of pharmacists led the federal government to pour money into pharmacy schools in the 1970s, creating a temporary bump in the number of graduates. The people in that bulge in the pharmacist pipeline have hit retirement age.
“Many of them owned independent pharmacies, and they were working in rural communities,” said University of Minnesota pharmacy professor Jon Schommer, who studies workforce issues.
Now, as the demand for pharmacists to provide testing and vaccinations during the covid-19 pandemic increases, drugstore chains are offering incentives — such as large salaries, signing bonuses and help paying off school loans — that are often more enticing than anything a rural pharmacy could muster.
How pharmacy graduates envision their careers has also shifted. Many no longer want to own a pharmacy and are content to work at pharmacy chains or other health care organizations, according to several pharmacy school professors. As of 2018, only about half of pharmacists worked in traditional retail drugstores.
That makes rural recruitment more difficult.
Denise Robins had worked at R&R Family Pharmacy in Springfield, Colorado, for 18 years when the owner retired. She and three family members bought the drugstore in a last-ditch effort to keep it open.
“None of us are pharmacists, so that made it a little tougher,” Robins said. “We just knew it was really going to make it hard for people here if they had to travel an hour to get to a pharmacy.”
But finding a pharmacist to work in the southeastern Colorado town of fewer than 1,400 people was a challenge. The first pharmacist Robins found commuted 48 miles one way from Lamar. But after a year and a half, the trip became too much.
She then hired someone who wanted to work for only a year, to make enough money to travel. Then Robins interviewed two University of Colorado pharmacy school graduates. She hired one, but that didn’t work out. So she called back the second candidate, who still had not found a permanent job. He had two young kids, and he and his wife were working opposite schedules. He took the job two years ago and has remained there since.
In Berryville, Virginia, pharmacist Patricia White opened Battletown Pharmacy in 2011 because she wanted to carry on the family business. Her father had owned a local pharmacy and had recently died. But when turning a profit with Battletown proved a struggle, White decided to retire.
She lined up two potential buyers, but neither went through with the sale. She then hoped to transfer the pharmacy to a recent graduate but didn’t want to saddle him with a failing business.
“I told him he couldn’t make any money, and he said, ‘Thanks for being honest,’” White recalled.
Closing seemed like the only palatable option. Battletown shut down at the end of August. “I did not want to sell out to a chain,” she said. “That’s always been my mentality.”
When a chain buys a pharmacy, it doesn’t always decide to run it. Instead, it might close the pharmacy and transfer the pharmacy’s prescription files to one of its outlets. Retiring pharmacists who spent decades serving a community generally don’t want to see that happen, said David Zgarrick, a Northeastern University pharmacy professor.
“They’d like to sell their pharmacy to another pharmacist who would continue to run it very much in the same manner,” he said.
Some plan ahead, hiring another pharmacist and offering that person an equity stake in the business. Over time, the new pharmacist can buy out the owner. Many independent pharmacist-owners plan to live off the profits from selling their pharmacy, its inventory and its prescription records.
“Their pharmacy is their retirement savings,” Zgarrick said.
But, Zgarrick said, the added pressure from the pandemic may be pushing more pharmacists into retirement. And a long-running bull stock market may mean some pharmacists have enough in their retirement portfolios to call it quits without a sale.
In Eads, Davis, 70, still loves being a pharmacist. He and his brother co-own seven pharmacies and have started to plan for retirement by hiring five young pharmacists and allowing them to buy ownership stakes in those pharmacies over time.
He had wondered how long he could keep the Kiowa pharmacy running, though. With fewer than 700 residents, Eads may be the smallest town in Colorado with a pharmacy. Combining Davis’ customer base with Cheyenne Wells’ may have saved pharmacy access for both communities.
“So maybe where we could have lost two pharmacies in the area, we’ve been able to exist. We’re stronger now than we had ever been,” Davis said. “That wasn’t the original plan. We cared about those people and just wanted to take care of them.”
Hospitals say the fees, which can add hundreds of dollars or even more than $1,000 to a patient’s bill, are necessary to cover the high cost of keeping a hospital open and ready to provide care 24/7.
When Arielle Harrison’s 9-year-old needed to see a pediatric specialist at Yale New Haven Health System in June, a telehealth visit seemed like a great option. Since her son wasn’t yet eligible to be vaccinated against covid-19, they could connect with the doctor via video and avoid venturing into a germy medical facility.
Days before the appointment, she got a notice from the hospital informing her that she would receive two bills for the visit. One would be for the doctor’s services. The second would be for a hospital facility fee, even though she and her son would be at home in Cheshire, Connecticut, and never set foot in any hospital-affiliated building.
Harrison, 40, who works in nonprofit communications, posted on Twitter about the unwelcome fee, including an image of Marge Simpson of TV’s The Simpsons with a disgusted look on her face, captioned “GROANS.”
She called the billing office the next morning and was told the facility fee is based on where the doctor is located. Since the doctor would be on hospital property, the hospital would charge a facility fee of between $50 and $350, depending on her insurance coverage.
“It’s just one of many examples of how this is a very difficult system to use,” Harrison said, referring to the intricacies of U.S. health care.
Hospital facility fees have long come under criticism from patients and consumer advocates. Hospitals say the fees, which can add hundreds of dollars or even more than $1,000 to a patient’s bill, are necessary to cover the high cost of keeping a hospital open and ready to provide care 24/7.
But it’s not only hospital visits that result in facility fees. Over the past several years, hospitals have been on a buying binge, snapping up physician practices that often then begin charging the fees, too. Patients seeing the same doctor for the same care as at earlier visits are now on the hook for the extra fee — because of a change in ownership.
Charging a facility fee for a video visit where the patient logs in from their living room is even more of a head-scratcher.
“The charges seem crazy,” said Ted Doolittle, who heads up Connecticut’s Office of the Healthcare Advocate, which provides help to consumers with health coverage issues. “It rankles, and it should.”
Facility fees for video appointments remain rare, health finance experts say, even as the use of telehealth has soared during the covid pandemic. Medicare has allowed hospitals to assess a small fee for certain beneficiaries who get telehealth care at home during the ongoing national public health emergency, and people in private health plans may also be charged for them.
Harrison, however, was lucky. Doolittle reached out to her after seeing her tweet to offer his office’s assistance. In Connecticut, hospitals are prohibited from charging facility fees for telehealth visits.
Connecticut imposed what may be the only state ban on telehealth facility fees as part of a broader law passed in May that was intended to help residents access telehealth during the pandemic. The prohibition on facility fees sunsets at the end of June 2023.
Pat McCabe, senior vice president of finance at Yale New Haven Health System, said he can’t explain why Harrison received a notice that she’d be charged a facility fee for a telehealth visit. He speculated that her son’s appointment might have been coded incorrectly. Under the new law, he said, the health system hasn’t charged any telehealth patients a facility fee.
But such fees are justified, McCabe said.
“It offsets the cost of the software we use to facilitate the telehealth visits, and we do still have to keep the lights on,” he said, noting that the providers doing telehealth visits are on hospital sites that incur heat and power and maintenance charges.
The American Hospital Association didn’t respond to requests for comment about the rationale for facility fees for telehealth care.
As the pandemic began overwhelming the health system last year, hospitals essentially closed their doors to most non-covid patients.
Telehealth visits, which made up about 1% of medical visits before the pandemic, jumped to roughly 50% at its height last year, said Kyle Zebley, vice president of public policy at the nonprofit American Telemedicine Association, which promotes this type of care. Those appointments have dropped off and now make up roughly 15% of medical visits across all types of coverage.
Before the pandemic, the Centers for Medicare & Medicaid Services severely limited telehealth coverage for Medicare fee-for-service beneficiaries. But with seniors more vulnerable during the pandemic, the agency loosened telehealth rules temporarily. As long as the public health emergency continues, the agency is allowing Medicare beneficiaries in urban areas to receive such care, which was previously covered only in rural areas. And patients can get telehealth care at home rather than having to go to a medical facility for the video appointment, as was previously required. The agency also beefed up covered telehealth services and expanded the types of providers who are allowed to offer them.
Medicare lets hospital outpatient departments bill about $27 for telehealth visits for certain beneficiaries receiving care at home. Patients are generally responsible for 20% of that amount, or about $5, although providers can waive patient cost sharing for telehealth, said Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF.
At the beginning of the pandemic, patients with commercial health plans were often not charged a copay for telehealth visits, said Rick Gundling, a senior vice president at the Healthcare Financial Management Association, a membership group for health care finance professionals. But lately, “those fees have been coming back,” he said.
Facility fees for telehealth visits in commercial plans averaged $55 for the year that ended June 30, before insurance discounts, according to data from Fair Health, a national independent nonprofit that maintains a large database of insurance claims. In 2020, just 1.1% of commercial telehealth claims included a facility fee, according to Fair Health. That’s lower than for 2019, when the figure was 2.5%.
Experts predict telehealth will remain popular, but it’s unclear how those visits and any accompanying facility fees will be handled in the future.
McCabe said he expects the Yale New Haven Health System to reinstitute the facility fees when state law permits it.
“There are real costs in the health system to provide those services,” he said.
As deadly coronavirus cases spiked this year, daily pressures intensified on hospital floors. Some nurses retired; some became travel nurses, hired by agencies that advertised more than double, even triple, the day rates for intensive care unit, telemetry and emergency room nurses. Others gave up their jobs to avoid possibly carrying the covid virus home to their families.
Nurses and health care workers across the country are finding strength in numbers and with labor actions not seen in years.
In California, which has a strong union tradition, Kaiser Permanente management misjudged workplace tensions during the covid-19 crisis and risked a walkout of thousands when union nurses balked at signing a four-year contract that would have slashed pay for new hires. In Colorado, Pennsylvania, North Carolina and Massachusetts, nurses have been embroiled in union battles over staffing and work conditions.
As deadly coronavirus cases spiked this year, daily pressures intensified on hospital floors. Some nurses retired; some became travel nurses, hired by agencies that advertised more than double, even triple, the day rates for intensive care unit, telemetry and emergency room nurses. Others gave up their jobs to avoid possibly carrying the covid virus home to their families.
“Things had gotten particularly stark for nurses,” said Rebecca Kolins Givan, an associate professor of labor studies at Rutgers University.
‘They Can Make More at McDonald’s’
It was so grim in Pittsburgh that registered nurses at West Penn Hospital, part of the Allegheny Health Network, voted this year to authorize a strike — less than a year after they unionized with SEIU Healthcare Pennsylvania. Chief among their complaints: The hospital system had balked at improving staff ratios even as it offered bonuses, up to $15,000 for some, to hire registered nurses to fill vacancies.
Kathleen Jae, a member of the bargaining team that reached a pact without a work stoppage, said nurses wanted management to work harder to retain veteran staff members: “We had to face the fact that nurses are retiring, nurses are leaving the bedside out of frustration, and, in certain instances this year, nurses had more patients than they felt comfortable taking care of.”
Allegheny Health Network said the first-ever pact with RNs at West Penn provides “competitive wages and benefits” to help it “recruit and retain talented, experienced nurses.”
Liz Soriano-Clark, a teacher-turned-nurse on the bargaining team, said the pandemic had made workers across the health sector more careful and choosier about what jobs they’ll take.
“There’s a nursing shortage and a shortage of nursing instructors, nationwide. They’ve seen aides leave. They’ve seen cleaners leave,” Soriano-Clark said. “Why is that? Because they can make more at McDonald’s and not have to clean up vomit.”
In September, the American Nurses Association alerted the Biden administration to an “unsustainable nurse staffing shortage facing our country” in a letter to the Department of Health and Human Services. The ANA said a “crisis-level human resource shortage” was evident: Mississippi had 2,000 fewer nurses than it did at the beginning of 2021. Tennessee called on its National Guard to reinforce hospital staffs. Texas was recruiting 2,500 nurses from outside the state.
Union membership among U.S. nurses has inched up over the past 15 years and held steady, at about 17%, for five years, according to unionstats.com, an academic website. But 2021, a year of union organizing and holdouts in such disparate workplaces as Starbucks cafes and John Deere tractor plants, might well be a turning point for essential workers in health care.
“If you ask nurses what they want,” said Givan, who interviewed dozens of nurses for a 2016 book on health care workers, “they want working conditions where they can provide a high level of care. They don’t want appreciation that is lip service. They don’t want marketing campaigns. They don’t want shiny new buildings.”
Still, Givan noted, the health care sector has spent handsomely to fight unions.
After years of staff retention issues at Longmont United Hospital in Colorado, nurses are awaiting the results of a vote on whether to join National Nurses United, the largest union of registered nurses in the U.S.
Stephanie Chrisley, a registered nurse in the hospital’s ICU, said nurses are regularly caring for double the number of patients considered appropriate — often three to four “ventilated, sedated, critically ill patients.”
She and others protested outside the hospital in early December. They said the company that runs the hospital, Centura Health, this year had employed aggressive union-busting tactics, including disputing a handful of votes, which dragged out the union election for about five months. In another instance, her colleague Kris Kloster said, Centura, founded by Catholic nuns, issued company-wide emails announcing raises and retention bonuses for everyone except nurses at her hospital.
“Where there should have been newly hired nurses, there were anti-union consultants roaming around the hospital,” Chrisley said. Since July, she added, the hospital has lost nearly 80 RNs, “nearly a third of our nursing staff.” Longmont United Hospital Interim CEO Kristi Olson said in a statement that the hospital “will remain open and fully operational” and that “we are committed to making sure that all voices were heard” in the union election.
Organizing can take a long time, Givan said, pointing to tense labor negotiations in Massachusetts, North Carolina and Pennsylvania. “But when there is a crisis — what we call a hot shop — you can get workers to organize quite quickly.” Nurses represented by the Massachusetts Nurses Association walked off the job March 8 in Worcester. A chance to break the bitter impasse collapsed when management, Tenet Healthcare, refused to allow some nurses to return to their original jobs. In North Carolina, registered nurses at Mission Hospital in Asheville ratified a contract with the HCA management that locked in 17% raises over three years and set up a committee to review patient care conditions.
A recent poll by Gallup, the global analytics firm, found that the share of Americans who say they approved of unions was at 68%, its highest point since 1965.
Sal Rosselli, president of the National Union of Healthcare Workers, said that in the past year “there has just been an explosion of leads,” queries from health workers exploring how to unionize.
Rosselli, whose organization represents about 15,000 health workers, said the pandemic exposed practices that had long antagonized employees. Too many hospitals scrambled for masks, gloves and gowns, he said, and front-line workers were on round-the-clock schedules and facing ghastly daily deaths. “They weren’t keeping their employees and their patients safe,” Rosselli said, “and all because these systems were focused on profit over anything else. That has been coming on for a long, long time.”
Registered nursing is among the U.S. occupations expected to experience the greatest levels of job growth in the next decade, according to the Bureau of Labor Statistics’ Employment Projections 2020-2030. Also among the fastest-growing occupations are nurse practitioners, home health care aides and assistants. Shortages of RNs and other health care workers are expected to be the most intense in the South and West.
Some of the most powerful nursing unions in the nation operate out of California, representing employees in Western states. “The nurses in California have the hours they have, the care they have, the protections they have because of the union,” said Soriano-Clark, who has worked at hospitals in California and Pennsylvania.
Ready to Picket in a Pandemic
Douglas Wong, a physician assistant, never imagined hoisting a “strike” sign outside Riverside Medical Center. But that nearly happened after a sobering breakdown in talks between Kaiser Permanente and a top nurses union at the facility, part of the KP system. Nurses, pharmacists and operations staffers are among the insurers’ 160,000-plus unionized employees, according to KP spokesperson Marc Brown.
The California-based health system giant tried to force a two-tier pay schedule that would have cut wages for new nurses by 26%. Wong and thousands of allies — many who dryly noted they had been heralded as “heroes” in the covid crisis — prepared to picket in the middle of a pandemic. Kaiser Permanente’s demands crumbled when dozens of affiliated unions threatened one-day sympathy strikes.
The tiered-pay demand and an attempt to lower wages in some markets were dropped. Staffing ratios were adjusted to ease safety concerns. Wong said that, despite the pact, the bruising negotiations “felt like a betrayal.”
“Make no mistake: This was an enormous win for labor, especially pushing back on the two-tier. At the end of the day, they pulled back. And we made huge strides toward improvement in our staffing,” said Wong, a six-year KP employee and an official with the United Nurses Associations of California/Union of Health Care Professionals.
The negotiations were a marked shift for Kaiser Permanente, which for most of three decades has relied on a labor-management partnership with its unions, emphasizing cooperative decision-making and robust discussions. Talks were held with teams, set around circular tables, hashing out concerns. KP was known for much of the past decade as a market leader in wages and quality of care, and the labor-management partnership was received by academics and labor experts as an innovative, successful approach to managing a workforce.
The health system recently hired new top executives, and, to the surprise of the unions, Kaiser Permanente used negotiations this year to offer the two-tier pay regimen, a tactic used by auto- and steel-makers during economic downturns in the 1980s. The union negotiators noted this: The health care giant’s management wanted to scale back wages after notching $6.8 billion in net revenue from 2018 to 2020.
On Thursday, workers voted to ratify a four-year contract with KP. The company declined to comment for this article. In a news release, Christian Meisner, KP’s chief human resources officer, said: “This contract reflects our deep appreciation for the extraordinary commitment and dedication of our employees” during the pandemic. “We look forward to working together with our labor partners,” he said, to “further our mission of providing high-quality, affordable care.”
The Wall Street Journal recently reported that nurses’ pay was sweetened in 2021 by thousands of dollars in raises — handed out without union wrangling — as hospitals competed for workers. Premier, a health care consultancy hired by the Journal, analyzed 60,000 registered nurses’ salaries and found that average annual pay, not including overtime or bonuses, grew about 4% in the first nine months of the year, to more than $81,000. That compares with a 2.6% rise in 2019, according to federal data.
Raises don’t necessarily mean retention.
“There always seems to be a shortage of nurses,” said professor Paul Clark, who is a former director of Penn State University’s School of Labor and Employment Relations and has studied nursing and labor organizing. “But it’s important to realize there’s not a shortage of RNs. There’s a shortage of RNs willing to work under the conditions they’ve been asked to work.”
Aya Healthcare, a national travel nurse provider, has found that the pandemic aggravated historical understaffing at hospitals, spokesperson Lisa Park said in an email. “There were over 100,000 vacancies at the start of the pandemic. And now, that number has increased to over 195,000,” Park said. Travel nurses account for fewer than 2% of the nursing workforce, she added, but “with the increase in permanent vacancies due to burnout/resignations, the demand for temporary healthcare workers has increased.”
David Zonderman, a professor of labor history at North Carolina State University, noted that nurses unions have grown more political and more outspoken — in Washington, D.C., and their home states. Nurses on the hospital floor lived through a crisis — fearing for their lives amid shortages of protective equipment — much like the trials of American workers in the mining and manufacturing industries in decades past.
“This may sound weird,” Zonderman said, “but nurses are a little like coal miners. They tend to help each other. They are watching each other’s back. They have solidarity.”
“And,” he said, “if you treat people badly long enough, they finally say, ‘I’m done.’”
Covid-19’s unrelenting spread exposed deep, systemic problems with the quality of care — or lack thereof — at nursing homes across the country. In the nation’s most populous state, the industry’s track record during the pandemic is spurring leaders to radically rethink how it pays and oversees them.
SACRAMENTO, Calif. — About 1 in 8 Californians who have died of covid lived in a nursing home.
They were among the state’s most frail residents: nearly 9,400 mothers, fathers, grandparents, aunts and uncles whom Californians entrusted to a nursing home’s care. An additional 56,275 confirmed covid cases among nursing home residents weren’t fatal.
“The number of covid infections and deaths that happened in skilled nursing facilities in California is truly appalling,” Jim Wood, a Democrat who chairs the state Assembly Health Committee, said at a recent hearing he convened on nursing homes. “I expect better from us.”
Covid-19’s unrelenting spread exposed deep, systemic problems with the quality of care — or lack thereof — at nursing homes across the country. In the nation’s most populous state, the industry’s track record during the pandemic is spurring leaders to radically rethink how it pays and oversees them.
Gov. Gavin Newsom’s administration is drafting a proposal to tie state funding more directly to performance: Among the state’s roughly 1,200 skilled nursing facilities, those that meet new quality standards would get a larger share of state funding than those that don’t.
But exactly how the Golden State would measure quality care and allocate the roughly $5.45 billion a year that nursing homes collectively receive is far from settled — and promises to spark one of 2022’s biggest health care fights. When the legislature debates those details as part of state budget negotiations, the nursing home industry vows to oppose any proposal tying Medicaid payments to quality metrics such as staffing levels, pay and turnover.
In fact, the industry plans to argue it needs more money to deliver better results — and it wields substantial power in the Capitol.
In the past decade, it has spent at least $10 million to influence lawmakers and has given one or more political donations to Newsom and at least 105 current members of the 120-member legislature, according to a KHN analysis of campaign finance records.
But patient advocates and family members who lost loved ones in nursing facilities during the pandemic are mobilizing a counterattack to convince lawmakers that now is the time to overhaul the system.
“There are a lot of problems people have complained about for a long time,” said Charlene Harrington, a professor emerita of social and behavioral sciences at the University of California-San Francisco and an expert on nursing homes. “This is an opportunity to correct those problems.”
At least 140,790 covid deaths have been reported in U.S. nursing homes, according to the latest data from the Centers for Disease Control and Prevention. Older adults have a heightened risk of dying of covid, and the coronavirus spreads more easily in institutional settings such as nursing homes and assisted living facilities.
That’s one reason Craig Cornett, CEO of the California Association of Health Facilities, thinks blaming nursing homes for high covid infection rates, especially early in the pandemic, is unfair. Not only are their residents naturally at higher risk than the rest of the public, he said, but the facilities were forced to accept hospital transfer patients who had not been tested for the virus, they couldn’t get adequate supplies of personal protective equipment, and they suffered as staff members got covid in the community and then brought it into work.
But multiple studies inCalifornia andelsewhere have found that nursing homes with fewer nursing staff members experienced significantly higher covid infection and death rates. That devastating outcome is bolstering a two-decades-long argument by patient advocates that nursing homes must hire more workers.
“Some of these problems that we saw in the pandemic could have been avoided if nursing homes had adequate staffing,” said Harrington, who co-authored a December 2020 study for the California Health Care Foundation that showed nursing homes with lower staffing levels earlier that year had twice the covid case rates than those with higher staffing levels. (California Healthline is an editorially independent publication of the foundation.)
Some lawmakers and patient advocates suggest that the best way to improve care is to boost staffing, and that the best way to achieve that is to alter the complicated formulas that determine the daily rate nursing homes are paid by Medicaid, the government insurance program that covers about two-thirds of nursing home residents.
Currently, Medicaid reimburses a portion of what nursing homes spend on staff, administrative and other expenses, paying them a higher proportion for staff costs than administrative costs. Facilities can receive bonus payments for meeting quality standards — although the bonuses are limited and have been criticized for not boosting performance at facilities that need it most.
The California Department of Health Care Services, which administers the state’s Medicaid program, called Medi-Cal, is drafting a plan that would do away with the bonus payments and integrate quality measures into the daily Medi-Cal payment rates nursing homes receive. The department is considering multiple ways to measure quality, spokesperson Anthony Cava said in a statement: Nursing homes that offer more staff education and training could receive higher per diem rates, as could those that have more staff and less staff turnover.
That’s a non-starter for the nursing home industry, which doesn’t consider staffing to be an appropriate measure of how well residents do. Rather, Cornett, whose lobbying group represents more than 800 nursing homes, said facilities should be graded on the number of patient falls and infections, as well as patients’ abilities to perform daily activities.
“We want more staff and want to pay our staff,” Cornett said. “But we need the state to change the system so we can get more money into the staffing line. And that’s going to require a higher amount of money.”
Nursing homes warn that a heavy focus on staffing misses other critical costs of running a facility safely. Even under the current reimbursement system, they say, facilities are scraping by.
“Not all of the costs in a facility are for staff. Skilled nursing facilities, like other healthcare providers, have a variety of costs including medical supplies, consulting, real estate, taxes, administrative services, overhead and many others,” said Mark Johnson, an attorney for Brius Healthcare, one of the largest nursing chains in California.
Whether lawmakers will be sympathetic to the industry’s plea for more money is questionable. They are increasingly demanding transparency about how skilled nursing facilities make and spend their money. Like hospitals and other health care providers, nursing facilities have received billions of dollars in federal covid relief funding to help offset the costs of hiring temporary workers, testing and protective gear. It isn’t lost on lawmakers that this $12 billion industry is attracting a growing number of private investors who are buying ownership shares in their facilities.
“That tells me there’s money out there, there’s profit out there,” said Wood, who also sits on the budget subcommittee that will review the administration’s proposal. “Private equity is not going to go into facilities if they don’t have a chance to make a pretty significant return.”
There’s a lot at stake for the roughly 400,000 residents of nursing homes in the state — and for the industry, which is a big spender and a powerful force in Sacramento.
The California Association of Health Facilities has given just over $2 million in contributions and spent $5.67 million lobbying lawmakers in the past 10 years, from Jan. 1, 2011, through Sept. 30, 2021, according to records filed with the California secretary of state’s office. And Cornett, its CEO, is a veteran of the state Capitol who worked as the top budget aide to four former Assembly speakers and two Senate leaders.
During that time frame, 50 of California’s largest individual and corporate nursing home owners and operators have given a combined $2.6 million directly to lawmakers, the Republican and Democratic state political parties and ballot measures. That figure is likely an undercount because it is difficult to identify everyone with an ownership stake in a nursing home or chain. Facilities are often partially owned by real estate investors, venture capital firms and other business interests not listed on government records.
Cornett downplayed his industry’s influence and said trial lawyers are the players with deep pockets and are funding the patient advocates, an allegation those groups dispute.
But a2018 report by the California State Auditor found that the three largest private operators — Brius Healthcare, Plum Healthcare Group and Longwood Management Corp. — are highly profitable. Their combined 2006 net income of $10 million grew to between $35 million and $54 million by 2015, the most recent year the state auditor analyzed.
Patient advocates say those profits negate the industry’s argument for needing more taxpayer dollars.
“To some extent, the state is being bamboozled with this idea that the money that they’re paying now is not enough to do the job that we’ve asked them to do,” said Tony Chicotel, an attorney with California Advocates for Nursing Home Reform. “The bottom line is it goes to profit.”
Methodology
KHN analyzed campaign finance records filed with the California secretary of state’s office from Jan. 1, 2011, through Sept. 30, 2021.
We downloaded contributions made by the California Association of Health Facilities, the organization that represents the industry in Sacramento.
To determine how much nursing homes have contributed directly to political campaigns, we identified 50 of California’s largest individual and corporate skilled nursing home owners using data published by the Centers for Medicare & Medicaid Services. We connected those owners to nursing home chains and management companies that run nursing homes.
We then searched each entity and individual on the secretary of state’s website to see if they made any political contributions. We did not include money they gave to the California Association of Health Facilities to ensure we did not double-count contributions.
To track lobbying, we created a spreadsheet of expenses reported on lobbying disclosure forms from Jan. 1, 2011, through Sept. 30, 2021, also available on the secretary of state’s website, by the California Association of Health Facilities. None of the nursing home companies we identified spent any money directly lobbying lawmakers. Instead, they gave money to the association.
Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.
Patients with other ailments are frustrated, and nurses and doctors are stressed and burned out, as unvaccinated covid-19 patients fill ICU and acute care beds.
Harold Burch's home has a spectacular view in Paonia, a rural part of Colorado's Western Slope at the foot of Mount Lamborn. But the landscape has been little consolation to the 60-year-old as he has battled a cascade of health problems during the pandemic.
"It's been a real rodeo," Burch said. "It's been a lot of ups and downs and lately it's been mostly just downers."
Burch has battled chronic osteoarthritis and rheumatoid arthritis and has had two major intestinal surgeries. One specialist he was seeing left her practice last year. Another wouldn't accept his insurance. Then, Nov. 1, he started experiencing major stomach pain.
"When we talk terrible problems, I can't leave the house," he said. He hasn't eaten anything substantial in three weeks, he added.
Burch had to wait that long to be seen by a primary care doctor. He said the doctor told him, "‘If things were different, I would tell you to go to the hospital and be diagnosed, have some tests run and see what's going on with you.' But he says, ‘As of today, Delta County hospital is clear full. There are no beds available.'"
The covid variant delta has overwhelmed the Colorado county of the same name. Hospitals on the Western Slope have been slammed for weeks, and the statewide picture is similarly grim. As of Monday, the state's coronavirus website reported 1,294 patients hospitalized with covid-19. Half of the state's hospitals said they anticipated a staffing shortage in mid-December; more than a third of them anticipated bed shortages in their intensive care units at the same time.
And behind those numbers, patients are feeling the impact.
Burch's doctor told him he might have to wait hours in the emergency room, perhaps with people who have flu or covid symptoms. So Burch stayed home.
"It's really frustrating because I did the right thing and like so many other people have, and we're being just kind of like told, ‘Unless you have a really serious problem, like a heart attack, a stroke, you're going to have a baby or something like that, we really don't have time to mess with you,'" Burch said. "I mean, it's just wrong."
Burch's situation is not uncommon this fall, as the state faces its second-worst covid surge for hospitalizations and deaths. Hospitals are under tremendous strain and that means delays and changes from normal care, as strapped providers do more with less.
"Hospitals across Colorado are in critical condition. We have been at 90%-plus capacity in our ICU and acute care beds for weeks now. And unfortunately, there doesn't appear to be an end to that situation in the near future," said Cara Welch, a spokesperson for the Colorado Hospital Association.
Diann Cullen, 72, a retiree in Broomfield, Colorado, was told by her doctor that her hernia surgery would have to be postponed for weeks. Her reaction: "Frustration, extreme frustration, actually anger, because I said a bad word. … He flat-out told me we can't even do it because of too many covid patients."
The combination of too many covid patients, the need to treat those who delayed care and staff shortages have pushed hospitals into crisis, said Robin Wittenstein, CEO of Denver Health, which runs one of the state's biggest hospital and clinic systems.
"They're coming into hospitals now sicker than ever before. And they're coming in larger numbers than we've ever seen before," Wittenstein said on the day when most metro-area counties announced they were enacting a new indoor, public mask mandate. "Our system is on the brink of collapse."
At the academic medical center UCHealth, Dr. Abbey Lara said the crush of unvaccinated patients in the ICU means patients face longer waits or they don't get much-needed diagnostic tests. In the worst-case scenario, "patients who could have survived something had their life cut short because they weren't able to access care," she said.
And when there are too many patients being treated by too few staffers, Lara said, that ratchets up the difficulty for providers.
"I just worry that there's going to be not only a lot of turnover in the near future," Lara said. "But I think that access to health care is just going to get even worse in the future."
Lara predicted the effects of the pandemic will be felt long after the emergency ends: "The sky isn't falling, but the sky is going to turn a very different color."
In Longmont, Colorado, about 50 miles north of Denver, nearly a third of Longmont United Hospital's registered nurses have left since the start of July and many have not been replaced, said Kris Kloster, who has been a nurse for 32 years. She is backing an effort by nurses to unionize there.
The stress nurses and doctors feel is compounded when they feel powerless to take what they regard as an ethically correct action in treating a patient.
There's a term for that, "moral distress," said Dr. Barbara Statland, a hospitalist at Denver Health. The tension comes "because you can't do what you feel is ethically proper. And I'd say that health care workers have been riddled with this."
Despite the stress and distress, many front-line providers are hanging in there, continuing to care for patients every day. That made the difference for at least one covid patient who said he was appreciative he was able to get care — just in time.
"They saved my life. I do feel grateful for everything they did," said 58-year-old Rob Blessin, of Fort Collins.
He caught the virus this fall and spent 30 days in an ICU ward with pneumonia at North Colorado Medical Center in Greeley. He described the efforts of his doctors and nurses as heroic, some working nine or 10 days in a row, many taking overtime. And others, Blessin said, were filling in.
"So often you'd have people from different departments being trained on the fly," Blessin said. "So there's a lot of pressure on people. They're just trying to get warm bodies in there."
Respiratory therapists are in short supply in hospitals, and Blessin said as more coronavirus patients were admitted, the staff struggled to keep up.
Blessin said he landed in the hospital because he was swayed by internet misinformation and didn't get vaccinated. It's a decision he came to regret.
"I guess my recommendation would be to get vaxed, you know, even if you're totally against it; don't fall into the internet hype," Blessin said.
After his experience being hospitalized for a month due to the coronavirus, and having talked with his physicians there, he now plans to get vaccinated.