Nursing homes been scrambling to obtain doses of antibody therapies following a change in federal policy that critics say limits supplies for the vulnerable population of frail and elder residents.

This article was published on Monday, November 1, 2021 in Kaiser Health News.

By JoNel Aleccia 

Of the dozens of patients Dr. Jim Yates has treated for COVID-19 at his long-term care center in rural Alabama, this one made him especially nervous.

The 60-year-old man, who had been fully vaccinated, was diagnosed with a breakthrough infection in late September. Almost immediately, he required supplemental oxygen, and lung exams showed ominous signs of worsening disease. Yates, who is medical director of Jacksonville Health and Rehabilitation, a skilled nursing facility 75 miles northeast of Birmingham, knew his patient needed more powerful interventions — and fast.

At the first sign of the man's symptoms, Yates had placed an order with the Alabama Department of Public Health for monoclonal antibodies, the lab-made proteins that mimic the body's ability to fight the virus. But six days passed before the vials arrived, nearly missing the window in which the therapy works best to prevent hospitalization and death.

"We've been pushing the limits because of the time frame you have to go through," Yates said. "Fortunately, once we got it, he responded."

Across the country, medical directors of skilled nursing and long-term care sites say they've been scrambling to obtain doses of the potent antibody therapies following a change in federal policy that critics say limits supplies for the vulnerable population of frail and elder residents who remain at highest risk of COVID infection even after vaccination.

"There are people dying in nursing homes right now, and we don't know whether or not they could have been saved, but they didn't have access to the product," said Chad Worz, CEO of the American Society of Consultant Pharmacists, which represents 1,500 pharmacies that serve long-term care sites.

Before mid-September, doctors and other providers could order the antibody treatments directly through drug wholesaler AmerisourceBergen and receive the doses within 24 to 48 hours. While early versions of the authorized treatments required hourlong infusions administered at specialty centers or by trained staff members, a more recent approach allows doses to be administered via injections, which have been rapidly adopted by drive-thru clinics and nursing homes.

Prompt access to the antibody therapies is essential because they work by rapidly reducing the amount of the virus in a person's system, lowering the chances of serious disease. The therapies are authorized for infected people who've had symptoms for no more than 10 days, but many doctors say they've had best results treating patients by Day 5 and no later than Day 7.

After a slow rollout earlier in the year, use of monoclonal antibody treatments exploded this summer as the delta variant surged, particularly in Southern states with low COVID vaccination rates whose leaders were looking for alternative — albeit costlier — remedies.

By early September, orders from seven states — Alabama, Florida, Georgia, Louisiana, Mississippi, Tennessee and Texas — accounted for 70% of total shipments of monoclonals.

Those Southern states, plus three others — Arkansas, Kentucky and North Carolina — ordered new courses of treatment even faster than they used their supplies. From July 28 to Sept. 8, they collectively increased their antibody stockpiles by 134%, according to a KHN analysis of federal data.

Concerned the pattern was both uncontrolled and unsustainable given limited national supplies, officials with the Department of Health and Human Services stepped in to equalize distribution. HHS barred individual sites from placing direct orders for the monoclonals. Instead, they took over distribution, basing allocation on case rates and hospitalizations and centralizing the process through state health departments.

"It was absolutely necessary to make this change to ensure a consistent product for all areas of the country," Dr. Meredith Chuk, who is leading the allocation, distribution and administration team at HHS, said during a conference call.

But states have been sending most doses of the monoclonal antibody treatments, known as mAbs, to hospitals and acute care centers, sidestepping the pharmacies that serve long-term care sites and depleting supplies for the most vulnerable patients, said Christopher Laxton, executive director of AMDA, the Society for Post-Acute and Long-Term Care Medicine.

While vaccination might provide 90% protection or higher against serious COVID in younger, healthier people, that's not the case for the elders who typically live in nursing homes.

"You have to think of the spectrum of immunity," Laxton said. "For our residents, it's closer to 60%. You know that 4 out of 10 are going to have breakthrough infections."

The mAb treatments have been authorized for use in high-risk patients exposed to the virus, and experts in elder care say that is key to best practices in preventing outbreaks in senior facilities. That could include, for example, treating the elderly roommate of an infected nursing home patient. But because of newly limited supplies, many long-term care sites have started to restrict use to only those who are infected.

Still, some states have worked to ensure access to mAbs in long-term care sites. Minnesota health officials rely on a policy that prioritizes residents of skilled nursing facilities for the antibody therapies through a weighted lottery. In Michigan, state Medical Director Dr. William Fales directed emergency medical technicians and paramedics to the Ascension Borgess Hospital system in Kalamazoo to help administer doses during recent outbreaks at two centers.

"The monoclonal antibodies made a huge difference," said Renee Birchmeier, a nurse practitioner who cares for patients in nine of the system's sites. "Even the patients in the assisted living with COPD, they're doing OK," she said, referring to chronic obstructive pulmonary disease. "They're not advancing, but they're doing OK. And they're alive."

Long-term care sites have accounted for a fraction of the orders for the monoclonal treatments, first authorized in November 2020. About 3.2 million doses have been distributed to date, with about 52% already used, according to HHS. Only about 13,500 doses have gone to nursing homes this year, according to federal data. That doesn't include other long-term care sites such as assisted living centers.

The use is low in part because the treatments were originally delivered only through IV infusions. But in June, the Regeneron monoclonal antibody treatment was authorized for use via subcutaneous injections — four separate shots, given in the same sitting — and demand surged.

Use in nursing homes rose to more than 3,200 doses in August and nearly 6,700 in September, federal data shows. But weekly usage dropped sharply from mid-September through early October after the HHS policy change.

Nursing homes and other long-term care sites were seemingly left behind in the new allocation system, said Cristina Crawford, a spokesperson for the American Healthcare Association, a nonprofit trade group representing long-term care operators. "We need federal and state public health officials to readjust their priorities and focus on our seniors," she said.

In an Oct. 20 letter to White House policy adviser Amy Chang, advocates for long-term care pharmacists and providers called for a coordinated federal approach to ensure access to the treatments. Such a plan might reserve use of a certain type or formulation of the product for direct order and use in long-term care settings, said Worz, of the pharmacy group.

So far, neither the HHS nor the White House has responded to the letter, Worz said. Cicely Waters, a spokesperson for HHS, said the agency continues to work with state health departments and other organizations "to help get COVID-19 monoclonal antibody products to the areas that need it most." But she didn't address whether HHS is considering a specific solution for long-term care sites.

Demand for monoclonal antibody treatments has eased as cases of COVID have declined across the U.S. For the week ending Oct. 27, an average of nearly 72,000 daily cases were reported, a decline of about 20% from two weeks prior. Still, there were 2,669 confirmed cases among nursing home residents the week ending Oct. 24, and 392 deaths, according to the Centers for Disease Control and Prevention.

At least some of those deaths might have been prevented with timely monoclonal antibody therapy, Worz said.

Resolving the access issue will be key to managing outbreaks as the nation wades into another holiday season, said Dr. Rayvelle Stallings, corporate medical officer at PruittHealth, which serves 24,000 patients in 180 locations in the Southeast.

PruittHealth pharmacies have a dozen to two dozen doses of monoclonal antibody treatments in stock, just enough to handle expected breakthrough cases, she said.

"But it's definitely not enough if we were to have a significant outbreak this winter," she said. "We would need 40 to 50 doses. If we saw the same or similar surge as we saw in August and September? We would not have enough."

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Even in parts of the country where COVID isn't overwhelming the health system, patients are showing up to the ER sicker than before the pandemic.

This article was published on Friday, October 29, 2021 in Kaiser Health News.

By Kate Wells, Michigan Radio   

Inside the emergency department at Sparrow Hospital in Lansing, Michigan, staff members are struggling to care for patients showing up much sicker than they've ever seen.

Tiffani Dusang, the ER's nursing director, practically vibrates with pent-up anxiety, looking at patients lying on a long line of stretchers pushed up against the beige walls of the hospital hallways. "It's hard to watch," she said in a warm Texas twang.

But there's nothing she can do. The ER's 72 rooms are already filled.

"I always feel very, very bad when I walk down the hallway and see that people are in pain, or needing to sleep, or needing quiet. But they have to be in the hallway with, as you can see, 10 or 15 people walking by every minute," Dusang said.

The scene is a stark contrast to where this emergency department — and thousands of others — were at the start of the pandemic. Except for initial hot spots like New York City, in spring 2020 many ERs across the country were often eerily empty. Terrified of contracting COVID-19, people who were sick with other things did their best to stay away from hospitals. Visits to emergency rooms dropped to half their typical levels, according to the Epic Health Research Network, and didn't fully rebound until this summer.

But now, they're too full. Even in parts of the country where COVID isn't overwhelming the health system, patients are showing up to the ER sicker than before the pandemic, their diseases more advanced and in need of more complicated care.

Months of treatment delays have exacerbated chronic conditions and worsened symptoms. Doctors and nurses say the severity of illness ranges widely and includes abdominal pain, respiratory problems, blood clots, heart conditions and suicide attempts, among other conditions.

But they can hardly be accommodated. Emergency departments, ideally, are meant to be brief ports in a storm, with patients staying just long enough to be sent home with instructions to follow up with primary care physicians, or sufficiently stabilized to be transferred "upstairs" to inpatient or intensive care units.

Except now those long-term care floors are full too, with a mix of COVID and non-COVID patients. People coming to the ER get warehoused for hours, even days, forcing ER staffers to perform long-term care roles they weren't trained to do.

At Sparrow, space is a valuable commodity in the ER: A separate section of the hospital was turned into an overflow unit. Stretchers stack up in halls. A row of brown reclining chairs lines a wall, intended for patients who aren't sick enough for a stretcher but are too sick to stay in the main waiting room.

Forget privacy, Alejos Perrientoz learned when he arrived. He came to the ER because his arm had been tingling and painful for over a week. He couldn't hold a cup of coffee. A nurse gave him a full physical exam in a brown recliner, which made him self-conscious about having his shirt lifted in front of strangers. "I felt a little uncomfortable," he whispered. "But I have no choice, you know? I'm in the hallway. There's no rooms.

"We could have done the physical in the parking lot," he added, managing a laugh.

Even patients who arrive by ambulance are not guaranteed a room: One nurse runs triage, screening those who absolutely need a bed, and those who can be put in the waiting area.

"I hate that we even have to make that determination," Dusang said. Lately, staff members have been pulling out some patients already in the ER's rooms when others arrive who are more critically ill. "No one likes to take someone out of the privacy of their room and say, 'We're going to put you in a hallway because we need to get care to someone else.'"

ER Patients Have Grown Sicker

"We are hearing from members in every part of the country," said Dr. Lisa Moreno, president of the American Academy of Emergency Medicine. "The Midwest, the South, the Northeast, the West … they are seeing this exact same phenomenon."

Although the number of ER visits returned to pre-COVID levels this summer, admission rates, from the ER to the hospital's inpatient floors, are still almost 20% higher. That's according to the most recent analysis by the Epic Health Research Network, which pulls data from more than 120 million patients across the country.

"It's an early indicator that what's happening in the ED is that we're seeing more acute cases than we were pre-pandemic," said Caleb Cox, a data scientist at Epic.

Less acute cases, such as people with health issues like rashes or conjunctivitis, still aren't going to the ER as much as they used to. Instead, they may be opting for an urgent care center or their primary care doctor, Cox explained. Meanwhile, there has been an increase in people coming to the ER with more serious conditions, like strokes and heart attacks.

So, even though the total number of patients coming to ERs is about the same as before the pandemic, "that's absolutely going to feel like [if I'm an ER doctor or nurse] I'm seeing more patients and I'm seeing more acute patients," Cox said.

Moreno, the AAEM president, works at an emergency department in New Orleans. She said the level of illness, and the inability to admit patients quickly and move them to beds upstairs, has created a level of chaos she described as "not even humane."

At the beginning of a recent shift, she heard a patient crying nearby and went to investigate. It was a paraplegic man who'd recently had surgery for colon cancer. His large post-operative wound was sealed with a device called a wound vac, which pulls fluid from the wound into a drainage tube attached to a portable vacuum pump.

But the wound vac had malfunctioned, which is why he had come to the ER. Staffers were so busy, however, that by the time Moreno came in, the fluid from his wound was leaking everywhere.

"When I went in, the bed was covered," she recalled. "I mean, he was lying in a puddle of secretions from this wound. And he was crying, because he said to me, 'I'm paralyzed. I can't move to get away from all these secretions, and I know I'm going to end up getting an infection. I know I'm going to end up getting an ulcer. I've been laying in this for, like, eight or nine hours.'"

The nurse in charge of his care told Moreno she simply hadn't had time to help this patient yet. "She said, 'I've had so many patients to take care of, and so many critical patients. I started [an IV] drip on this person. This person is on a cardiac monitor. I just didn't have time to get in there.'"

"This is not humane care," Moreno said. "This is horrible care."

But it's what can happen when emergency department staffers don't have the resources they need to deal with the onslaught of competing demands.

"All the nurses and doctors had the highest level of intent to do the right thing for the person," Moreno said. "But because of the high acuity of … a large number of patients, the staffing ratio of nurse to patient, even the staffing ratio of doctor to patient, this guy did not get the care that he deserved to get, just as a human being."

The instance of unintended neglect that Moreno saw is extreme, and not the experience of most patients who arrive at ERs these days. But the problem is not new: Even before the pandemic, ER overcrowding had been a "widespread problem and a source of patient harm, according to a recent commentary in the New England Journal of Medicine.

"ED crowding is not an issue of inconvenience," the authors wrote. "There is incontrovertible evidence that ED crowding leads to significant patient harm, including morbidity and mortality related to consequential delays of treatment for both high- and low-acuity patients."

And already-overwhelmed staffers are burning out.

Burnout Feeds Staffing Shortages, and Vice Versa

Every morning, Tiffani Dusang wakes up and checks her Sparrow email with one singular hope: that she will not see yet another nurse resignation letter in her inbox.

"I cannot tell you how many of them [the nurses] tell me they went home crying" after their shifts, she said.

Despite Dusang's best efforts to support her staffers, they're leaving too fast to be replaced, either to take higher-paying gigs as a travel nurse, to try a less-stressful type of nursing, or simply walking away from the profession entirely.

Kelly Spitz has been an emergency department nurse at Sparrow for 10 years. But, lately, she has also fantasized about leaving. "It has crossed my mind several times," she said, and yet she continues to come back. "Because I have a team here. And I love what I do." But then she started to cry. The issue is not the hard work, or even the stress. She struggles with not being able to give her patients the kind of care and attention she wants to give them, and that they need and deserve, she said.

She often thinks about a patient whose test results revealed terminal cancer, she said. Spitz spent all day working the phones, hustling case managers, trying to get hospice care set up in the man's home. He was going to die, and she just didn't want him to have to die in the hospital, where only one visitor was allowed. She wanted to get him home, and back with his family.

Finally, after many hours, they found an ambulance to take him home.

Three days later, the man's family members called Spitz: He had died surrounded by family. They were calling to thank her.

"I felt like I did my job there, because I got him home," she said. But that's a rare feeling these days. "I just hope it gets better. I hope it gets better soon."

Around 4 p.m. at Sparrow Hospital as one shift approached its end, Dusang faced a new crisis: The overnight shift was more short-staffed than usual.

"Can we get two inpatient nurses?" she asked, hoping to borrow two nurses from one of the hospital floors upstairs.

"Already tried," replied nurse Troy Latunski.

Without more staff, it's going to be hard to care for new patients who come in overnight — from car crashes to seizures or other emergencies.

But Latunski had a plan: He would go home, snatch a few hours of sleep and return at 11 p.m. to work the overnight shift in the ER's overflow unit. That meant he would be largely caring for eight patients, alone. On just a few short hours of sleep. But lately that seemed to be their only, and best, option.

Dusang considered for a moment, took a deep breath and nodded. "OK," she said.

"Go home. Get some sleep. Thank you," she added, shooting Latunski a grateful smile. And then she pivoted, because another nurse was approaching with an urgent question. On to the next crisis.

This story is part of a partnership that includes Michigan Radio, NPR and KHN.

Critics of the Medicare Advantage program have long argued that the government is too generous in paying the private plans.

This article was published on Thursday, October 28, 2021 in Kaiser Health News.

By Michelle Andrews  

"Did you think we wouldn't notice?" an older woman says, speaking into the camera. "You thought you could sneak this through?" an older man later adds. Others warn that Washington is "messing with" their Medicare Advantage health coverage and trying to raise their premiums.

But the television ad, paid for by Better Medicare Alliance, a research and advocacy group for Medicare Advantage plans, doesn't spell out what cuts congressional lawmakers might be trying to slip past unsuspecting seniors.

Concerned that viewers could be confused and alarmed about coverage changes, we asked the Better Medicare Alliance for specifics about the sneaky moves the organization aims to alert people to. It's not just one ad. The organization has launched a $3 million TV, radio and online advertising campaign, according to advertising tracker AdImpact.

In response, the group offered this emailed comment from its president and CEO, Mary Beth Donahue.

"Better Medicare Alliance is airing messages encouraging Congress to guard against cuts to seniors' Medicare Advantage coverage, whether through benchmark policies in the reconciliation bill or other avenues."

While still light on specifics, Donahue's comment offered an important detail not mentioned in the ad. The group is concerned about coverage cutbacks through "benchmark policies in the reconciliation bill."

Now we were getting somewhere. In the Democrats' climate and social-spending bill being hammered out in Congress, one key healthcare proposal would add dental, hearing and vision coverage to the traditional Medicare program.

The provision, championed by Sen. Bernie Sanders (I-Vt.), is estimated to cost $350 billion over 10 years. As Democrats have labored to winnow their $3.5 trillion social-spending bill to make it palatable to moderates in the party, it's unclear whether the Medicare benefits expansion will make it into the final version.

Assuming it does, here's where benchmark calculations, and presumably the Better Medicare Alliance's concerns, come into play.

Traditional Medicare vs. Medicare Advantage

First, some background. Most Medicare beneficiaries are in the so-called traditional Medicare program, in which members generally pay 20% of the cost of medical services after meeting a deductible. A separate plan covers prescription drugs. Enrollees can visit any doctor, hospital or other medical provider participating in the program, the vast majority of whom do nationwide. Many beneficiaries buy supplemental Medigap policies that cover their cost-sharing obligations and fill in other financial gaps.

However, a growing number of Medicare beneficiaries — more than 26 million, or 42% of Medicare enrollees — are in Medicare Advantage plans. Cost sharing is generally lower in these private-sector managed-care plans than in traditional Medicare, but the networks of doctors and hospitals are smaller, too. Many Medicare Advantage plans offer supplemental benefits such as dental, vision and hearing coverage, although the level of coverage varies widely.

"Traditional Medicare is a lousy program, and that's why Medicare Advantage has really taken off over the last five or 10 years," said Joseph Antos, a senior fellow at the American Enterprise Institute. "Medicare Advantage looks like the coverage you used to have [before joining Medicare] and there [isn't] confusing cost sharing that most people don't understand. Whereas with traditional Medicare, there are different deductibles and holes in coverage."

The Benchmark

The federal Medicare program pays Medicare Advantage plans a set amount per member. Medicare Advantage health plans submit bids annually to federal officials that reflect how much they estimate it will cost to provide a package of benefits covering hospitalization (Medicare Part A) and outpatient services (Medicare Part B) to enrollees. Those bids are compared against a "benchmark," which is based on the average spending per beneficiary in the traditional Medicare program, with geographic adjustments.

Plans that bid below the benchmark, as most do, receive a rebate they can use to reduce beneficiary cost sharing, subsidize premiums or pay for supplemental benefits like dental, vision and hearing.

The Benchmark Controversy

Groups like the Better Medicare Alliance say they support providing dental, hearing and vision coverage to all Medicare beneficiaries. But they're worried that congressional leaders won't factor the cost of new traditional Medicare benefits into the benchmark, resulting in lower rebates from the program, which could threaten other supplemental benefits that Medicare Advantage members enjoy, such as meals and transportation services, gym memberships and in-home care.

It's not evident that lawmakers are considering excluding the benefit from the benchmark, however.

"I feel like this is the industry flexing its muscles and sending loud signals, but it's not clear that Congress has any intention to modify payments as part of this legislation," said Tricia Neuman, executive director of the program on Medicare policy at KFF.

Still, excluding the new benefits from the Medicare benchmark has generated interest as one way to pay for the pricey new benefits. According to one analysis, excluding the cost of the new benefits from the benchmark would reduce the fiscal cost by an estimated 41%, compared with a scenario that included the cost in the benchmark.

"This is because federal payments to [Medicare Advantage] plans would rise only modestly if the benchmarks excluded the new benefits, whereas they would rise substantially if the benchmarks included them," according to the analysis by Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy.

Since rebates would fall, Medicare Advantage plans would have less to spend on supplemental benefits. But dental, vision and hearing would no longer be considered supplemental and would need to be incorporated into plans' estimate of regular Medicare coverage costs, Fiedler noted.

That shift would mean that the rebate dollars that plans currently devote to dental, vision and hearing could be used for other supplemental benefits, which could shield those other benefits from substantial reductions, Fiedler said.

An analysis commissioned by AHIP, an industry group, estimated that incorporating a dental, vision and hearing benefit without adjusting the benchmark would have a substantial impact, resulting in a 48% decline in the national average rebate amount, or $58 per member per month.

No Sympathy

Critics of the Medicare Advantage program have long argued that the government is too generous in paying the private plans. When the Medicare program began incorporating private plans in the 1970s, part of the rationale was that the private plans could provide care more efficiently and save the program money. That hasn't happened. In a June report to Congress, the Medicare Payment Advisory Commission estimated that the government pays 4% more for beneficiaries enrolled in Medicare Advantage than for those in traditional Medicare.

MedPAC recommended a 2% reduction in capitated payments to Medicare Advantage plans.

In addition, in a September report, the Office of Inspector General for the Department of Health and Human Services found that 20 of 162 Medicare Advantage companies used patient chart reviews and health risk assessments to boost their payments disproportionately compared with their enrollment size.

Losing Their Competitive Advantage

A big selling point for Medicare Advantage plans has been that they provide coverage for valuable benefits that the traditional Medicare program does not. In 2021, 94% of Medicare Advantage enrollees in individual plans are in plans with some level of dental coverage, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

But "some" coverage doesn't necessarily mean comprehensive coverage. In a separate analysis, KFF found that Medicare beneficiaries faced high out-of-pocket costs for dental and hearing services, no matter what type of plan they had. In 2018, average out-of-pocket spending on dental care for traditional Medicare enrollees was $992. Medicare Advantage members spent modestly less out-of-pocket: $766.

In 2010, when the Affordable Care Act reduced Medicare Advantage plan payments to bring them in line with traditional Medicare, some in the industry predicted plans would pull out and benefits would be cut. That didn't happen.

"The truth is Medicare Advantage has grown rapidly since then and extra benefits have proliferated," Neuman said. So, if the payment methodology changes because of the addition of dental, hearing and vision benefits, "it's hard to say what would really happen."

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

A quick exam to evaluate labor in a small triage room can generate substantial charges.

This article was published on Wednesday, October 27, 2021 in Kaiser Health News.

By Rae Ellen Bichell

Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn't prepare her for the resources the conservation biologist would owe after the birth of her second son.

Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colorado, because it was the only entrance open.

Despite the weird COVID vibe — the emptiness, the quiet — everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse offering to wheel her to the labor and delivery department. She even took a selfie, smiling, as she entered the delivery room.

"I was just thrilled that he was here and it was on his due date, so we didn't have to have an induction," she said. "I was doing great."

Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.

Wells Salerno expected the bill for Gus' birth to be heftier than that for her first child, Hank, which had cost the family a mere $30. She was a postdoctoral fellow in California with top-notch insurance when Hank was born, about four years earlier. They were braced to pay more for Gus, but how much more?

Then the bill came.

The Patient: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.

Medical Service: A routine vaginal delivery of a full-term infant.

Total Bill: $16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.

Service Provider: Poudre Valley Hospital in Fort Collins, Colorado, operated by UCHealth, a nonprofit health system.

What Gives: In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.

The total bill was huge, but what really made Wells Salerno's eyes pop was a line for the highest level of emergency services. It didn't make any sense. Was it for checking in at the ER desk, as she'd been instructed to? She recalls going through security there on her way to labor and delivery, yet there was a $2,755 charge for "Level 5" emergency department services — as if she had received care there like a patient with a heart attack or fresh from a car wreck. It is the biggest item on the bill other than the delivery itself.

Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California-San Francisco and a practicing ER doctor, said Level 5 charges are supposed to be reserved for serious cases — "a severe threat to life, or very complicated, resource-intense cases" — not for patients who can walk through a hospital on their own. Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required.

But over the past 20 years, hospitals and doctors have learned there's great profit in upcoding visits. After all, the insurer isn't in the exam room to know what transpired. An investigation by the Center for Public Integrity found that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent homefrom the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5 steadily grew from 23% to 34% for patients with commercial insurance.

After repeated calls questioning the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with KHN, explaining that "the emergency room charge is actually the OB triage little area before they take you to the labor and delivery room." 

A customer service representative later explained it was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken — although none of that was performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately — and are routine, not emergency, procedures.

Some hospitals provide that package of services via an "obstetrical emergency department." OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they aren't physically located anywhere near the ER.

Health care staffing company TeamHealth — owned by the investment company Blackstone, and known for marking up ER bills to boost profit — essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In a white paper, the company said an OB-ED is an "entrepreneurial approach to strengthening hospital finances" because with "little to no structural investment" it allows hospitals to "collect facility charges that are otherwise lost in the obstetrical triage setting."

The OB Hospitalist Group, which is owned by a private equity company, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitals "leave a lot of money on the table" by billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.

An Arizona facility said its revenue increased $365,000 per quarter after turning their obstetric triage area into an OB-ED. Poudre Valley Hospital's website doesn't list "OB-ED" as part of the facility's offerings, though UCHealth documents do reference OB-ED beds in other facilities.

KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other area moms after getting a whopping charge — for the 10 minutes she spent in the triage room, while fully dilated and in active labor.

In Wells Salerno's case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. "Being seen there in OB-ED did not impact this bill whatsoever," said Dan Weaver, a spokesperson with UCHealth.

But in one of the other moms' cases, it did: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.

Ge Bai, a professor of accounting and health policy at Johns Hopkins University, said it's a "questionable" billing practice, and one that can matter to those who don't have the same kind of insurance as Wells Salerno, or have none at all.

Dr. Mark Simon, chief medical officer with OB Hospitalist Group, said OB-EDs can help women avoid being admitted to the hospital too early in labor, ensuring timelier, more appropriate care.

UCHealth's Weaver said they can also help pregnant patients with actual emergencies like preterm labor, preeclampsia or vaginal bleeding get quick care from specialists available 24/7, often without having to be admitted to the hospital. But at hospitals like Poudre Valley, healthy women having healthy births also get routine "OB-ED" treatment, without their knowledge.

Weaver said the only time someone in labor would not go through the OB-ED — and therefore the only time they would not receive the emergency charge — is if they have a scheduled induction or cesarean section or are directly admitted from a provider's office.

Hsia, the UCSF researcher and ER doctor, is unconvinced: "If they're actually going to charge a special fee that you didn't get directly admitted from your physician, that's absolutely ridiculous."

Wells Salerno's "OB-ED" exam was performed by her clinician, but the OB-ED charge still showed up on her bill.

Resolution: After trying to determine that the charge wasn't a mistake, Wells Salerno eventually threw in the towel and paid the bill.

"I was at a very vulnerable time during pregnancy and immediately postpartum," she said. "I just felt like I had kind of been taken advantage of financially at a time when I couldn't muster the energy to fight back."

The fact that two healthy brothers could come with such different price tags isn't surprising to Dr. Michelle Moniz. "There is no clinical reason that we have this level of variation," said Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Her research shows that people with private insurance pay anywhere from nothing to $10,000 for childbirth.

"You don't get what you pay for," said Wells Salerno, who maintains that — despite their price difference — both of her children are equally "awesome."

Data from the Colorado Division of Insurance shows that Poudre Valley typically received about $12,000 for similar births in 2020, about 43% more than the typical Colorado hospital. So the more than $14,000 Wells Salerno and her insurer paid is very high.

The Takeaway: Anything in our health system labeled as an emergency room service likely comes with a big additional charge.

Expectant parents should be aware that OB-EDs are a relatively new feature at some hospitals. Ask whether your hospital has that kind of charge and how it will affect your bill. Ahead of time, ask both the hospital and your insurer how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a price comparison tool for common medical procedures, including vaginal delivery.

If you do require a genuine ER encounter, look at your bill to see how it was coded, Levels 1 to 5 — and protest if your visit was misrepresented. Ask, "Has this bill been upcoded?" You are the only one who knows how much time you spent with a medical provider and how much care was given. Here's a chart that will help with the proper definition of each level.

Know that victory is possible. At least one mom won the battle and got the emergency charge removed from her Poudre Valley Hospital birth bill. It took hours on the phone with UCHealth, a lot of confidence and countless repetitions of the birth story — and how an emergency charge for a routine delivery just didn't, and doesn't, make sense.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Rae Ellen Bichell: rbichell@kff.org, @raelnb