Montana's Governor Nixed a Kids' Vaccine Campaign, So Health Officials Plan Their Own

KFF Health News, November 3, 2021

The lack of public messaging could contribute to Montana's continuing lag in vaccination rates and high ranking in COVID cases, hospitalizations and deaths.

This article was published on Wednesday, November 3, 2021 in Kaiser Health News.

By Aaron Bolton   

Montana Gov. Greg Gianforte's administration quashed plans for a public service campaign to promote COVID-19 vaccinations for eligible teenagers over the summer, a former state health official said. That has led public health and medical experts to plan their own ad campaigns, in anticipation of the administration not publicly backing shots for kids 5 and up when doses for those children roll out.

A state endorsement and ad campaign on television, radio and the internet could encourage and persuade undecided parents to get their kids vaccinated. The lack of such public messaging could contribute to Montana's continuing lag in vaccination rates and high ranking in COVID cases, hospitalizations and deaths.

Jim Murphy, a former communicable disease bureau chief for the Montana Department of Public Health and Human Services, said state health officials began discussing plans to launch public service campaigns for the vaccine under former Gov. Steve Bullock, a Democrat. The plans included promotion of the vaccine for eligible teenagers, Murphy said.

Gianforte, a Republican, took office in January as the vaccines were rolling out around the country. In the months that followed, Murphy and other officials in the state health department began drafting language encouraging parents to get their teens vaccinated, he said. The governor's office had the ultimate say over what ended up in the ads and in late spring, Murphy said, the Gianforte administration scrubbed references promoting vaccines for kids.

"The word that our team got was that those scripts were being revised and we wouldn't be directly promoting teen vaccination for COVID from a state level," Murphy said.

Murphy said the Gianforte administration expressed concern that the ads could be viewed as undermining parental consent. Many officials inside DPHHS thought the concern was unfounded as medical providers, pharmacies and public health departments administering shots all regularly deal with parental consent, he said.

Murphy retired from the agency at the end of June, and recently pointed out that the state's TV and radio ads since then lack any direct promotion for children and their parents. The first vaccine for children 12 and older was authorized in May.

Gianforte's office declined to make the governor available for an interview, but in a written statement spokesperson Brooke Stroyke said Murphy wasn't involved in the creation of promotional materials for COVID vaccines under the Gianforte administration. Murphy disputed that assertion, and said many divisions within the health department, including the communicable disease and laboratory sections under his watch, helped craft vaccine public service announcements sent to the governor's office.

Stroyke said in the statement Gianforte encourages parents to talk to their healthcare providers about getting their children vaccinated against COVID.

Gianforte's office said DPHHS will continue to revise its vaccine awareness campaign but did not say whether the state would promote vaccines for kids.

During a news conference last month, when asked, Gianforte also declined to say whether his office had plans to promote shots for teens or the estimated 90,000 5- to 11-year-olds in the state.

"We will have to see what guidance we get that accompanies the approval and we'll make decisions based on that," Gianforte said.

The Food and Drug Administration has authorized the emergency use of lower doses of the Pfizer-BioNTech vaccine for children ages 5 to 11. The U.S. government and states are now preparing to roll out the shots after Tuesday's official recommendation from the federal Centers for Disease Control and Prevention.

About 55% of eligible Montanans are fully vaccinated, compared with 68% of people nationally age 12 and up. Roughly 40% of eligible 12- to 17-year-olds have received both of their shots, according to state data. Nationally, nearly 50% of kids 12-17 are fully vaccinated, according to the Mayo Clinic.

Public health and medical experts worry the 5- to 11-year-old group in Montana will also lag behind national averages in the absence of a coordinated vaccination campaign targeting skeptical parents.

Hayley Devlin is the spokesperson for the Missoula City-County Health Department, one of the largest health departments in the state. She said typically it's the state health department that creates content for public health campaigns like social media ads, video or audio that can be repackaged at the local level.

"We haven't received any promotional materials from DPHHS as far as encouraging child vaccinations goes," Devlin said.

In the absence of a state-coordinated vaccine promotion for kids, Devlin has spearheaded the launch of the county health department's COVID vaccination campaign for parents and kids.

However, Matt Kelley, CEO of the nonprofit Montana Public Health Institute, said smaller county or tribal health departments don't have the resources to undertake their own campaigns.

"We're working to find ways to help them increase their capacity by helping to provide some of that messaging, but also building their own skill sets so they can do it themselves," Kelley said.

The Montana Medical Association is also launching a statewide campaign aimed at parents of children ages 5 to 17.

Kelley said finding effective messages that boost vaccine uptake among kids, especially younger ones, is particularly important ahead of the winter, when conditions will become more ideal for the highly infectious delta variant to spread.

"Any parent knows how much crud comes home with kids when sick season hits in the winter. COVID is no exception to that," he said.

Montana schools saw nearly five times as many COVID cases statewide during the first month of school this fall compared with last year's. Public health experts said that's largely due to fewer schools imposing mask mandates and other precautions. Kelley and others said this next round of kids becoming eligible for vaccines could help lower that transmission rate.

Jen Kates, a senior vice president and the director of global health and HIV policy at KFF, said, nationally, parents' feelings about getting their 5- to 11-year-olds vaccinated are similar to those expressed when shots were approved for kids 12 and up.

"About a third of parents say they're ready to go, rush out and get their kid vaccinated as soon as it's authorized and then there's a lot of wait-and-sees," Kates said.

Another third of parents don't plan to get their younger children vaccinated, and the rest say they're in the wait-and-see crowd, she said.

Kates said those wait-and-see parents largely decided to get their 12- to 15-year-olds vaccinated once their questions were answered.

Public vaccine campaigns for younger kids will be helpful in getting parents with questions to seek out pediatricians, which will be important for the upcoming rollout, she said.

Dr. John Cole, president of the Montana Chapter of the American Academy of Pediatrics, who practices in Kalispell, said his members have been having these conversations and will remind parents that while most kids infected with the COVID virus do well, it's hard to predict who will be seriously affected.

He has seen children with multisystem inflammatory syndrome, or MIS-C, a rare COVID complication in children that can be life-threatening.

"We need a consistent message," Cole said. "When we're hearing silence or not much of a message from the state level, I think that breathes a sense of nervousness or insecurity about the vaccine."

Unvaccinated? Don't Count on Leaving Your Family Death Benefits

KFF Health News, November 3, 2021

Now that vaccines are widely available, some employers have considered limiting other benefits paid to unvaccinated workers.

This article was published on Wednesday, November 3, 2021 in Kaiser Health News.

By Michelle Andrews 

These days, workers who refuse to get vaccinated against COVID-19 may face financial repercussions, from higher health insurance premiums to loss of their jobs. Now, the financial fallout might follow workers beyond the grave. If they die of COVID and weren't vaccinated, their families may not get death benefits they would otherwise have received.

New York's Metropolitan Transportation Authority no longer pays a $500,000 death benefit to the families of subway, bus and commuter rail workers who die of COVID if the workers were unvaccinated at the time of death.

"It strikes me as needlessly cruel," said Mark DeBofsky, a lawyer at DeBofsky Sherman Casciari Reynolds in Chicago who represents workers in benefit disputes.

Other employers have similar concerns about providing death or other benefits to employees who refuse to be vaccinated.

In Massachusetts, the New Bedford City Council sought to extend accidental death benefits to city employees who died of COVID, but the mayor didn't sign that legislation because, among other things, it didn't prohibit payment if the worker was unvaccinated.

President Joe Biden has leaned hard on businesses to make sure their workers are vaccinated. In September, the administration announced all employers with 100 or more workers would be required to either ensure they're vaccinated or test employees every week for COVID.

Among employers, "there's a frustration level, particularly at this point when these vaccines are fully approved," said Carol Harnett, president of the Council for Disability Awareness, an industry group. "You're trying to protect yourselves and your employees, both from themselves and the general public."

The New York transportation authority is the highest-profile employer to take this action. Since the pandemic crisis began in 2020, 173 MTA workers have contracted COVID and died. Five of those deaths occurred after June 1 of this year, when the policy changed, according to the MTA.

"We are not aware they have been vaccinated," an MTA spokesperson said of the five workers who died since the policy took effect.

The transit authority's policy was a shift from an earlier pact with workers. In April 2020, as COVID ravaged New York, transit officials and the labor unions representing employees reached agreements that workers who died of COVID would be eligible to receive a $500,000 lump-sum death benefit, just like payments to which families of MTA workers who have other job-related deaths are entitled. The program will continue through the end of this year.

But with COVID vaccines now widely available and fully approved by the Food and Drug Administration, the MTA Board determined that, starting June 1, workers who died of COVID had to have been vaccinated for their families to be eligible for the payment.

The change comes as the MTA has struggled to improve vaccination rates among its roughly 67,000 workers. More than 70% of transit employees are estimated to be vaccinated, according to MTA officials.

A spokesperson for the MTA stressed that the program remains in effect, and noted that it has been extended past its original one-year term. The only change is the vaccination requirement.

"The program is not being revoked," the MTA spokesperson said in an email. "In fact, the MTA has twice extended it."

Local 100 of the Transport Workers Union, which represents roughly 38,000 MTA workers, pushed hard to negotiate the benefit. "No other workforce in the city, probably the country, secured what TWU secured: a $500,000 payment from the employer to the families of workers who died after getting COVID," said Pete Donohue, a union spokesperson. "We look at it that during a terrible time, we got [the benefit] for people."

It's not unusual for employers of workers in risky occupations — such as police, firefighters, utility company workers and transit workers, who could succumb to an industrial accident or get hit by a train on the tracks — to offer extra insurance coverage that pays if they die on the job. The coverage is often provided in addition to a regular life insurance policy.

These so-called line-of-duty or accidental death and dismemberment policies typically don't pay out if someone dies of a disease. How can it be proved that someone picked up a deadly infection at work rather than at the supermarket?

But with COVID, some front-line workers have been considered eligible for accidental death benefits because they are presumed to have gotten sick on the job, DeBofsky said.

Workers may be denied death benefits, however, if they didn't follow established safety protocols, said John Ehrlich, the national lead consultant at Willis Towers Watson on group life insurance. Failing to wear a bulletproof vest, a helmet or other safety equipment, for example, might make their families ineligible for payment under a policy.

Now that vaccines are widely available, some employers have considered limiting other benefits paid to unvaccinated workers, including reducing short-term disability payments, said Rich Fuerstenberg, a senior partner at benefits consultant Mercer. But Fuerstenberg said he had not heard of other employers eliminating death benefits for unvaccinated workers.

In the New Bedford case, the City Council unanimously passed a petition in August stating the COVID death of any city employee would be considered to have occurred in the line of duty, enabling family members to receive accidental death benefits.

Mayor Jon Mitchell, however, objected for several reasons — the question of vaccination among them.

"As I am certain the Council would agree, it would be inappropriate to extend accidental death benefits where the employee refused to take a vaccine that had been found to be nearly 100% effective," Mitchell said in a letter to the council. The proposal has been tabled for further negotiation, according to a spokesperson for the mayor.

For more than 17 years, Joseph Fletcher worked for the MTA in Brooklyn, doing body work and other maintenance on buses.

When he died of COVID on April 11, 2020, at age 60, he left behind his wife, Veronica, a former high school teacher who was disabled after a car accident, and three children, now 9, 13 and 16.

Coping with his death was hard enough, but looking toward the future has been overwhelming, Veronica said.

"How am I going to keep afloat financially?" she worried. "Everything about this journey is terrifying."

The $500,000 death benefit helped cover the family's regular bills and pay the mortgage on their Brooklyn home. But she's aware it will go only so far, and her three children need to go to college.

If the MTA vaccination requirement had been in place when her husband died, it wouldn't have been a problem, Fletcher said.

"I wish that my husband were able to have been vaccinated," she said. "Knowing my late husband, he would have taken the opportunity to protect himself and his family."

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

'An Arm and a Leg': Need Surgery to Save Your Life? Tips for Getting Insurance to Pay

KFF Health News, November 2, 2021

Laurie Todd calls herself the "Insurance Warrior." She helps people get their health insurance companies to pay for treatment and has written books sharing her knowledge.

This podcast was published on Tuesday, November 2, 2021 in Kaiser Health News. Click here to listen.

By Dan Weissmann  

Healthcare — and how much it costs — is scary. But you're not alone with this stuff, and knowledge is power. "An Arm and a Leg" is a podcast about these issues, and its second season is co-produced by KHN.

Laurie Todd calls herself the "Insurance Warrior." She helps people get their health insurance companies to pay for treatment and has written books sharing her knowledge.

Hers is a wealth of knowledge that was hard-won. In 2005, Todd was diagnosed with a rare form of cancer. Although she found a doctor who could treat it, her health insurance said it wouldn't be covered. But Todd didn't accept that refusal and got her insurance company to pay for a lifesaving surgery.

Over the next 15 years, Todd honed her insurance-slaying powers. She has fought — and won — more than 200 insurance appeals on behalf of patients, she said.

Listen to the episode to hear some of her time-tested strategies.

Here's a transcript of the episode.

"An Arm and a Leg" is a co-production of KHN and Public Road Productions.

To keep in touch with "An Arm and a Leg," subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you've got stories to tell about the healthcare system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to "An Arm and a Leg" on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

High Court Hears Cases on Novel Texas Law, but Outcome May Not Affect Abortion Access

KFF Health News, November 2, 2021

Supporters of the law have said it was specifically designed to prevent federal courts from blocking the law since no state officials are involved in enforcement.

This article was published on Tuesday, November 2, 2021 in Kaiser Health News.

By Julie Rovner 

The Supreme Court, whose conservative majority is considered poised to overturn decades-old decisions guaranteeing abortion rights, heard its first two abortion cases of the 2021-22 term Monday. But the court could decide this case without deciding the fate of abortion rights in America.

At stake is the future of a Texas law, which severely limits the procedure, that the high court refused to block from taking effect in September. The state law has cut the number of abortions in the state by half.

The Texas law — known as SB 8 — is similar to laws passed by several states over the past few years in that it bans abortion after fetal cardiac activity can be detected, which typically occurs about six weeks into pregnancy. That is in direct contravention of Supreme Court precedents in 1973's Roe v. Wade and 1992's Planned Parenthood of Southeastern Pennsylvania v. Casey, which say states cannot ban abortion until fetal "viability," which is about 22 to 24 weeks. The law also makes no exception for pregnancies caused by rape or incest.

The Texas law, however, varies from other state "heartbeat" laws because it has a unique enforcement mechanism that gives state officials no role in ensuring that the ban is obeyed. Rather, it leaves enforcement to the general public, by authorizing civil suits against not just anyone who performs an abortion, but anyone who "aids and abets" the performance of an abortion, which could include those who drive patients to an abortion clinic or counsel them. Those who bring suits and win would be guaranteed damages of at least $10,000. Opponents of the law call that a "bounty" to encourage individuals to sue their neighbors.

Supporters of the law have said it was specifically designed to prevent federal courts from blocking the law since no state officials are involved in enforcement and therefore not responsible for it.

It is that enforcement mechanism that the Supreme Court considered during three hours of arguments Monday. The first case, Whole Woman's Health et al. v. Jackson et al., was brought by a group of abortion providers, the second, U.S. v. Texas et al., by the Justice Department. The question before the justices was not directly whether the Texas ban is unconstitutional, but whether either the abortion providers or the federal government can challenge it in court.

Marc Hearron of the Center for Reproductive Rights, who represented the abortion providers, said the Texas law, if upheld, could influence far more than abortion. "To allow the Texas scheme to stand would provide a road map for other states to abrogate any decision of this court with which they disagree," he told the justices.

U.S. Solicitor General Elizabeth Prelogar, in her first appearance before the court in that role, expressed similar sentiments, calling the Texas law "a brazen attack" on the other branches of government. States, she said, "are not free to place themselves above this court, nullify the court's decisions and their borders, and block the judicial review necessary to vindicate federal rights."

But Texas Solicitor General Judd Stone insisted that neither case should be allowed to proceed and that any legal actions should be handled by state courts. What both sets of plaintiffs want, he said "is an injunction against the law itself. But federal courts don't enjoin state laws, they enjoin officials." And because of the unique way the law was crafted, Texas officials are not involved in the law's enforcement.

At least a few members of the court's conservative majority, notably Justices Amy Coney Barrett and Brett Kavanaugh, seemed at least somewhat dubious about whether Texas could evade all federal court review and what that could mean for issues other than abortion. Several justices cited a "friend of the court" brief filed by a gun rights group that sided with the abortion providers, not because it agreed with the position on abortion, but because the group wrote "that the judicial review of restrictions on established constitutional rights, especially those protected under this Court's cases, cannot be circumvented in the manner used by Texas."

That was a point made repeatedly by the liberal-leaning justices, who have made it clear they oppose the Texas law. "Essentially, we would be inviting states, all 50 of them, with respect to their un-preferred constitutional rights, to try to nullify the law … that this Court has laid down as to the content of those rights," said Justice Elena Kagan. "I mean, that was something that until this law came along no state dreamed of doing."

The court has already demonstrated its division over the law when it voted 5-4 in September to allow it to take effect. Barrett and Kavanaugh were among the majority in that vote. The court also refused to block the law when it accepted the current case 10 days ago.

Typically, in major cases like this, decisions come at the end of the court term, which would be next spring or summer. However, this case was considered on the court's "rocket docket," in the fastest consideration of a case since the justices decided who should become president in 2000's Bush v. Gore.

Another complication is that the court is scheduled to hear arguments next month in a separate Mississippi case in which they will consider the future of abortion rights. That case, Dobbs v. Jackson Women's Health Organization, challenges a law that seeks to ban abortions after 15 weeks of gestation. The court has agreed in that case to consider whether states can ban abortion prior to viability.

The Texas case could be decided before the Mississippi case is heard, or after, or the cases could be decided together.

Julie Rovner: jrovner@kff.org, @jrovner

Nursing Home Residents Overlooked in Scramble for COVID Antibody Treatments

KFF Health News, November 1, 2021

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

California Law Aims to Strengthen Access to Mental Health Services

KFF Health News, November 1, 2021

The law requires that mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session.

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

By Bernard J. Wolfson November 1, 2021

The number of people with symptoms of depression and anxiety has nearly quadrupled during the COVID pandemic, which has made it even more maddeningly difficult to get timely mental healthcare, even if you have good insurance.

A California law signed Oct. 8 by Gov. Gavin Newsom could help. It requires that mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session, unless their provider OKs less frequent visits.

Current insurance regulations already require giving patients an initial mental health visit no more than 10 days after they request it. But there's been nothing on the books specifically about follow-up care until now.

The law doesn't take effect until July, which lawmakers said will give health plans time to comply — mainly by hiring or contracting with more therapists. Proponents say that, with effective enforcement, the new law will help a lot of people get the care they need.

The law, SB 221, "will ensure that people can actually use their insurance to get mental health treatment," says Sen. Scott Wiener (D-San Francisco), the law's author. "For far too long, health plans have frequently made people wait long periods of time to get mental health appointments, which undermines their care."

If you are not getting the care you need, there are already ways you can seek redress. When the law takes effect in eight months, it will strengthen your hand. More on that in a moment.

There are two competing explanations for why it's so hard to get consistent mental healthcare. Insurers say there's a shortage of therapists. Therapists say insurers are too cheap to pay them adequately. Many therapists decline to join insurance networks and set their own fees, which a lot of people can't afford.

The National Union of Healthcare Workers, which sponsored the legislation, has been particularly critical of Kaiser Permanente, the state's largest commercial health insurer, for its well-publicized mental healthcare deficiencies.

Kaiser Permanente, with over 9 million members in California, was fined $4 million by state regulators in 2013 for failure to provide timely mental healthcare. It was cited twice after that for failure to resolve the problems.

Former and current KP therapists say the managed-care giant has addressed the complaint by trying to ensure that members seeking mental health treatment get an initial appointment quickly. But that has only made it harder for those patients to get subsequent sessions, the therapists say.

"Any available appointment would be given to a person needing to initiate services," says Susan Whitney, a marriage and family therapist who worked for Kaiser Permanente in Bakersfield for 18 years before leaving the organization in September. "Our schedules would be fully booked for six to eight weeks — so follow-up appointments were difficult to make, to say the least."

The American Psychological Association recommends weekly therapy for people with depression and twice weekly for post-traumatic stress disorder. In a letter to California's Department of Managed Healthcare last year, the association said the long waits for follow-up care reported by KP patients and therapists "fall far below what is appropriate care for most patients."

Because of the shortage of available therapists, Kaiser Permanente often refers its members to an outside network of providers for mental health treatment. But members, therapists and public officials say those networks often fail to deliver.

Maya Polon, a KP member in Sacramento, began feeling emotionally frayed in March, after caring for her terminally ill grandmother. She tried to get help through Kaiser but had to make numerous calls and kept getting conflicting information about how to get care.

Finally, after more than a month, a Kaiser Permanente therapist told Polon, 27, that her depression, anxiety and panic attacks qualified her for a year of therapy. But if she wanted to do it through Kaiser, it would take six months to get her first appointment.

KP referred her to an outside mental health contractor, Beacon Health Options, which took two weeks to send her a list of therapists. She called all 20 providers on the list, during breaks in her workday, and left messages.

"As someone with anxiety and who suffers from depression, having to actively sit down and call people who are over and over again telling you, 'Oh, I'm not actually taking new patients,' is an overwhelmingly defeating process," Polon says. "I walked away from that thinking, 'Do I even want to do therapy if this is what I am going to have to go through to even get there?'"

She ended up seeing the one therapist who had space for her, but she wasn't contracted with Beacon. Polon had to wrangle with Kaiser Permanente for months over the paperwork.

In June, San Diego's city attorney, Mara Elliott, sued Kaiser over what she termed "ghost networks" that "falsely describe the breadth of an insurer's provider network, promising consumers access to healthcare that in reality is unavailable under the plan." Elliott sued Molina Healthcare and Health Net on similar grounds.

Dr. Yener Balan, vice president of behavioral health and specialty services at Kaiser Permanente in Northern California, says the organization could do better, but claims that it meets the follow-up appointment recommendations of its mental health clinicians 84% of the time — a figure hotly contested by union officials and therapists.

Balan says SB 221's July implementation date is helpful, "given the shortage of mental health clinicians faced by all healthcare organizations."

Critics of the health insurance industry question whether a shortage of therapists is the main problem. Wiener says health plans aren't paying mental health practitioners enough to join their networks.

A 2019 report by the California Future Health Workforce Commission projected that within a decade there would be 41% fewer psychiatrists than needed and 11% fewer psychologists, marriage and family therapists, and other mental health workers.

But a report the same year by the state Legislative Analyst's Office said the number of graduates of mental health programs had grown significantly — although there was, it reported, a shortage of psychiatrists.

The Department of Managed Healthcare, which regulates health plans covering a large majority of Californians, will monitor compliance with the new law and investigate consumer complaints, says Rachel Arrezola, an agency spokesperson.

What You Can Do

If you believe your health plan is shortchanging you on mental health treatment, you don't have to wait for the new law. You can challenge your insurer under existing regulations. Once the law takes effect, however, it will offer additional ballast for any challenges and allow regulators to pursue health plans for violations.

To contest a lack of coverage, you must first appeal directly to your health plan. If you are in a private plan, you must file the appeal within six months of care being denied. The insurer must decide on your appeal within 30 days.

If you don't get a satisfactory decision, take your case to the agency that regulates your insurer for an independent review. And if there's an urgent health risk, you don't need to wait 30 days. Contact your regulator immediately.

To find out what agency that is, call the customer service line of your health plan. If it is the Department of Managed Healthcare, you can request an independent review by calling 888-466-2219 or logging on to HealthHelp.ca.gov. If your regulator is the California Department of Insurance, call 800-927-4357.

If you are in managed-care Medi-Cal and your plan is regulated by the Department of Managed Healthcare, you can ask that department for an independent review. You can also seek a "fair hearing" through the state, as can any Medi-Cal beneficiary, by going online or calling 855-795-0634.

Of course, all this takes time and effort. But if the delay is making it impossible for you to get treatment, it may be worth it.

A series of columns by Bernard J. Wolfson addressing the challenges consumers face in California's healthcare landscape.

Send questions to bwolfson@kff.org, @bjwolfson

ERs Are Swamped With Seriously Ill Patients, Although Many Don't Have COVID

KFF Health News, October 29, 2021

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.

Listen: Texas Abortion Law Gets Speedy High-Court Hearing Monday

KFF Health News, October 29, 2021

Amy Howe of SCOTUSblog breaks down the issues before the court and what the court might do about Texas' abortion law.

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

By Julie Rovner October 29, 2021

The Supreme Court on Nov. 1 will hear oral arguments challenging the constitutionality of a new Texas abortion law — just days after agreeing to hear the case. That's just one of many unusual things about the Texas law, which halted almost all abortions in the nation's second-most populous state.

The court plans to hear another major abortion case this fall: Justices previously set Dec. 1 as the day for arguments in a case from Mississippi that directly challenges Roe v. Wade and other decisions that guaranteed a constitutional right to an abortion before a fetus is viable.

The high court does not need to weigh in on the constitutional right to abortion in the Texas case, which is actually two separate suits joined together — one brought by the Biden Justice Department and a second brought by abortion providers in Texas. The court instead has asked the lawyers to weigh in on the Texas law's unique enforcement mechanism. Designed to evade legal challenges, the law, S.B. 8, rests enforcement not with Texas officials, but with private citizens who can sue anyone who performs an abortion or "aids and abets" someone in obtaining an abortion. The law took effect Sept. 1 after the Supreme Court refused earlier requests to void it. It bans abortions after six weeks, well before the generally accepted standard for viability of 22 to 24 weeks.

Amy Howe of SCOTUSblog breaks down the issues before the court and what the court might do about Texas' abortion law in this conversation for KHN's "What the Health?" that aired Thursday. She notes this is the quickest turnaround for a case to be heard by the justices since the Bush v. Gore decision in the 2000 presidential election.

"Everything about this is so unusual," she said.

Can't see the audio player? Click here to listen on Acast. And subscribe to KHN's What the Health? on Apple Podcasts,  Spotify, Stitcher, Pocket Casts or wherever you listen to podcasts.

Julie Rovner: jrovner@kff.org, @jrovner

Democrats' Plans to Expand Medicare Benefits May Pinch Advantage Plans' Funding

KFF Health News, October 28, 2021

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

Medicare Punishes 2,499 Hospitals for High Readmissions

KFF Health News, October 28, 2021

In its 10th annual round of penalties, Medicare is reducing its payments to 47% of all facilities.

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

By Jordan Rau   

The federal government's effort to penalize hospitals for excessive patient readmissions is ending its first decade with Medicare cutting payments to nearly half the nation's hospitals.

Here are the hospitals hit with readmissions penalties for 2022. You can filter by location, hospital name or year.

In its 10th annual round of penalties, Medicare is reducing its payments to 2,499 hospitals, or 47% of all facilities. The average penalty is a 0.64% reduction in payment for each Medicare patient stay from the start of this month through September 2022. The fines can be heavy, averaging $217,000 for a hospital in 2018, according to Congress' Medicare Payment Advisory Commission, or MedPAC. Medicare estimates the penalties over the next fiscal year will save the government $521 million. Thirty-nine hospitals received the maximum 3% reduction, and 547 hospitals had so few returning patients that they escaped any penalty.

An additional 2,216 hospitals are exempt from the program because they specialize in children, psychiatric patients or veterans. Rehabilitation and long-term care hospitals are also excluded from the program, as are critical access hospitals, which are treated differently because they are the only inpatient facility in an area. Of the 3,046 hospitals for which Medicare evaluated readmission rates, 82% received some penalty, nearly the same share as were punished last year.

The Hospital Readmissions Reduction Program (HRRP) was created by the 2010 Affordable Care Act and began in October 2012 as an effort to make hospitals pay more attention to patients after they leave. Readmissions occurred with regularity — for instance, nearly a quarter of Medicare heart failure patients ended up back in the hospital within 30 days in 2008 — and policymakers wanted to counteract the financial incentives hospitals had in getting more business from these boomerang visits.

MedPAC has found readmission rates declined from 2008 to 2017 after the overall health conditions of patients were taken into account. Heart failure patient readmission rates dropped from 24.8% to 20.5%, heart attack patient rates dropped from 19.7% to 15.5%, and pneumonia patient rates decreased from 20% to 15.8%, according to the most recent MedPAC analysis. Readmission rates for chronic obstructive pulmonary disease, hip and knee replacements, and conditions that are not tracked and penalized in the penalty program also decreased.

"The HRRP has been successful in reducing readmissions, without causing an adverse effect on beneficiary mortality," MedPAC wrote. The commission added that untangling the exact causes of the readmission rates was complicated by changes in how hospitals recorded patient characteristics in billing Medicare and an increase in patients being treated in outpatient settings. Those factors made it difficult to determine the magnitude of the readmission rate drop due to the penalty program, MedPAC said.

The current penalties are calculated by tracking Medicare patients who were discharged between July 1, 2017, and Dec. 1, 2019. Typically, the penalties are based on three years of patients, but the Centers for Medicare & Medicaid Services excluded the final six months in the period because of the chaos caused by the pandemic as hospitals scrambled to handle an influx of COVID-19 patients.

Jordan Rau: jrau@kff.org, @JordanRau

Pages