Illinois trails many other states in allowing dental hygienists unsupervised contact with patients. In Colorado, on the extreme end, hygienists can own practices.

This article was published on Tuesday, October 19, 2021 in Kaiser Health News.

By Giles Bruce 

This year, the Illinois legislature was considering measures to expand oral health treatment in a state where millions of people live in dental care deserts.

But when the Illinois State Dental Society met with key lawmakers virtually for its annual lobbying day in the spring, the proposals to allow dental hygienists to clean the teeth of certain underprivileged patients without a dentist seemed doomed.

State Sen. Dave Syverson, a Republican legislative leader, warned against the bills even if they sounded minor. "It's just getting the camel's nose under the tent," he said in an audio recording of the meeting obtained by KHN. "We'll have, before long, hygienists doing the work that, if they wanted to do, they should have gone to dental school for."

The senator added that he missed "the reception and the dinners that you guys host" and the "nice softball questions that I usually get" from the dental society's past president, who happens to be his first cousin.

The bills never made it out of committee.

The situation in Illinois is indicative of the types of legislative dynamics that play out when lower-level healthcare providers such as dental hygienists, nurse practitioners and optometrists try to gain greater autonomy and access to patients. And the fate of those Illinois bills illustrates the power that lobbying groups such as the Illinois dental society have in shaping policies on where health professionals can practice and who keeps the profits.

"There's always a struggle," said Margaret Langelier, a researcher for the Center for Health Workforce Studies at the University of Albany in New York. "We have orthopedists fighting podiatrists over who can take care of the ankle. We have psychiatrists fighting with clinical psychologists about who can prescribe and what they can prescribe. We have nurses fighting pharmacists over injections and vaccinations. It's the turf battles."

In 2015, the Illinois Dental Practice Act was revised to let hygienists treat low-income patients on Medicaid or without insurance in "public health settings" — such as schools, safety-net clinics and programs for mothers and children — without a dentist examining them or being on-site. Besides doing cleanings, the hygienists can take X-rays, place sealants and apply fluoride.

This year, lawmakers proposed bills that would have expanded those settings to include nursing homes, prisons and mobile dental vans.

The state dental society, in a memo to members, wrote that the fact it took years for hygienists to develop their public health training program shows "they have no real interest in providing access to care to needy patients."

As it is, Illinois trails many other states in allowing dental hygienists unsupervised contact with patients. In Colorado, on the extreme end, hygienists can own practices.

"It's just the nature of the beast politically in Illinois. The dental lobby isn't as strong in those other states," noted Margaret Vaughn, executive director of the Illinois Rural Health Association. "The Illinois State Dental Society is much more powerful, and they're much more organized than the hygienists are politically."

From 2015 to 2019, the dental society spent more than $55,000 on lobbying, for its annual gathering and meals for lawmakers, typically hosted at a swanky Italian spot near the state Capitol in Springfield, according to public disclosures. In the same period, the Illinois Dental Hygienists Association reported spending nothing in its lobbying reports. (Neither group has listed any expenditures since the beginning of 2020.)

The dental society has two exclusive lobbyists and four lobbying firms on contract, state records show. The hygienist group, meanwhile, employs no lobbyists and contracts with just one firm.

The dental society donates generously to both Republicans and Democrats. Its political action committee had nearly $742,000 in cash on hand as of June 30, according to Reform for Illinois' Sunshine Database. While the PAC has given $4,050 since 2014 to support the campaigns of state Sen. Melinda Bush, a Democrat who sponsored the nursing home bill, the database shows it has contributed far more to help elect Syverson, the senator who spoke at the conference. It has given more than $123,000 to his campaigns since 1999, with bigger annual gifts than to Bush.

"I receive contributions from many groups on both sides of issues," Syverson emailed KHN. "They are not contributing to influence my vote on a particular bill. In fact, if a PAC sent a check while we were negotiating or voting on an issue they are involved with, I would not accept it."

The hygienists' PAC gave $1,100 to the campaign committee of Bush, according to the database, but nothing to Syverson. Bush did not respond to requests for comment.

"The bottom line is, if you don't have a healthy mouth, you don't have a healthy body," said Ann Lynch, director of advocacy and education for the American Dental Hygienists Association. "It only makes sense that we would remove any barriers that do not allow a licensed healthcare provider to practice at the top of their scope."

But Dave Marsh, a lobbyist for the Illinois dental society, said it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick.

"I just don't feel anybody with a two-year associate's degree is medically qualified to correct your health," Marsh added. "They're trained to clean teeth. They take a sharp little instrument and scrape your teeth. That's what they do. That's all they do."

He said the problem is not a shortage of dental professionals but, rather, a lack of dentists who can afford to accept Medicaid patients — and "nobody wants to raise taxes to actually be able to reimburse" dentists at higher rates.

He also pointed to the scarcity of research on the benefits of dental hygienists having more professional freedom.

Langelier acknowledged that little academic literature exists on this topic, in part because of inadequate data collection on oral health. But in 2016, a study she co-authored in Health Affairs found that, as dental hygienists gained more autonomy, fewer people had teeth removed because of decay or disease. And she said Medicaid data shows more children had dental visits as hygienists expanded their practice.

"I don't want this to be acrimonious," said Laura Scully, chair of the access-to-care committee of the state hygienists association. "I would like it to be more of a collaboration, because truly that's what this is about: getting together so we can help more people."

Karen Webster works as a dental hygienist for the Tri City Health Partnership, a free clinic in St. Charles, Illinois, about 40 miles west of Chicago. In the past, she could only briefly screen patients before scheduling them with one of the center's volunteer dentists, often months out.

"Imagine if you had a toothache and the doctor couldn't see you that day," she said, noting that her patients have low incomes. "They can't afford the services. They wait till something hurts."

But since becoming a public health dental hygienist, Webster now does immediate cleanings, takes X-rays she sends to teledentists for exams, and applies a solution called silver diamine fluoride that can halt tooth decay.

"The whole thing, start to finish, it's just a lot more efficient," she said.

Kentucky is in the midst of a COVID-19 wildfire sparing no part of the state; new case counts topped 4,000 a day for much of September, before easing somewhat this month.

This article was published on Monday, October 18, 2021 in Kaiser Health News.

By Sarah Varney   

SMILAX, Ky. — In the end it was the delta variant that drove Rose Mitchell, 89, down the winding mountain road to the Full Gospel Church of Jesus Christ to get the shot. Her pastor, Billy Joe Lewis, had told his congregation that, No, ma'am, a COVID vaccine would not leave the "mark of the beast" nor rewrite their genetic codes.

Mitchell, who has known the deaths of eight of her 13 children over the years, was done taking chances with the virus stealing up the hollers along Cutshin Creek.

"That stuff's getting so bad, I was afraid to not take it," she said, sitting in her daughter's car in the church parking lot. "I said, 'Well, if all the rest of them are going to take it, I'll take it too.'"

Kentucky is in the midst of a COVID-19 wildfire sparing no part of the state; new case counts topped 4,000 a day for much of September, before easing somewhat this month. Hospital intensive care units are still at capacity in some regions, with COVID patients occupying half the beds. Gov. Andy Beshear has called the situation "dire."

Across the nation, older people have been steadfast takers of the COVID vaccines: About 95% of people 65 and older have received at least one shot. But geographic variations cloud that math. Older Kentuckians in rural hamlets far from Louisville and Lexington are trailing in vaccination, with rates as low as 55% in Wayne County, on the Tennessee state line.Bottom of Form

While seniors are still more likely to be vaccinated than younger adults in Kentucky, the simple truth of the pandemic is that older people who forgo the shots face a far greater chance of severe sickness and death. People 60 and older account for nearly 90% of the 9,184 COVID-related deaths in Kentucky. Residents 80 and older account for 41% of deaths.

In Leslie County, in the foothills of the rugged Pine Mountain ridge that anchors the state's eastern coalfields, gravel roads wind through thick forests blanketed with kudzu vines. House by house, church by church, public health workers are trying to outsmart the fantastical tales about the COVID vaccines spread on Facebook and overcome the everyday hurdles of financial hardship and isolation.

"Some of our older people don't have access to vehicles because their family works," said Maxine Shepherd, a regional health coordinator for Leslie County and four-decade-long member of Full Gospel Church. Even for those with a car, gas is expensive, she said, and trips from secluded hollers to town are rationed out carefully.

While Kentuckians watched the devastating early months of the pandemic from afar, COVID has long since made its arrival — and it hasn't spared the church on Cutshin Creek. In recent weeks, Pastor Lewis held a funeral service for a 53-year-old unvaccinated former coal miner, suspended Sunday services after more members fell ill, and with heavy heart canceled Homecoming, a cherished yearly gathering of area churches that marks the fall foliage with a celebration of the gospel and shared faith.

Local health agencies have been eager to enroll churches in the all-hands-on-deck vaccination effort; older residents are more likely to attend religious services, and in communities like Smilax, ministers are trusted advisers.

Some church leaders have refrained, afraid of offending congregants in a state where distrust of government intrusion runs deep. But not Lewis, who helped build Full Gospel Church on a rare flat parcel of land in 1972 and has led it ever since. With a smooth pelt of silver hair and a luminous smile, Lewis spends long stretches of the day in prayer, and he says God told him to protect his flock.

When "Sister Maxine" from the regional health department suggested a drop-in vaccine clinic in the church parking lot, Lewis was all in favor. He promoted it from the pulpit and on the church's must-read Facebook page.

Some church leaders in Kentucky have refrained from promoting COVID vaccination, afraid of offending congregants. But Pastor Billy Joe Lewis, leader of the Full Gospel Church of Jesus Christ in Smilax, says God told him to protect his flock. He promoted vaccination from the pulpit and on the church's lively Facebook page.

"We've still got to use common sense," he said. "Anything that can ward off suffering and death, I think, is a wonderful thing."

Vexed by the slow uptake in vaccinations by some Americans, President Joe Biden has mandated shots for healthcare workers in facilities such as hospitals and nursing homes, as well as for federal workers and employees of large companies. While the exact timing and details of the private-sector mandates are still being hammered out, the specter of coercion outrages many Kentuckians, particularly in Appalachia, where government directives have been met with derision.

"We do not like to be shoved," said David McKenzie, who grew up in Louisa, a once-booming coal town on the West Virginia border, and now owns the local nursing home. "We resent it, and we shove back."

Opposition to the vaccines in Lawrence County, where the vaccination rate is 39%, is not overtly political so much as willful. "They're fearful of 'the Man,'" McKenzie said. "The Man could be your employer, it could be the government, it could be a newspaper reporter." People who boasted about refusing the vaccines cannot change their minds, or "they'll look like they're weak, or they caved to the Man."

In nearby Salyersville, the virulence of the delta variant has shaken some holdouts. Santana Salyers, 22, braved torrential rain to get her shot at the county health department, a one-story building on a stretch of freshly paved road. In her third trimester of pregnancy, she feared the hospital would not let her hold her newborn if she wasn't vaccinated. Salyers works at the IGA grocery store and says to vax or not to vax comes up there almost every day. "I'm a fence-straddler," she said. But around town, "you're either against it or for it."

Turnout for the Salyersville health fair was muted by the remnants of a tropical storm, but a few dozen people still showed up to get their shots. In the waiting room, vaccine takers received $25 Walmart cards and a chance to win a Fitbit or Instant Pot. The prizes were a big draw.

James Shepherd, who is both the town's mayor and director of the Magoffin County Health Department, bemoans the county's 44% vaccination rate: "In a small community like this, they make up their mind 'yes' or 'no,' and that's it." What will it take to boost vaccinations? "A miracle," he said with an exasperated laugh.

Shepherd's close friend Carter Conley, the beloved captain of the county rescue squad, died last month of COVID, despite being vaccinated. Conley's death has been deeply felt around town, but also has given fuel to those who see vaccination as pointless.

Doubts about the vaccines' effectiveness extend to nursing homes in Kentucky despite the persistent correlations between nursing home outbreaks and low vaccination rates among staff.

On a mid-September weekday in Danville, a small city southwest of Lexington, residents at the Landmark of Danville Rehabilitation and Nursing Center sat on a quaint covered porch playing a game of 20 questions with the activities staff. Although 80% of the residents in the facility were fully vaccinated as of September, according to the Centers for Medicare & Medicaid, that was true for just 28% of healthcare personnel, who dash out and back at lunchtime ferrying takeout fast food.

A short drive away, the city's other nursing home, the Danville Centre for Health and Rehabilitation, also had a staff vaccination rate of 28% in September, according to federal records. (A month later, staff vaccination rates at both facilities are still below 60%.)

The unprotected workforce does not faze one man who is moving his elderly father into Landmark. The man, who works as a registered nurse at the local hospital, and a family friend accompanying him did not want to give their names, but they doubt the vaccines' efficacy.

The man's parents were vaccinated in March but fell ill with COVID in August, he said. His mother was put on a ventilator and died; his father was still in the hospital recovering and would soon be moved to the nursing home.

The facility's low staff vaccination rate is "not necessarily pertinent," he said, since his father would be receiving "end-of-life care." His companion said she personally knew four people who died of COVID and that two had been vaccinated and two had not. These cases, she said, "don't get reported because they don't fit the narrative."

Standing on the porch amid festive fall decorations, Landmark's administrator, Cindy Hollins, declined to discuss what might account for her staff's low uptake and politely asked a reporter to leave.

In Louisa, three hours east of Danville, David McKenzie believes the high rates of vaccination among residents and staff at his Jordan Center will be a selling point. "I advertise I'm the safest nursing home in the state of Kentucky to live and work in," he said.

McKenzie and his sister lived in the nursing home as kids; their parents opened the home and couldn't find another house to rent when the town was overflowing with coal miners. He learned to play piano from a resident, down a few fingers from diabetes, who had once played in Duke Ellington's band.

Last winter, COVID ravaged the nursing home for months, infecting nearly every resident. An employee's 33-year-old daughter, who didn't want the vaccine, was buried in early September; then a former employee, who had quit to work at a hospital that didn't require vaccination, died.

As soon as vaccines became available, McKenzie and his staff went room to room, explaining the science to residents. Only one family refused. Then he gathered the staff, many shaken by the loss of residents who were family members and friends.

Now, nearly every resident of the Jordan Center is vaccinated with three shots, and the staff vaccination rate hovers at 85%. But the holdouts keep McKenzie on edge.

"I sat over here on this front porch until 2 o'clock in the morning talking to two of the nurses that don't want to vaccinate," McKenzie said. "One has been here for 37 years and the other for 15 years. They're dug in. They're adamant."

Testing staff members who refuse to get vaccinated falls to Misty Robertson, a registered nurse who has worked at the facility for decades. She views every interaction as a chance to educate her co-workers about why they should get the shot. "I'm not mean about it," she said. "I say, 'I really don't want you to be on a vent and die.'"

Robertson's father, who lived at the Jordan Center, died of COVID in January. Her entire family is vaccinated, including her three children and her husband, who works at Walmart. Everyone except her twin sister, a receptionist for a local pediatrician. She tells Robertson COVID is fake and "it's all because of Biden."

"I get mad," said Robertson. She vehemently disputes the conspiracy theories circulating through the town's social networks, but, she said with a sour laugh, that she sometimes goes too far. "I was put in Facebook jail."

McKenzie's public stance has made him a pariah in some quarters, too. A customer attacked him at Walmart and threatened to wait for him in the parking lot. The darkened mood has carved the town into opposing camps, and he thinks Biden's vaccine mandates will just stiffen that divide.

Certainly, they are proving too much for some of his nursing home staffers. Many of the unvaccinated workers at the Jordan Center are on the same shift, and McKenzie fears he may lose his entire night crew.

"They told me Sunday night they were going to leave healthcare and work at Tractor Supply," he said, "where they can make more money per hour."

Sarah Varney: svarney@kff.org, @SarahVarney4

In many cases, the companies are not actually getting paid to provide insurance.

This podcast was published on Monday, October 18, 2021 in Kaiser Health News.

By Dan Weissmann

Can't see the audio player? Click here to listen.

After Stanford professor Jeffrey Pfeffer got back surgery years ago, he kept a file folder labeled "Blue Shield Troubles."

When Pfeffer got an offer to collaborate with the polling company Gallup, he suggested a study on how much time Americans spend on the phone with their health insurers. Gallup agreed.

Their finding: We spend about 12 million hours a week calling our health insurance. (They also found that, as workers, calling our health insurance companies means we're more likely to miss work, and to be more checked-out and burned-out on the job.)

And given all that … it's important to know as much as possible about who we're actually on the phone with when we make those calls. Like, how do they make money? What are the incentives?

Here's something few of us know: In many cases, the companies are not actually getting paid to provide insurance. If you get your insurance through work, your employer probably "self-insures." (That's true for about two-thirds of all workers, and more than 90% of people who work for companies with more than 1,000 employees.)

But it isn't obvious if your job self-insures. You'll have an insurance card that says Cigna or United or Aetna etc. But you're operating in a different universe. For instance, self-funded plans are governed by federal law, so your state insurance commission can't step in and help. And that's just a start. 

In this episode, we start to get our bearings on that different universe. We talk to Pfeffer, to one of our favorite insurance brains, Karen Pollitz of KFF and to journalist Leslie Walker, whose reporting for the podcast "Tradeoffs" indicates that when companies are playing their role in "self-insured" setups, they can get up to some shady practices. And the employers they're working for — even big, powerful outfits — often don't exercise a lot of oversight or even have a lot of leverage.

Here's a transcript for this 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.

Many insurers offering virtual-first plans hire outside firms to provide medical staff.

This article was published on Friday, October 15, 2021 in Kaiser Health News.

By Julie Appleby  

At the height of the COVID-19 pandemic, people often relied on telemedicine for doctor visits. Now, insurers are betting that some patients liked it enough to embrace new types of health coverage that encourages video visits — or outright insists on them.

Priority Health in Michigan, for example, offers coverage requiring online visits first for nonemergency primary care. Harvard Pilgrim Healthcare, selling to employers in Connecticut, Maine and New Hampshire, has a similar plan.

"I would describe them as virtual first, a true telehealth primary care physician replacement product," said Carrie Kincaid, vice president of individual markets at Priority Health, which launched its plans in January as an addition to more traditional Affordable Care Act offerings.

The often lower-premium offerings capitalize on the new familiarity and convenience of online routine care. But skeptics see a downside: the risk of overlooking something important.

"There's a gestalt of seeing a patient and knowing something is not right, such as maybe picking up early on that they have Parkinson's," or listening to their heart and discovering a murmur, said Dr. David Anderson, a cardiologist affiliated with Stanford Healthcare in Oakland, California. He said online medicine is a great tool for follow-up visits with established patients but is not optimal for an initial exam.

When enrolling in one of the new plans, patients are encouraged to select an online doctor, who then serves as the patient's first point of contact for most primary care services and can make referrals for in-person care with an in-network physician, if needed. It's possible patients never meet their online doctor in person.

Many insurers offering virtual-first plans hire outside firms to provide medical staff. The physicians may hold licenses in several states and not be located nearby. Insurers say participating online doctors can access patients' medical information and test results through the insurers' electronic medical records system or those of the third-party online staffing firm. What might prove tricky, experts warn, is transferring information from physicians, clinics or hospitals outside of an insurer's network. Sharing patient information via EMRs is challenging even for doctors operating under traditional insurance plans with in-person visits — especially moving data between different health systems or specialty practices.

The virtual-first concept was so new that Priority Health called those enrolling this year to ensure they understood how it worked. "If people were more comfortable with brick-and-mortar, they should choose other options," Kincaid said, adding that the plans have drawn 5,000 enrollees since January, a number she hopes will double next year.

Other versions of telehealth plans are available, offered by big names such as Humana, Kaiser Permanente, Oscar and UnitedHealthcare. Some emphasize but don't require that primary care starts online. Some are aimed directly at consumers. Others are sold to employers.

Oscar Virtual Care health plans, sold in several states including Texas, Florida and New York, allow patients to choose between online or in-person services.

"These are not virtual-only plans," said Marianna Spanos, an Oscar vice president and general manager of its virtual care division. "You can always opt to see a more traditional provider."

Although Kaiser Permanente uses its own in-house medical staff, most insurers rely on contracted physicians, mental health therapists and other staff members, often provided by San Francisco-based Doctor on Demand.

Doctor on Demand launched in 2013, aimed at individual consumers. Starting with a Humana contract in 2019, it has since expanded to offer staffing for several other insurers. The company, which has its own electronic medical records system, hires a range of primary care, mental health and other medical providers. Physicians must be board-certified. Pay is partly based on how many patients they see, and there is no upper limit. Some want to work part time, for example, and many work from home.

In general, virtual-first health plans may carry lower premiums or provide such financial incentives as no copays for online visits. All boast that members can get appointments quickly, sometimes within minutes. Patients with serious problems are assisted in arranging emergency help. If online physicians determine patients need a blood test, immunization or a visit with a specialist, they refer them to a local practice, clinic or specialist within the insurer's network.

As a strategy to contain costs, think HMO 2.0.

"There's more control over the patient interaction and where they get referred," said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Still, patients should be aware that some of these plans may allow a brick-and-mortar visit only if their virtual doctor, who may have never examined them in person, deems it necessary.

Skeptics note that many circumstances demand in-person care. One recent study estimated about 66% of primary care visits required it. For example, it's impossible to check reflexes and difficult to examine tonsils for infection virtually.

Patients in some programs, including Harvard Pilgrim's, are sent kits that can include devices like blood pressure cuffs and thermometers — though at-home medical measuring devices are often not as accurate as those used in offices. Online physicians may also ask a patient to feel for swollen lymph nodes, shine a light into their throat while on camera or take other actions to help the physician diagnose a problem.

Kincaid, at Priority Health, noted that Doctor on Demand also sets protocols on children's wellness visits, which it says must be done in person.

"It's important for children's wellness visits to get accurate height and weight measures and immunizations," Kincaid said.

When considering virtual-first plans, advocates say, patients should look closely not just at premiums but also at deductibles and copayments, which may be set at levels that discourage in-person care. Rules are varied and dizzying.

The VirtualBronze plan offered through the federal ACA marketplace in parts of Texas by Community Choice Health, for example, requires hefty patient contributions for many types of in-person visits.

Patients incur no copay for using online Doctor on Demand physicians for primary care visits or for accessing in-person preventive services as defined by the ACA, such as immunizations or cancer screenings. But for other in-person services, Community Choice's virtual plan will cost patients out-of-pocket because they pay the cost of the care until they meet an annual $8,530 deductible.

Kaiser Permanente's Virtual Complete plan offered to large employers carries no copay for online care. Patients can opt to see an in-person doctor three times a year for primary care if they're willing to pay a copay. After those three visits, any additional in-person visits are subject to a deductible.

Plans sold through federal or state marketplaces and those offered by employers must meet the ACA's requirements. That includes a range of services, from doctor visits to hospital care.

Corlette, at Georgetown, said consumers should be wary of plans that are not ACA-compliant.

She fears the advent of plans that give patients "access to online providers, but nothing else." And that, she said, "would not be considered major medical insurance."

Julie Appleby: jappleby@kff.org, @Julie_Appleby