How a Doctor Breaks Norms to Treat Refugees and Recent Immigrants

KFF Health News, July 27, 2021

Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and even a Boy Scout troop.

This article was published on Tuesday, July 27, 2021 in Kaiser Health News.

By Markian Hawryluk

AURORA, Colo. — Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid. But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she'd lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn't lose her job.

So, Osman came to Mango House, a clinic in this eastern suburb of Denver that caters primarily to refugees and turns no one away, regardless of their ability to pay. Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. reject as too low.

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations. When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants.

"This is what I call a medical home," Parmar said.

Although it's not part of the formal U.S. refugee resettlement program, Mango House is in many ways emblematic of refugee healthcare in the U.S. It's a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population.

Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients' needs. As a result, Mango House looks nothing like the rest of the U.S. healthcare system and, at times, draws the ire of the medical establishment.

"How do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on? It's a struggle for sure," said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. "It's these heroes, these champions out there, these cowboys that are taking this on."

Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

"If we ask for an appointment to get Medicaid, P.J. makes the call," Yussef said. "If we call, we're on hold for an hour, and then it hangs up. If we go to the ER, it's a three-hour wait. Here, the majority of people walk in and sit for 30 minutes. It's good for the community."

As for Osman's knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?

"I can almost guarantee it's arthritis," Parmar replied. "You could do an X-ray. That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do? It will cost you $100,000."

Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it's an imperfect solution. "Most orthopedists don't take Medicaid," Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. to qualify for Medicare.

Medicaid, which covers low-income people, generally pays primary healthcare providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English.

Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients. If he limited his practice to just Medicaid, he said dryly, he'd have guaranteed customers and no competition.

So how does he survive on Medicaid rates? By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries.

Because he takes only Medicaid, he knows how to bill the program and doesn't have to hire billing specialists to deal with 10 insurance companies.

It's also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

"Really none of our innovations are new or unique; we just put them together in a unique way to help low-income folks, while making money," Parmar said. "And then, instead of taking that money home, I put it back into the refugee community."

The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine. He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street.

"There's a good three-, four-year dip in the red here, intentionally, as we move from there to here," Parmar said. "But that red is going to go away soon."

The COVID pandemic has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster.

Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health. Parmar won't get paid but sees her anyway. Another patient brings paperwork showing he's being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn't want creams or ointments; good medicine, he believes, comes through a needle.

"A lot of this is, basically, geriatrics," Parmar said. "You have to add 20 years to get their age in refugee years."

When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn't be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn't find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar's creative solutions, however, often rub many in healthcare the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn't possible, so hospitals and clinics must pay interpreters themselves. And that's beyond the capabilities of most refugee clinics, unless they're affiliated with a larger health system that can absorb those costs.

"It's a good thing to have the standards, but it's another thing altogether to implement them," said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing COVID vaccines, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission.

During a recent lull at the clinic, Parmar took stock of that day's inventory of patients. Six were assigned to Denver Health, one patient's Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn't get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill.

"We see the rest of them anyway," he said.

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk

Want Fries With That Vaccine? Even at a Fast-Food Restaurant, Pop-Up Clinics See Slow Traffic

KFF Health News, July 27, 2021

Recent polling shows that no matter which tactics are used, a strong majority of unvaccinated people are unlikely to budge on getting a shot.

This article was published on Tuesday, July 27, 2021 in Kaiser Health News.

By Anna Almendrala

SAN BERNARDINO, Calif. — A few months ago, the boxy, teal truck parked outside a McDonald's in this Inland Empire city might have drawn hundreds of people willing to stand in line for hours under the scorching sun.

The truck is San Bernardino County's mobile vaccine unit, which brings COVID-19 vaccines directly to people. But on July 15, only 22 people got a COVID shot during the four hours it sat there.

Roughly 12 feet away, more people were often seen waiting by a red canopy for free, government-subsidized smartphones, intended for low-income people, than were stepping up for the potentially lifesaving shots.

Barry Luque, a 37-year-old car wash worker who visited the red canopy that day for a free phone, was lured by the truck. He had been eligible for a COVID vaccine since April but never got around to making an appointment. Had he not seen the truck in the parking lot on his day off, "this wouldn't have gotten done," he said.

It's Luque's job to guide drivers into the car wash, but his boss won't let him take his mask off unless he can show proof he's vaccinated.

"People come in from different lives, different styles, different moods at different times," he said after getting his first dose of the Pfizer-BioNTech vaccine. "I've got to guide them carefully and gently, and it's kinda hard for them to see the smile on my face."

Luque and the other 21 people who got vaccinated that day — in addition to the scores of others who drove by or waited in the McDonald's drive-thru line without seeking a shot — offer a snapshot of California's stalling vaccination effort.

Some who finally got the shot, like Luque, were motivated by mandates from employers or are tired of wearing masks. Others want to visit other countries, and vaccinations may help ease travel or quarantine requirements. Some were persuaded, at long last, by family and friends.

Those who continued to hold out primarily cited potential side effects and distrust of the medical system.

Recent polling shows that no matter which tactics are used, a strong majority of unvaccinated people are unlikely to budge on getting a shot, creating an increasingly dangerous scenario as the highly contagious delta variant burns through the country. In California, about 2,800 people were hospitalized for COVID or suspected COVID — more than twice the number six weeks earlier — as of Wednesday.

About 61% of Californians age 12 and up were fully vaccinated by then, according to the U.S. Centers for Disease Control and Prevention, ranking the state 18th among other states and the District of Columbia.

But the overall rate masks deep disparities among, and even within, regions. In geographically and ethnically diverse San Bernardino County, about 47% of eligible residents were fully vaccinated as of Wednesday, with the lowest rates among young people, men, Latinos, Blacks and those who live in the poorest and unhealthiest communities. Statewide, the profile of unvaccinated people is largely the same.

One way local and state leaders are trying to get shots into residents' arms is by hosting pop-up clinics that make COVID vaccines more convenient and accessible for those who can't or won't sign up for an appointment.

San Bernardino County is organizing pop-up events at supermarkets, schools, churches and community centers. The state is also funding vaccine clinics, including 155 events at more than 80 McDonald's restaurants in 11 counties as of Wednesday.

The pop-ups require significant resources and are showing diminishing returns. About 2,500 doses have been administered at the McDonald's clinics so far — an average of 16 shots per event. The California Department of Public Health declined to say how much these events cost, saying it varies.

At the McDonald's in San Bernardino, a city of more than 200,000 that serves as the county seat, eight staffers were on hand to check people in, administer shots and watch for side effects from 9 a.m. to 1 p.m. They also scheduled the necessary second dose for another local pop-up event.

Jeisel Estabillo, 36, hadn't been vaccinated, even though she is a registered nurse who sometimes cares for COVID patients at a hospital. She was one of the first people in the county to become eligible for vaccines, in December, but avoided getting a shot because she wanted to wait and see how it would affect others. She also tested positive for COVID during the winter surge.

But Estabillo changed her mind and visited the vaccine clinic with her father and teenage son because they plan to vacation in the Philippines next year and hope vaccination will reduce travel restrictions or quarantines.

Estabillo also likes that vaccinated people can forgo masks in most public places, although that perk may slip away as more California counties respond to the delta surge by calling on residents to mask up again indoors.

But Jasmine Woodson continued to hold out against the vaccine even though she was hired to provide security and direct traffic for the clinic. Woodson, 24, is studying to become a pharmacy technician and has been tracking vaccine news. She said she was alarmed by the brief pause in the administration of the one-shot Johnson & Johnson vaccine over concern about blood clots, and reports of rare heart inflammation linked to the Moderna and Pfizer vaccines. She also knows that no COVID vaccine has been fully approved by the Food and Drug Administration, which puts her on high alert.

Woodson, who is Black, is also wary because these mobile vaccine events seem to take place only in low-income Black and Latino neighborhoods — a tactic public health officials say is meant to increase uptake in these communities.

"Every day there's always something new. You're not meant to live that long, so if you get it, you get it, and if you don't, you don't," Woodson said of COVID.

Maxine Luna, 69, who came to the nearby red canopy to get a phone, also was not swayed. A longtime smoker whose doctor has been pleading with her to get a COVID shot, she fears side effects, mentioning a friend who battled two weeks of headaches, diarrhea and vomiting after getting vaccinated.

To mitigate her risk, Luna sticks close to her home, which she shares with her brother, who is vaccinated, and her sister and brother-in-law, who are not.

"We're not out and about, we don't go to shows, and we don't go to crowded places," she said.

Concern about side effects is the most common reason holdouts cite for not getting a COVID vaccine, said Ashley Kirzinger, associate director of public opinion and survey research for KFF. (The KHN newsroom is an editorially independent program of KFF.) This is followed by fear that the vaccine is too new or hasn't been tested enough.

Kirzinger said it's important to acknowledge that some people simply can't be persuaded.

"They don't see themselves at risk for COVID, they think that the vaccine is a greater risk to their health than the virus itself, and there's really no incentive, no stick, no message, no messenger that's going to convince these populations," she said. "It's going to be really hard to reach the goals set by public health officials, with the decreasing enthusiasm around the vaccine that we have seen in the past several weeks."

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Anna Almendrala: aalmendrala@kff.org, @annaalmendrala

Watch: More Long-COVID Cases Seen in Kids

KFF Health News, July 26, 2021

Children are increasingly among the COVID "long haulers" and physician concern is growing.

This video was posted on Monday, July 26, 2021 in Kaiser Health News.

The vast majority of the pandemic's 4.1 million COVID infections in children have been mild. However, doctors are concerned about a growing number of long-haul COVID cases and a rare but dangerous inflammatory disease, particularly among Black and Latino children. KHN correspondent Sarah Varney, in collaboration with PBS NewsHour, reports on the phenomena.  

As Holdout Missouri Joins Nation in Monitoring Opioid Prescriptions, Experts Worry

KFF Health News, July 26, 2021

Some in public health now argue that monitoring programs to cut off prescription opiate misuse, will push addicts to use heroin and fentanyl.

This article was published on Monday, July 26, 2021 in Kaiser Health News.

By Eric Berger

Kathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction.

The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started "doctor-shopping" at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose.

If the state had had a monitoring program, doctors might have detected Mullane's addiction and, Arbini thinks, her son might still be alive. She said it's been embarrassing that it's taken Missouri so long to agree to add one.

"As a parent, you would stand in front of a train; you would protect your child forever — and if this helps, it helps," said Arbini, 61. "It can't kill more people, I don't think."

But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates. Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF.

Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri's new toll could cause more people to overdose and leave the state with buyer's remorse.

"If we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others' mistakes and not repeat them," said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.

Before Missouri's monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills.

State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed.

The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it's important to mandate that prescribers review a patient's information in the database. "We know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis," she said.

But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don't use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted.

"Rather than pulling out a piece of paper and being accusatory, I find it's much better to present myself as a caring provider and sit down and have an honest discussion," Wood said.

When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.

But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation's second-largest increase in drug overdose deaths.

When efforts to establish Missouri's statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department. The county now plans to move its program into the state one, which is scheduled to launch in 2023.

Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has "saved lives across the state." Opioid prescriptions decreased dramatically once the county established the monitoring program. In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people; in 2019, it was down to 58.3 prescriptions, according to the CDC.

The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020.

Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can't obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said.

"We absolutely are not prepared for that in Missouri," said Winograd, of NoMODeaths. "Substance use treatment providers will frequently tell you that they are at max capacity."

Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St. Louis-based nonprofit that aims to reduce harm from alcohol and drug use.

For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri.

Tipton, who has worked at the clinic for 17 years, said that before the COVID-19 pandemic, people struggling with opioid addiction mainly used prescription pills; now it's mostly heroin and fentanyl, because they are cheaper. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse.

Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help.

Inez Davis, diversion program manager for the Drug Enforcement Administration's St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because "doctor shoppers and those who commit prescription fraud now have one less avenue."

Winograd said it's possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate. "I don't think that's the answer," she said. "We need to move in the direction of decriminalization and a regulated drug supply." Specifically, she'd rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe.

State Rep. Justin Hill, a Republican from St. Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri's opioid problem any worse than many other states'. He also worries the monitoring program will lead to an increase in overdose deaths.

"I would love the people that passed this bill to stand by the numbers," Hill said. "And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board."

The Pandemic Made Telemedicine an Instant Hit. Patients and Providers Feel the Growing Pains.

KFF Health News, July 26, 2021

Video services were not equally prepared for the titanic influx in users.

This article was posted on Monday, July 26, 2021 in Kaiser Health News.

By Hannah Norman

Crystal Joseph pays for two telemedicine video services to ensure that her small therapy practice in Silver Spring, Maryland, can always connect with its clients.

She's been burned before. During one hours-long service outage of SimplePractice in late May, PsycYourMind, which offers mental health counseling and group sessions for Black patients, lost about $600 because of missed appointments. Livid, Joseph requested a small credit from the telemedicine service, which costs $432 monthly for her team of clinicians and trainees. SimplePractice refused, she said.

"What they offer is phenomenal, especially being founded by a therapist," said Joseph, a licensed clinical professional counselor. "But with a private practice, if you don't get paid, you don't eat." For some sessions, she was able to hop onto her backup, VSee, which costs her $49 each month. Some of her peers use Zoom. But even though Joseph keeps links to both her SimplePractice and VSee accounts in her email signature, a last-minute switch-up can feel messy for clients, and she never charges a no-show fee when it's an "act of God."

Major health systems, clinics and private practices alike pivoted swiftly to telemedicine when the COVID-19 pandemic forced the nation to shelter in place and patients could no longer safely venture into healthcare settings. But the video services were not equally prepared for the titanic influx in users, said Kapil Chalil Madathil, an engineering professor at Clemson University who has researched how easy — or difficult — telemedicine platforms are to use.

Videoconferencing vendors, including Zoom, tech giants like Microsoft and Cisco, and a host of telemedicine startups absorbed an explosion of demand over the past pandemic months. PitchBook estimates that revenue from the global telehealth market will hit $312.3 billion in 2026, up from $65.5 billion in 2019. But beyond connectivity issues, some services seemed designed for dissatisfaction. They required patients to download a desktop application or made them click through multiple steps to log in. "On an iPhone, I can click one button to see my grandkids," Madathil said. "Can we not make telemedicine systems as easy as that?"

Providers often were locked in with telemedicine options from services they were already using — or what they could afford. Joseph was already paying SimplePractice to house her practice's electronic health records, so moving to another platform would have been time-consuming and costly, she said.

Practitioners have depended on telemedicine to keep their businesses afloat in the pandemic, and Joseph plans to keep a portion of her sessions virtual. A one-stop shop for private practice clinicians, SimplePractice offers scheduling, an electronic medical records system and insurance claims filing along with its video services. The company said it hosted 17 million telehealth appointments last year.

"The expectations are rising," said Diana Stepner, a SimplePractice vice president. "Individuals want screen sharing, they want grid views, so we've added new capabilities since the pandemic began and will continue to do so."

Zoom became an overnight poster child for staying connected as employees in every line of business across the country worked from home. Its revenue jumped 326% in the fiscal year that ended on Jan. 31, 2021, over the previous year's. Even before the pandemic, the Silicon Valley company offered a service tailored for healthcare practitioners that complied with the Health Insurance Portability and Accountability Act, which protects patient privacy, and could be synced with Epic Systems electronic medical records.

"It was 'all bets are off' once the pandemic hit," said Heidi West, who heads the healthcare division at Zoom. West pointed to the CARES Act and the loosening of telehealth regulations, which allowed doctors to be reimbursed for telemedicine at the same rate as for in-office visits.

UCSF Health, which had contracted with Zoom for virtual visits since 2016, gave every doctor and clinician a personal link for its videoconference line and a separate virtual waiting room. Telemedicine calls for outpatient care within the San Francisco academic medical system spiked from 2% of visits in February 2020 to more than 60% by that April. Doctors were seeing patients — who often used their cellphones — in their homes, in parked cars and in one case on skyscraper scaffolding, where a construction worker stepped away for a quick doctor's visit, said Linda Branagan, director of telehealth at UCSF Health.

Zoom is not immune to glitches, Branagan said, but it seems to bounce back faster than many other vendors and "recovers quite gracefully."

UCSF surveyed its patients and found they were more satisfied with their video visits than their in-person ones. More than a year later, almost one-third of outpatient visits are still conducted virtually.

Elsewhere, the initial transition was rockier. Dr. James McElligott, who runs Medical University of South Carolina's Center for Telehealth, said the hospital could not afford to upgrade its Vidyo conferencing system, so he opted for Doxy.me, which the center already used for research and had an easy-to-use interface.

"We were able to get clever, and many doctors really liked it," McElligott said. The software has a waiting room from which patients can be transferred into virtual rooms with providers. The health system sent patients a text with a direct link for their appointments so that they didn't lose time.

"But we couldn't control quality or solve connectivity issues ourselves," he said. "We did have a lot of patients who, despite it just being a link, were uncomfortable waiting." That led to some patients abandoning visits, he added.

Doxy.me employed just eight people when the video telemedicine service saw an unwieldy increase in users in March 2020. For two weeks straight, the company signed up 20,000 new healthcare providers a day, said founder and CEO Brandon Welch, amassing a backlog of customer service inquiries. One day, Welch recalled, there was a 30-second queue for the website to load because so many people were logging on simultaneously.

"We hired anyone who could walk and chew gum at the same time," joked Welch, noting that many of those early pandemic hires, largely tackling customer service, had been recently laid off from other industries, like restaurants.

Doxy.me automated the sign-up process as quickly as possible. The service ballooned from 80,000 users to 850,000 as it assembled a team of 120 employees. And it is still hiring. Doctors and clinicians can sign up for the basic HIPAA-compliant service — which includes audio, video and a patient waiting room — at no charge. But for enhanced options, like screen sharing or shared rooms, there's a price tag of at least $29 a month.

For many doctors and clinicians, the move to virtual visits may be permanent, even with all the technical hiccups. A survey conducted by SimplePractice of over 2,400 clinicians in February found that 88% expected to continue offering a telehealth option.

Jessica Ehrman, a Santa Monica, California, therapist who plans to keep her practice fully remote, finds telemedicine much easier for scheduling, particularly for kids who have short windows of availability. Still, connectivity issues during that small time frame can tarnish the whole session.

"If you're talking about deep childhood trauma — having your connection time out then? It's really frustrating when we're paying for a service," said Ehrman, who has been suddenly dropped from sessions, experienced lags and even once saw back-end coding pop up in her provider portal. Like Joseph in Maryland, she uses SimplePractice through her agency and personally pays for Zoom's HIPAA-compliant option to head off technical difficulties.

Despite the problems, few healthcare providers want to forsake the technology. "Video visits are cemented," said Branagan. "I will never again have to have a conversation with a physician to convince them that you can do healthcare via video."

Hannah Norman: hannahn@kff.org, @hnorms

Contraception Is Free to Women, Except When It's Not

KFF Health News, July 23, 2021

Despite the ACA's guarantees of free contraception coverage, even for women whose health plans are subject to the law's requirements, obtaining the right product at no cost can be onerous.

This article was posted on Friday, July 23, 2021 in Kaiser Health News.

By Michelle Andrews

For Stephanie Force, finding a birth control method that she likes and can get without paying out-of-pocket has been a struggle, despite the Affordable Care Act's promise of free contraceptives for women and adolescent girls in most health plans.

The 27-year-old physician recruiter in Roanoke, Virginia, was perfectly happy with the NuvaRing, a flexible vaginal ring that women insert monthly to release hormones to prevent pregnancy. But her insurer, Anthem, stopped covering the branded product and switched her to a generic version in early 2020. Force said the new product left her with headaches and feeling irritable and short-tempered.

After talking to her OB-GYN, Force tried an IUD. But that made her feel worse: She had bad cramps, gained 10 pounds and developed severe hormonal acne. Plus, she was charged $248 for an ultrasound her provider used to guide the insertion of the device, a charge she successfully fought.

Force also considered a couple of birth control products approved in recent years: a non-hormonal vaginal gel called Phexxi and a vaginal ring called Annovera that can be used for a year. But Phexxi isn't covered by her employer health plan, and she would owe a $45 copayment for Annovera.

Despite the ACA's guarantees of free contraception coverage, Force's experience illustrates that even for women whose health plans are subject to the law's requirements, obtaining the right product at no cost can be onerous. New types of contraceptives aren't automatically incorporated into the federal list of required methods that insurers use to guide coverage decisions. In addition, some health plans continue to discourage use of even long-established methods like IUDs by requiring providers to get approval from the plan before prescribing them.

Consumer advocates who have studied the issue say a process is spelled out in federal rules for women to get the contraceptive they need, but far too few people know that is an option.

Ultimately, Force went back to the generic version of the NuvaRing, despite the side effects she continues to experience. She'd prefer to be on the branded NuvaRing, which didn't give her problems, and the ping-ponging from method to method has left her exhausted and furious.

"I cannot believe what hoops I have had to jump through between September 2020 and June 2021," Force said, "between switching from the generic NuvaRing to the IUD and then back, fighting my insurance and OB-GYN's office on the ultrasound charge."

In a statement, Anthem said, "Anthem health plans cover 222 contraceptive products at $0 cost share on our ACA Preventive List. We cover at least one product" in each of 18 categories of contraception methods approved by the FDA.

Contraception is a very personal choice, and what meets one woman's needs may not meet another's. If avoiding pregnancy is a woman's top priority, a virtually fail-safe method like an IUD may be the right solution. But for someone who's considering getting pregnant soon, a readily reversible method like a birth control pill might be the best option. Side effects are important to consider as well, since women respond differently to the hormones in various birth control products.

Before the ACA required no-cost birth control coverage, researchers estimate, up to 44% of women's out-of-pocket healthcare spending went toward contraceptives. The ACA required most commercial health plans to cover a comprehensive list of FDA-approved methods without charging women anything. Church plans and religious nonprofits as well as employers and schools that object to contraception are exempt from the coverage requirements. Plans that were grandfathered under the law are also exempt. Uninsured women don't benefit from the mandate either.

But the federal rules do not require health plans to cover every contraceptive. After the ACA passed in 2010, the federal Health Resources & Services Administration developed guidelines for women's preventive services. Those guidelines say women should have access without cost sharing to a list that covers the 18 FDA-approved methods, including oral contraceptives, vaginal rings and cervical caps, IUDs, implantable rods and sterilization. Under federal rules, health plans must cover at least one product in each category.

But neither the HRSA guidelines nor a birth control chart published by the FDA addresses newer methods, including the gel Phexxi, which regulates vaginal acidity to reduce the odds a sperm reaches an egg. It was approved by the FDA last year.

Nor do they incorporate fertility-awareness mobile apps the FDA approved in recent years such as Natural Cycles, which tracks a woman's temperature and menstrual cycle to avoid pregnancy.

"There's a real need for new guidance that keeps up with new methods," said Mara Gandal-Powers, director of birth control access at the National Women's Law Center.

Many insurers have balked at covering Phexxi, said Rameshwari Gupta, director of strategic markets for Evofem Biosciences, which markets Phexxi. A box of 12 single-use applicators — consumers use one before having sex — costs $267.50 without insurance, she said.

"When I started talking to payers, they all said, 'Where are you on this FDA chart?'" she said.

According to an FDA spokesperson, the birth control chart is for consumer education purposes only and "was not created with the intent of driving coverage decisions." The agency is in the process of updating it.

In a statement, HRSA said it is reviewing the evidence on contraceptives and expects to complete its review late this year. If it opts to make revisions, it will publish draft recommendations to update the women's preventive services guidelines. These will be finalized after a public comment period and become effective a year later.

At this point, health plans consider Phexxi a spermicide and are required to cover only one type of spermicide without cost sharing, said Kristine Grow, a senior vice president at AHIP, a health insurance trade organization.

"If Phexxi is indeed considered a new 'method' of contraception, both the FDA and HRSA would need to make this clear," she added.

The vaginal ring Annovera, approved by the FDA in 2018, is typically covered by health plans, according to Grow, though it may not be available without cost sharing. The average retail price is $2,457 a year, according to GoodRx.

One way plans have made it difficult for women to access certain contraceptives, even those on the list of approved methods, is by requiring that their providers get approval from the insurer first, often by providing documentation that the product is medically necessary.

Under UnitedHealthcare's coverage policy for Phexxi, for example, before coverage will be authorized, members must have documented reasons that they are unable to use eight other contraceptive methods, including oral contraceptives, the contraceptive patch, a vaginal ring, injections and spermicides. Providers also must attest that they have counseled patients that Phexxi is less effective at preventing pregnancy than some other methods.

In a statement, UHC said it covers "a broad array" of generic and brand-name options, and it follows scientific evidence to develop its list.

Yet consumers have a way to get the specific drug that is most appropriate for them, according to a report by the National Women's Law Center.

Under federal rules, if a doctor or other healthcare provider determines that a patient needs a particular contraceptive, even if it's not on the list of approved products for the patient's plan, the insurer is required to have an expedient process for the patient to seek a waiver.

"It's not up to the insurance company whether to cover that method; it's up to the provider," said Adam Sonfield, executive editor for policy analysis at the Guttmacher Institute, a research and advocacy organization focused on women's reproductive health.

But according to the National Women's Law Center report, many insurers, patients and their providers aren't aware of the requirement, and state agencies don't enforce these so-called exceptions policies.

If patients run into trouble getting the method they want, "we typically recommend filing an appeal with their insurance provider," said Gretchen Borchelt, vice president for reproductive rights and health at the National Women's Law Center.

Stephanie Force said she was unaware of any process she could have used to get the NuvaRing covered without cost sharing. Neither her healthcare provider nor the insurer mentioned the possibility.

She recently had an appointment with a new provider, who she hopes will be a better advocate for her.

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

After 18 Months, Sutter Antitrust Settlement Finally Poised for Formal Approval

KFF Health News, July 23, 2021

Numerous twists and turns have slowed the court's approval of the settlement in late 2019.

This article was published on Friday, July 23, 2021 in Kaiser Health News.

By Jenny Gold

More than 18 months after Sutter Health agreed to a tentative settlement in a closely watched antitrust case joined by the California Attorney General's Office, the judge presiding over the case indicated she would sign off on the terms, pending agreement on attorney fees. The nonprofit healthcare giant, based in Sacramento, stood accused of violating California's antitrust laws by using its market dominance to drive up prices. 

The settlement is expected to have nationwide implications on how hospital systems negotiate prices with insurers. 

"These plaintiffs are among the first, but will not be the last, to successfully challenge dominant healthcare systems who undertake land grabs to mark up prices at the expense of patients and employers," Leemore Dafny, a Harvard Business School professor who studies the industry, wrote in an email. "This settlement has provided a marker for the rest of the nation." 

The settlement, which includes $575 million in damages, was announced on a preliminary basis in December 2019. It marked a dramatic turn in a long-running legal battle initiated in 2014 as a class-action lawsuit filed by the United Food and Commercial Workers International Union & Employers Benefit Trust, representing employers, unions and local governments whose workers use Sutter services. Then-Attorney General Xavier Becerra joined the case in 2018. 

Numerous twists and turns have slowed the court's approval of the settlement in the months since.

San Francisco Superior Court Judge Anne-Christine Massullo had been expected to issue a preliminary approval of the terms in August 2020, but rejected the independent monitor the parties had chosen to oversee the rollout of the agreement. The monitor chosen was neither a woman nor a person of color, and Massullo said the parties' selection process did not properly take into account the court's emphasis on diversity, equity and inclusion. 

More months passed as Sutter argued for further delays and suggested it would push to alter the settlement in light of the potentially dramatic effects of the COVID-19 pandemic on the healthcare system's finances and operations. 

Preliminary approval was eventually granted, but most recently, final approval was postponed because of a dispute between UEBT and their lawyers over attorney fees. The parties had agreed at the outset to plaintiffs' attorneys, led by Richard Grossman of Pillsbury & Coleman, getting 30% of the settlement amount. Given the size of the settlement, that comes to $172.5 million in attorney fees, a figure UEBT argues is unreasonably high. 

An additional 2% in fees will go to the Attorney General's Office. UEBT expects to receive about $15 million, and what is left of the $575 million will be distributed among the rest of the class, made up of other unions and employers who purchase health insurance for their workers. 

Thursday's hearing was largely devoted to a tense back-and-forth over the attorney fees. Ultimately, the hearing concluded without resolution on the issue. But Massullo indicated she would approve the terms of the settlement in a written order once the fees had been sorted out. The timing of that final order was left unclear. 

Sutter has 23 hospitals, 33 surgery centers and 12,000 physicians across Northern California, with $13 billion in operating revenue in 2020. Among other allegations, the state's lawsuit argued Sutter has aggressively bought up hospitals and physician practices throughout the Bay Area and the rest of Northern California, and exploited that market dominance for profit. 

Healthcare costs in Northern California are 20% to 30% higher than in Southern California, even after adjusting for the cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley that was cited in the complaint. 

Among other terms, the settlement requires Sutter to: 

  • Limit what it charges patients for out-of-network services. 
     
  • Increase transparency by allowing insurers and employers to give patients pricing information. 
     
  • Cease bundling services and products, and instead offer stand-alone pricing. 

In agreeing to the settlement, Sutter did not admit wrongdoing. Throughout the proceedings, it has maintained that its integrated health system offers tangible benefits for patients, including affordable rates and consistent high-quality care. Sutter spokesperson Amy Thoma Tan said in an email that the settlement would not reduce the quality of patient care. 

"Our commitment to providing high-quality care to our patients is unwavering, and independent data shows that our quality yields better health outcomes and a lower total cost of care," she wrote. "Sutter's quality of care is nationally recognized, with the majority of our hospitals and facilities outperforming state and national averages in nearly every measure of quality." 

Still, under the terms of the settlement, Sutter agreed to end a host of practices that Becerra, who now heads the U.S. Department of Health and Human Services, alleged unfairly stifled competition. Among other conditions, the settlement also requires Sutter to limit what it charges patients for out-of-network services and end its all-or-nothing contracting deals with payers, which demanded that an insurer that wanted to include any one of the Sutter hospitals or clinics in its network must include all of them. 

Sutter has earned an average 42% annual profit margin over the past decade from medical treatments paid for by commercial insurers like the plaintiff companies, according to a recent analysis by Glenn Melnick, a healthcare economist at the University of Southern California.  

Sutter also faces a second federal class-action lawsuit alleging anti-competitive behavior. But while Sutter remains in the crosshairs, its practices are not unique. Experts say negotiating tactics including all-or-nothing contracts and anti-tiering provisions have become widespread among hospital systems nationwide. 

"Any system could change their practices tomorrow. If we have to wait for the courts to force them to not use anti-competitive practices, that's really disappointing," said Elizabeth Mitchell, CEO of the Purchaser Business Group on Health, which represents employers that buy insurance coverage for their workers. 

"What the Sutter case proves is that the people who pay for and receive care can achieve accountability from the healthcare system. But it shouldn't be that hard." 

Jenny Gold: jgold@kff.org, @JennyAGold

Facing Headwinds on New Alzheimer's Drug, Biogen Launches Controversial Campaign

KFF Health News, July 23, 2021

The drugmaker is running an educational campaign directed at the consumer, one who is already worried about whether those lost keys or a hard-to-recall name is a sign of something grave.

This article was published on Friday, July 23, 2021 in Kaiser Health News.

By Julie Appleby

Do you sometimes lose your train of thought or feel a bit more anxious than is typical for you?

Those are two of the six questions in a quiz on a website co-sponsored by the makers of Aduhelm, a controversial new Alzheimer's drug. But even when all responses to the frequency of those experiences are "never," the quiz issues a "talk to your doctor" recommendation about the potential need for additional cognitive testing.

Facing a host of challenges, Aduhelm's makers Biogen and its partner Eisai are taking a page right out of a classic marketing playbook: Run an educational campaign directed at the consumer, one who is already worried about whether those lost keys or a hard-to-recall name is a sign of something grave.

The campaign — which also includes a detailed advertisement on The New York Times' website, a Facebook page and partnerships aimed at increasing the number of places where consumers can get cognitive testing — is drawing fire from critics. They say it uses misleading information to tout a drug whose effectiveness is widely questioned.

"It's particularly egregious because they are trying to convince people with either normal memories or normal age-related decline that they are ill and they need a drug," said Dr. Adriane Fugh-Berman, a pharmacology professor at Georgetown University Medical Center, who wrote about the website in an opinion piece. 

The website's "symptoms quiz" asks about several common concerns, such as how often a person feels depressed, struggles to come up with a word, asks the same questions over and over, or gets lost. Readers can answer "never," "almost never," "fairly often" or "often." No matter the answers, however, it directs quiz takers to talk with their doctors about their concerns and whether additional testing is needed.

While some of those concerns can be symptoms of dementia or cognitive impairment, "this clearly does overly medicalize very common events that most adults experience in the course of daily life: Who hasn't lost one's train of thought or the thread of a conversation, book or movie? Who hasn't had trouble finding the right word for something?" said Dr. Jerry Avorn, a professor of medicine at Harvard Medical School who has been sharply critical of the approval.

Aduhelm was approved in June by the Food and Drug Administration, but that came after an FDA advisory panel recommended against it, citing a lack of definitive evidence that it works to slow the progression of the disease. The FDA, however, granted what is called "accelerated approval," based on the drug's ability to reduce a type of amyloid plaque in the brain. That plaque has been associated with Alzheimer's patients, but its role in the disease is still being studied.

News reports also have raised questions about FDA officials' efforts to help Biogen get Aduhelm approved. And consumer advocates have decried the $56,000-a-year price tag that Biogen has set for the drug.      

On the day it was approved, Patrizia Cavazzoni, the FDA's director of the Center for Drug Evaluation and Research, said the trial results showed it substantially reduced amyloid plaques and "is reasonably likely to result in clinical benefit."

Describing the website as part of a "disease awareness educational program," Biogen spokesperson Allison Parks said in an email that it is aimed at "cognitive health and the importance of early detection." She noted that the campaign does not mention the drug by name.

Earlier Thursday, in "an open letter to the Alzheimer's disease community," Biogen's head of research, Dr. Alfred Sandrock, noted the drug is the first one approved for the condition since 2003 and said it has been the subject of "extensive misinformation and misunderstanding." Sandrock stressed a need to offer it quickly to those who have only just begun to experience symptoms so they can be treated before the disease moves "beyond the stages at which Aduhelm should be initiated."

While the drug has critics, it is also welcomed by some patients, who see it as a glimmer of hope. The Alzheimer's Association pushed for the approval so that patients would have a new option for treatment, although the group has objected to Biogen's pricing and the fact that it has nine years to submit follow-up effectiveness studies.

"We applaud the FDA's decision," said Maria Carrillo, chief science officer for the association. "There's a benefit to having access to it now" because it is aimed at those in the early stages of dementia. Those patients want even a modest slowdown in disease progression so they have more time to do the things they want to accomplish, she said.

The drug is given by infusion every four weeks. It also requires expensive associated care. About 40% of the patients in the trials experienced brain swelling or bleeds, so regular brain imaging scans are also required, according to clinical trial results and the drug's label. In addition, patients will likely need to be checked for amyloid protein, which is done with expensive PET scans or invasive spinal taps, according to Alzheimer's experts.

To educate more potential patients, and customers, Biogen announced it has teamed with CVS to offer cognitive testing, and with free clinics for dementia education efforts. 

Biogen is also picking up some of the laboratory costs for patients who get a spinal tap.

Still, the drug faces headwinds: There's a congressional probe of the drug's approval, the head of the FDA has called for an independent investigation of its review process, and there's pushback from policy experts and insurers over its price, which they say could seriously strain Medicare's finances. Some medical systems, including the Cleveland Clinic and Mount Sinai, say they won't administer it, citing efficacy and safety data.    

None of that is mentioned in Biogen's campaign.

Instead, the advertisements and websites focus on what is called mild cognitive impairment, including a warning that 1 in 12 people over age 50 have that condition, which it describes as the earliest clinical stage of Alzheimer's.

On its website, Biogen doesn't cite where that statistic comes from. When asked for the source, Parks said Biogen's researchers made some mathematical calculations based on U.S. population data and data from a January 2018 article in the journal Neurology.

Some experts say that percentage seems high, particularly on the younger end of that spectrum.

"I can't find any evidence to support the claim that 1 in 12 Americans over age 50 have MCI due to Alzheimer's disease. I do not believe it is accurate," said Dr. Matthew S. Schrag, a vascular neurologist and assistant professor of neurology at Vanderbilt University Medical Center in Nashville, Tennessee.

While some people who have mild cognitive impairment progress to Alzheimer's — about 20% over three years — most do not, said Schrag: "It's important to tell patients that a diagnosis of MCI is not the same as a diagnosis of Alzheimer's."

Mild cognitive impairment is tricky to diagnose — and not something a simple six-question quiz can uncover, said Mary Sano, director of the Alzheimer's Disease Research Center at the Icahn School of Medicine at Mount Sinai in New York.

"The first thing to determine is whether it's a new memory problem or a long-standing poor memory," said Sano, who said a physician visit can help patients suss this out. "Is it due to some other medical condition or a lifestyle change?"

Carrillo, at the Alzheimer's Association, agreed that MCI can have many causes, including poor sleep, depression or taking certain prescription medications.

Based on a review of medical literature, her organization estimates that about 8% of people over age 65 have mild cognitive impairment due to the disease.

She declined to comment on the Biogen campaign but did say that early detection of Alzheimer's is important and that patients should seek out their physicians if they have concerns rather than rely on "a take-at-home quiz."

Schrag, however, minced no words in his opinion of the campaign, saying it "feels like an agenda to expand the diagnosis of cognitive impairment in patients because that is the group they are marketing to."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Big Leagues Balk at Endorsing Vaccination

KFF Health News, July 22, 2021

Despite resources that other industries can only dream of, most pro leagues in the U.S. are struggling to get their teams' COVID-19 vaccination rates to 85%.

This article was published on Thursday, July 22, 2021 in Kaiser Health News.

By Mark Kreidler   

Santa Clara County, where the San Francisco 49ers train and play their NFL home games, has one of the highest COVID vaccination rates in California. As of July 11, more than 76% of its vaccine-eligible residents were fully vaccinated, partly because the county and the 49ers franchise turned Levi's Stadium into a mass inoculation site where more than 350,000 doses were administered over four months.

The 49ers themselves, however, are not so enthusiastic about the shots. In June, head coach Kyle Shanahan said only 53 of the 91 athletes on the team roster — 58% — were fully vaccinated. The team has issued no updates since.

It's a familiar story in the world of professional sports. Despite resources that other industries can only dream of, most pro leagues in the U.S. are struggling to get their teams' COVID-19 vaccination rates to 85%, a threshold considered high enough to protect the locker room or clubhouse from spread of the disease. Only the Women's National Basketball Association, at 99%, can boast a highly successful campaign to educate and vaccinate its players.

And while the public might expect sports figures, and the rich leagues they play for, to help rally the national vaccination effort, that's not happening. Although the leagues and unions have advocated for players to get the shots, the industry clearly regards vaccination as a personal decision — not a responsibility.

"It's everyone's choice whether they want to get vaccinated or not," Sam Darnold, the Carolina Panthers' quarterback and a former USC star, said in June when revealing that he had not gotten a shot. "For me, I'm staying by myself right now. I don't have a family or anything like that. There's a ton of different things that go into it."

Comments like Darnold's and those of Buffalo Bills receiver Cole Beasley, who tweeted a long rant casting the COVID vaccines as a threat to "my way of living and my values," have dominated news cycles. Meanwhile, the leagues themselves, whose overall vaccination numbers outpace those of the country at large, pad around the topic carefully.

"Push? No. Encourage," said Tony Clark, executive director of the Major League Baseball Players Association, when asked at an MLB All-Star Game news conference about the union's position on player vaccination. "We've encouraged from the beginning."

And most players have shunned the role of public health spokesperson, making the pro-vaccination campaign a largely faceless one. Few have publicly endorsed vaccination or acknowledged receiving shots, even though the league's numbers suggest large majorities are vaccinated. Most don't want to discuss it.

In May, NBA superstar LeBron James pointedly refused to answer questions about whether he'd been vaccinated, saying, "Anything of that nature is all family talk." Tampa Bay Buccaneers linebacker Shaq Barrett said he and his wife had received vaccines, but as for encouraging teammates, "it's to each their own. I don't know why people wouldn't get it, but whatever makes you comfortable, whatever helps you sleep at night, you do that."

Zachary Binney, a sports epidemiologist at Emory University in Atlanta, believes pro athletes aren't that different from the rest of us when it comes to vaccines: "A lot of them are vaccinated. A lot of them are willing to become vaccinated. Some of them have concerns. And some of them just are not going to do it — and they are never going to do it."

In fact, most of the teams are doing well by overall U.S. standards. More than 70% of NFL and NBA players are at least partially vaccinated, according to reports. That puts both leagues' rates higher than they are for young U.S. adults as a whole.

Some players may be reluctant to speak up, Binney said, because the vaccine has been so politicized that they could lose fans by taking a stand one way or another — a far cry from the 1950s, when the country embarked on the nationwide March of Dimes campaign for polio vaccination with backing from ballplayers like Joe DiMaggio and Jackie Robinson. The country was united in viewing polio as a menace, whereas many conservatives shrug off the coronavirus. Then too, COVID's risks increase with age. Professional athletes are often in peak physical condition and may seldom visit a doctor outside of the team training room.

Sports teams' lack of leadership on the issue is a crucial miss for those pushing for greater vaccination rates, and it may also depress the chances of success within their own locker rooms, Binney said.

"One of the things we've learned is that people, not just athletes, are more likely to get vaccinated if the folks around them have become vaccinated," he said. "If your locker room leaders aren't speaking up, or if they're mostly sharing concerns or misinformation, that all has an effect on the numbers."

The NFL has set heavy restrictions on unvaccinated players — they must be tested daily and wear masks at team facilities, and can't leave the hotel when they're on the road — while mostly lifting the restraints on those who've received their shots.

The teams and union have informed players about the risks and benefits of the vaccines, even bringing in experts to meet with players. On a recent media call, Dr. Thom Mayer, the NFL players association's medical director, said players had contacted him with all manner of questions about the vaccines, including about reports of rare heart inflammation in young men post-mRNA vaccination, how long antibodies might last in their systems and whether the Food and Drug Administration's emergency use authorization of the vaccines meant they were less well-tested than fully licensed products.

"They are serious, thoughtful questions that deserve serious and thoughtful answers," Mayer said during the call. "I'll say what our players say: They're grown-ass men. You give them grown-ass facts and they'll make a grown-ass decision."

For the NFL, the urgency of a looming pro football season may kick vaccination rates upward. Major League Baseball, meanwhile, reported June 25 that 23 of its 30 teams had reached the 85% threshold, which triggers loosened restrictions — but acknowledged that its efforts to get more teams to that level had begun to stall despite months of advocacy.

"I can't make any assumptions about the other leagues, but baseball is such a mixture of people with differing opinions on everything," said Jerry Blevins, 37, who retired in April after a 13-year MLB career as a pitcher. Blevins got his first dose on the first day it was available to him.

But some star athletes, current and former, are taking a stand.

Detroit Tigers slugger Miguel Cabrera agreed to serve as a spokesperson for Michigan Gov. Gretchen Whitmer's effort to promote vaccination. Basketball Hall of Famer Bill Russell, 87, got vaccinated and recorded a public service announcement on behalf of the NBA, as did San Antonio Spurs coach Gregg Popovich and fellow Hall of Famer Kareem Abdul-Jabbar.

Women's basketball has been in a league of its own, vaccination-wise, notes WNBA Commissioner Cathy Engelbert. Its campaign was led by the players union, which began providing information and addressing its members' concerns during a series of video conferences in December, before vaccines were readily available.

What came out of those conversations was a better understanding by the players of the outsize risk of COVID infection and death for Black women, who make up at least 70% of league rosters. By April, stars from the league were appearing in a public service announcement urging vaccination with the slogan "Our health is worth a shot," and appealing to Black women specifically. And they were receiving the vaccine themselves.

No other league, however, appears to have discovered such a catalyst, and the numbers show it.

"It's a different decision for everybody," the 49ers' Shanahan said. Pro athletes, seldom of one mind, don't agree on this topic, either.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Wildfire Smoke Drives People in Low-Vaccinated Areas Indoors, Raising Outbreak Fears

KFF Health News, July 22, 2021

The smoke and unrelenting heat pummeling Montana have driven people to seek refuge at libraries, movie theaters, museums and other indoor venues.

This article was published on Thursday, July 22, 2021 in Kaiser Health News.

By Aaron Bolton

MISSOULA, Mont. — Missoula's new downtown library was teeming with people who might typically spend a Saturday afternoon hiking, biking or otherwise making the most of Montana's abundant outdoor recreation. One look at the soupy haze blanketing the city and it was clear why.

"We're definitely trying to stay out of the smoke," Charlie Booher said as his kids picked out books from the stacks.

Smoke from the wildfires burning through bone-dry forests and grasslands in the West has damaged air quality this week from California to the Eastern Seaboard. The polluting smoke has been thickest in the Northwest, including Montana, where over the past week Missoula, Helena, Great Falls and other cities ranked among the 10 places with the worst air quality, according to AirNow.

The smoke and unrelenting heat pummeling the state have driven people to seek refuge at libraries, movie theaters, museums and other indoor venues. In areas with low COVID-19 vaccination rates where people have largely abandoned masks and physical distancing, health officials are concerned the result will be COVID outbreaks.

Adding to that worry is the rise of the highly transmissible delta variant of the coronavirus, and research suggests that COVID cases and deaths increase during periods of intense wildfire smoke.

Missoula County has the highest vaccination rate in Montana, at 60%, but Whitney Kors was still mindful of the risks as she took her family to the library to get out of the smoke.

"My daughter and I are still masked because she's not vaccinated," Kors said.

She said that until her daughter, who's under 12 years old, becomes eligible for her shot, her family will continue to distance from others when they're out. However, health officials worry that not everyone seeking out smoke-free activities indoors this summer will take the same precautions if they are unvaccinated.

To the north in Flathead County, Joe Russell, the county health officer, said he's tracking a roughly 50% increase in COVID cases over the past two weeks, mostly from unvaccinated people catching the virus at events.

"These are activities that are happening specific to events or settings, and they are indoors," he explained.

Russell said his team is more closely investigating new clusters to see if people went inside to escape heat and smoke. About 6 of 10 county residents who are eligible for COVID vaccines have not gotten them, and Russell is worried these large clusters could get worse if more people gather indoors.

The dangers of the pandemic appear to have waned in people's minds as they gather in indoor public spaces, many of which dropped masking and physical distancing requirements earlier this year.

In Yellowstone County and Billings, Montana's largest city, the pandemic is still being felt in hospitals that have been treating younger, sicker patients than they saw earlier in the pandemic. COVID deaths also spiked there in early July.

Yellowstone County Health Officer John Felton hoped the summer would provide time to boost the county's 50% vaccination rate before cold weather sends people indoors and increases the risk of unvaccinated people transmitting COVID.

"But this year has been so hot, so dry and with so much smoke, we are concerned we're going to have increases happening a little earlier," he said.

Across Montana, about 48% of the eligible population is fully vaccinated, but Magdalena Scott with the state Department of Public Health and Human Services said county rates range from about 23% to 60%. She said that means case numbers, hospitalizations and deaths are likely to vary more widely than they did last summer, when vaccines weren't yet available. "We are concerned that it's going to be a long smoke season for sure," Scott said.

There are also worries that wildfire smoke could drive up COVID transmission not just by driving people indoors, but also by making them more susceptible to the coronavirus.

Fine particulate matter in wildfire smoke, known as PM 2.5, is so small it bypasses the body's natural defenses, building up in the bloodstream, inflaming the lungs and wearing down the immune system, according to the Centers for Disease Control and Prevention.

PM 2.5 from urban air pollution and wildfire smoke is increasingly associated with susceptibility to respiratory infections in general, but researchers have been racing to study the same possible association with the coronavirus, a respiratory virus, since last summer.

Daniel Kiser is a researcher at the Desert Research Institute in Reno, Nevada. He worked on a recently published paper about an increase in COVID cases in Reno during the wildfire season.

"What we found was that there was about an 18% increase in the rate of positive tests during the period that was most affected by wildfire smoke," Kiser said.

Other studies also have shown a correlation between increases in particulate levels and COVID deaths. Sultan Ayoub Meo with King Saud University in Saudi Arabia led a team of researchers that studied 10 California counties where levels of fine particulate matter increased on average by 220 times at the height of the state's wildfire season last year.

"We found that the COVID-19 cases and deaths increased by 57% and 148%" at the same time, Meo said.

Meo said his team now is studying infection rates among partially and fully vaccinated people during wildfire smoke events.

University of Montana researcher Erin Landguth is also expanding her past study showing intense wildfire seasons in Montana have been followed by bad flu seasons months later in the fall and winter.

"Comparing bad fire seasons to non-bad fire seasons, one would expect to see three to five times worse flu seasons," Landguth said.

Landguth is compiling particulate-matter readings across the western U.S. to examine whether the same association holds across a larger area for not only the flu, but COVID and other respiratory diseases, too.

While evidence showing COVID cases and deaths have increased during wildfire events continues to emerge, more study is needed. However, Landguth said, we know enough to be concerned and to advise people to protect themselves.

Back in Missoula, county Air Quality Specialist Sarah Coefield said the best thing people can do is get vaccinated, especially if they plan to seek out public spaces to escape heat and smoke. They can also create a clean-air space at home.

With about 2.5 million acres already burned this year in the U.S., and drought worsening across the West, Coefield said, "There's nothing in the forecast to suggest it's going to end anytime soon — and it's not going to get any easier as it goes on."

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