When Robert Woodrum fell off his bike in July, he got stitches at Carson Tahoe Regional Medical Center. The family's insurer initially denied the claim.
This article was published on Wednesday, November 25, 2020 in Kaiser Health News.
Because they were on bikes, he called the fire department in Carson City, Nevada.
“They were great,” said Woodrum. “They took him on a stretcher to the ER.”
Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.
Then the denial letter came.
The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program
Total Bill: $18,933.44, billed by the hospital
Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health
Medical Service: Stitches and anesthesia during an emergency department visit
What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.
This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.
The legal name for the process of determining which type of insurance is primarily responsible is subrogation.
Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?
Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.
Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.
About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.
The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.
The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”
Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.
The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.
Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.
“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”
When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.
The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”
Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”
Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.
“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”
Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.
Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.
That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.
Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.
“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.
After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.
His child just fell off his bicycle.
HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.
The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.
The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.
It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.
But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.
If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.
Don’t panic.
If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.
And do so promptly.
That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.
“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
Across the nation, workplaces have been the source of major coronavirus outbreaks largely among the so-called essential workers who bear the brunt of COVID infections and deaths.
This article was published on Wednesday, November 25, 2020 in Kaiser Health News.
Brandon Hudgins works the main floor at Fleet Feet, a running-shoe store chain, for more than 30 hours a week. He chats with customers, measuring their feet and dashing in and out of the storage area to locate right-sized shoes. Sometimes, clients drag their masks down while speaking. Others refuse to wear masks at all.
So he worries about COVID-19. And with good reason. Across the U.S., COVID hospitalizations and deaths are hitting record-shattering new heights. The nation saw 198,633 new cases on Friday alone.
Unlike in the early days of the pandemic, though, many stores nationwide aren't closing. And regular COVID-19 testing of those working remains patchy at best.
"I've asked, what if someone on staff gets symptoms? 'You have to stay home,'" said Hudgins, 33, who works in High Point, North Carolina. But as an hourly employee, staying home means not getting paid. "It's stressful, especially without regular testing. Our store isn't very big, and you're in there all day long."
To the store's credit, Hudgins said the manager has instituted a locked-door policy, where employees determine which customers can enter. They sanitize the seating area between customers and administer regular employee temperature checks. Still, there's no talk of testing employees for COVID-19. Fleet Feet did not respond to multiple requests to talk about its testing policies.
The federal Centers for Disease Control and Prevention issued guidance to employers to include COVID testing, and it advised that people working in close quarters be tested periodically. However, the federal government does not require employers to offer those tests.
But the board overseeing the California Division of Occupational Safety and Health, known as Cal/OSHA, on Thursday approved emergency safety rules that are soon likely to require the state's employers to provide COVID testing to all workers exposed to an outbreak on the job at no cost to the employees. Testing must be repeated a week later, followed by periodic testing.
California would be the first state to mandate this, though the regulation doesn't apply to routine testing of employees. That is up to individual businesses.
The U.S. Occupational Safety and Health Administration inspects workplaces based on workers' complaints — over 40,000 of which related to COVID-19 have been filed with the agency at the state and federal levels.
Workers "have every right to be concerned," said Dr. Peter Chin-Hong, an epidemiologist at the University of California-San Francisco. "They are operating in a fog. There is little economic incentive for corporations to figure out who has COVID at what sites."
Waiting for symptoms to emerge before testing is ill-considered, Chin-Hong noted. People can exhibit no symptoms while spreading the virus. A CDC reportfound that, among people with active infections, 44% reported no symptoms.
Yet testing alone cannot protect employees. While workplaces can vary dramatically, Chin-Hong emphasized the importance of enforcing safety guidelines like social distancing and wearing face masks, as well as being transparent with workers when someone gets sick.
Molly White, who works for the Missouri state government, was required to return to the office once a week starting in July. But White, who is on drugs to suppress her immune system, feared her employer's "cavalier attitude toward COVID and casual risk taking." Masks are encouraged for employees but are not mandatory, and there's no testing policy or even guidance on where to get tested, she said. White filed for and received an Americans With Disabilities Act exception, which lasts through the end of the year, to avoid coming into the office.
After a cluster of 39 COVID cases emerged in September in the building where she normally works, White was relieved to at least get an email notifying her of the outbreak. A few days later, Gov. Mike Parson visited the building, and he tested positive for COVID-19 soon after.
Following pressure from labor groups, Amazon reported in a blog post last month that almost 20,000 employees had tested positive or been presumed positive for COVID-19 since the pandemic began. To help curb future outbreaks, the online retailing giant, which also owns Whole Foods, built its own testing facilities, hired lab technicians and said it planned to conduct 50,000 daily tests across 650 sites by this month.
The National Football League tests players and other essential workers daily. An NFL spokesperson said the league conducts 40,000 to 45,000 tests a week through New Jersey-based BioReference Laboratories, though both organizations declined to share a price tag. Reports over the summer estimated the season's testing program would cost about $75 million.
Not all companies, particularly those not in the limelight, have the interest — or the money — to regularly test workers.
"It depends on the company how much they care," said Gary Glader, president of Horton Safety Consultants in Orland Park, Illinois. Horton works with dozens of companies in the manufacturing, construction and transportation industries to write exposure control plans to limit the risk of COVID-19 outbreaks and avoid OSHA citations. "Some companies could care less about their people, never have."
IGeneX, a diagnostic testing company in Milpitas, California, gets around 15 calls each day from companies across the country inquiring about its employer testing program. The lab works with about 100 employers — from 10-person outfits to two pro sports teams — mainly in the Bay Area. IGeneX tests its own workers every other week.
One client is Tarana Wireless, a nearby telecommunications company that needs about 30 employees in the office at a time to operate equipment. In addition to monthly COVID tests, the building also gets cleaned every two hours, and masks are mandatory.
"It's definitely a burden," said Amy Beck, the company's director of human resources. "We are venture-backed and have taken pay cuts to make our money extend longer. But we do this to make everyone feel safe. We don't have unlimited resources."
IGeneX offers three prices, depending on how fast a company wants the results: $135 for a polymerase chain reaction (PCR) test with a 36- to 48-hour turnaround — down to around $100 a test for some higher-volume clients; one-day testing costs $250, and it's $400 for a six-hour turnaround.
In some cases, IGeneX is able to bill the companies' health insurance plan.
"Absolutely, it's expensive," said IGeneX spokesperson Joe Sullivan. "I don't blame anyone for wanting to pay as little as possible. It's not 'one and done,' which companies are factoring in."
For those going into work, Chin-Hong recommends that companies test their employees once a week with PCR tests, or twice a week with the less sensitive antigen tests.
Ideally, Chin-Hong said, public health departments would work directly with employers to administer COVID testing and quash potential outbreaks. But, as KHN has reported extensively, these local agencies are chronically underfunded and overworked. Free community testing sites can sometimes take days to weeks to return results, bogged down by extreme demand at commercial labs like Quest Diagnostics and LabCorp and supply chain problems.
Hudgins, who receives his health insurance through North Carolina's state exchange, tries to get a monthly COVID test at CVS on his own time. But occasionally, his insurance — which requires certain criteria to qualify — has declined to pay for it, he said.
"Being in the service industry in a state where numbers are ridiculously high," he said in an email, "I see volumes of people every day, and I think getting tested is the smart and considerate thing to do."
For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.
This article was published on Tuesday, November 24, 2020 in Kaiser Health News.
If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.
There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.
Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.
This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.
For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.
The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.
Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.
“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”
Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.
Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.
But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.
Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.
However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.
“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.
You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.
Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.
The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.
The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.
California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.
These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.
If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.
Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.
Beware of the risks, however.
Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)
However, Medigap policies will often protect you against large medical bills if you need lots of care.
In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.
Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.
The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.
Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.
“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”
Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.
There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.
Make sure you understand the rules and exceptions that apply to you.
Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.
When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”
Back in March, just as anxiety over COVID-19 began spreading across the U.S., Erinn Baldeschwiler of La Conner, Washington, found herself facing her own private dread.
Just 48 and the mother of two teenagers, Baldeschwiler was diagnosed with stage 4 metastatic breast cancer after discovering a small lump on her chest, no bigger than a pea. Within weeks, it was the size of a golf ball, angry and red. Doctors gave her two years to live.
"It's heartbreaking," she said. "Frankly, I was terrified."
But instead of retreating into her illness, Baldeschwiler is pouring energy into a new effort to help dying patients gain legal access to psilocybin — the mind-altering compound found in so-called magic mushrooms — to ease their psychic pain.
"I have personally struggled with depression, anxiety, anger," Baldeschwiler said. "This therapy is designed to really dive in and release these negative fears and shadows."
Dr. Sunil Aggarwal, a Seattle palliative care physician, and Kathryn Tucker, a lawyer who advocates on behalf of terminally ill patients and chairs a psychedelic practice group at Emerge Law Group, are championing a novel strategy that would make psilocybin available using state and federal "right-to-try" laws that allow terminally ill patients access to investigational drugs.
They contend that psilocybin — whether found in psychedelic mushrooms or synthetic copies — meets the criteria for use laid out by more than 40 states and the 2017 Right to Try Act approved by the Trump administration.
"Can you look at the statute and see by its terms that it applies to psilocybin?" Tucker said. "I think the answer is yes."
Still, the pair admit they're pushing a legal theory still untested in the courts. "This is untrodden ground," Aggarwal said.
This month, Aggarwal, who works at the Advanced Integrative Medical Science Institute, known as AIMS, took the first step toward federal authorization of the substance in Washington state and perhaps across the nation. He submitted an application to manufacture psilocybin to the state's Pharmacy Quality Assurance Commission, which would allow him to grow psilocybin mushrooms from spores at his clinic and administer them for therapeutic use.
Commission members haven't yet reviewed the application, but Gordon MacCracken, an agency spokesperson, said there "would be a path" for possible license and use — if the application meets the requirements of state regulators and the federal Drug Enforcement Administration.
Currently, psilocybin use is illegal under federal law, classified as a Schedule 1 drug under the U.S. Controlled Substances Act, which applies to chemicals and substances with no accepted medical use and a high potential for abuse, such as heroin and LSD.
Recently, however, several U.S. cities and states have voted to decriminalize possession of small amounts of psilocybin. This month, Oregon became the first state to legalize psilocybin for regulated use in treating intractable mental health problems. The first patients will have access beginning in January 2023.
It's part of a wider movement to rekindle acceptance of psilocybin, which was among psychedelic drugs vilified — and ultimately banned — after the legendary counterculture excesses of the 1960s and 1970s.
"I think a lot of those demons, those fears, have been metabolized in the 50 years since then," Aggarwal said. "Not completely, but we've moved it along so that it's safe to try again."
Psilocybin therapy appears to work by chemically altering brain function in a way that temporarily affects a person's ego, or sense of self. In essence, it plays on the out-of-body experiences made famous in portrayals of America's psychedelic '60s.
By getting out of their heads — and separating from all the fear and emotion surrounding death — people experience "being" as something distinct from their physical forms. That leads to a fundamental shift in perspective, said Dr. Ira Byock, a palliative care specialist and medical officer for the Institute for Human Caring at Providence St. Joseph Health.
"What psychedelics do is foster a frame shift from feeling helpless and hopeless and that life is not worth living to seeing that we are connected to other people and we are connected to a universe that has inherent connection," he said.
"Along with that shift in perspective, there is very commonly a notable dissolution of the fear of dying, of nonexistence and of loss, and that's just remarkable."
The key is to offer the drugs under controlled conditions, in a quiet room supervised by a trained guide, Byock said. "It turned out they are exceedingly safe when used in a carefully screened, carefully guided situation with trained therapists," he said. "Almost the opposite is true when used in an unprepared, unscreened population."
Baldeschwiler is one of several AIMS cancer patients eager to undergo psilocybin therapy. Another is Michal Bloom, 64, of Seattle, who was diagnosed in 2017 with stage 3 ovarian cancer. The anxiety of living with the terminal disease is overwhelming, she said.
"It's as if someone came up to you, put a gun to the back of your head, whispered, 'I have a gun to your head and I'll have a gun to your head for the rest of your life. I may pull the trigger, I may not,'" she said. "How do you live like that?"
Research shows that a single six-hour session of psilocybin therapy may be enough to quell that fear, Aggarwal said. "I'm really interested in a right-to-try approach because it's really what we need for patients right now," he said.
Under the state and federal laws, to be eligible for "right-to-try" status, a treatment must have completed a phase 1 clinical trial approved by the federal Food and Drug Administration, be part of active clinical trials and in ongoing development or production.
So far, psilocybin ticks all those boxes, Tucker said.
The FDA has granted "breakthrough therapy" status to psilocybin for use in U.S. clinical trials conducted by Compass Pathways, a psychedelic research group in Britain, and by the Usona Institute, a nonprofit medical research group in Wisconsin. More than three dozen trials are recruiting participants or completed, federal records show.
But access to the drug remains a hurdle. Though psychedelic mushrooms grow wild in the Pacific Northwest and underground sources of the drug are available, finding a legal supply is nearly impossible.
Tucker and Aggarwal asked Usona last summer for a supply of the synthetic psilocybin its researchers produce for clinical trials, but so far have received nothing. Penny Patterson, a Usona spokesperson, said there's been no "definitive resolution" and that conversations are continuing.
The firm's reluctance may reflect a larger unease with employing right-to-try laws to speed use of psilocybin, said Dr. Anthony Back, a palliative care physician at the University of Washington.
Back supports the use of psilocybin for cancer patients and has even tried the drug to better understand the experience. But he said using psilocybin outside of formal clinical trials might endanger Usona's ability to get traditional FDA approval. Adverse events may occur that will have to be reported to the FDA, an agency already watching the research closely.
"I can see why they're hesitant, to be honest," Back said. "I think right-to-try is an uphill battle."
Still, Tucker and other advocates say it's a battle worth fighting. End of Life Washington, a group focused on helping terminally ill patients use the state's Death With Dignity Act, recently published a policy that supports psilocybin therapy as a form of palliative care. Other treatments for anxiety and depression, such as medication and counseling, may simply not be practical or effective at that point, said Judith Gordon, a psychologist and member of the group's board of directors.
"When people are dying, they don't have the time or the energy to do a lot of psychotherapy," she said.
Baldeschwiler agrees. With perhaps less than two years to live, she wants access to any tool that can ease her pain. Immunotherapy has helped with the physical symptoms, dramatically shrinking the size of the tumor on her chest. Harder to treat has been the gnawing anxiety that she won't see her 16-year-old daughter, Shea McGinnis, and 13-year-old son, Gibson McGinnis, become adults.
"They are beautiful children, good spirits," she said. "To know I might not be around for them sucks. It's really hard."
Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus.
This article was published on Tuesday, November 24, 2020 in Kaiser Health News.
For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies and other surgeries.
That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. "It's paralyzing, I'm not going to lie," said Nester, who's worked at the Worcester hospital for nearly two decades. "My little clan of nurses that I work with, we panicked when it started to uptick here."
Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus's surge is not contained this winter, advocates and researchers warn.
Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.
"They have become, in some ways, a kind of emotional surrogate for family members who can't be there, to support and advise and offer a human touch," Rushton said. "They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses."
A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.
Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called "moral injury." That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.
Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, "Probably the biggest driver of burnout is unrecognized unattended moral injury."
In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.
"Not enough to really process it all," she said. "I think that's a process that will take several years. And it's probably going to be extended because the pandemic itself is extended."
Before the pandemic hit her Massachusetts hospital "like a forest fire" in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.
Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn't breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn't even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester's unit.
"Then both parents died, and the daughter died," Nester said. "There's not really words for it."
During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has written a book about preventing moral injury among healthcare providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.
At St. Vincent Hospital, the nurses on Nester's unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.
"You're trying to yell through all of these barriers and try to show them with your eyes that you're here and you're not going to leave them and will take care of them," she said. "But yet you're panicking inside completely that you're going to get this disease and you're going to be the one in the bed or a family member that you love, take it home to them."
When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic "we have prioritized the safety and well-being of our staff, and we remain focused on that."
Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, 6% of adults hospitalized were healthcare workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.
As cases mount in the winter months, moral injury researcher Dean said, "nurses are going to do the calculation and say, 'This risk isn't worth it.'"
Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he's been seeing a therapist "to navigate my powerlessness in all of this."
Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.
Innocenti said he was concerned about "the lack of planning and just blatant disregard for the basic safety of patients and staff." Profit motives too often drive decisions, he suggested. "That's what I'm taking a break from."
Building Resiliency
As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.
The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have compiled online resources with links to mental health programs as well as tips for getting through each pandemic workday.
Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.
"It doesn't mean that you're not taking it home with you," Henry said, "but you're actually verbally processing it to your peers."
When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn't want to return.
"But you know that your friends are there," she said. "And the only ones that really truly understand what's going on are your co-workers. How can you leave them?"
Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.
This article was published on Tuesday, November 24, 2020 in Kaiser Health News.
Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.
But when she returns home to her small town of Spring Hill, Kansas, she's often stunned by what she sees, like on a recent stop for carryout food.
"No one in the entire restaurant was wearing a mask," Muhindura said. "And there's no social distancing. I had to get out, because I almost had a panic attack. I was like, 'What is going on with people? Why are we still doing this?'"
Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.
Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.
Kansas City has a mask mandate, but in many smaller communities nearby, masks aren't required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.
At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouridon't have a single intensive care unit bed, so when people from these places get critically ill, they're sent to city hospitals.
A recent patient count at St. Luke's Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.
Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke's.
"Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients," said Larsen. "We get the sickest of the sick."
Dr. Rex Archer, head of Kansas City's health department, warns that capacity at the city's 33 hospitals is being put at risk by the influx of rural patients.
"We've had this huge swing that's occurred because they're not wearing masks, and yes, that's putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed," Archer said.
A study newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while counties without mask mandates recorded increases.
Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas' conservative legislature, to implement stringent, statewide mask requirements but without success.
Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of "making the mask a political issue." He said county leaders should decide whether to close businesses or mandate masks.
"We're going to encourage them to take some sort of action," Parson saidThursday. "The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door."
In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.
The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to healthcare experts.
Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.
Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.
Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.
"It's not just the rural healthcare infrastructure that becomes overwhelmed when there aren't enough hospital beds, it's also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well," Monnat said.
Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.
Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states' hospital systems.
The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.
"It's sort of the nature of epidemics that things often look like they're relatively under control, and then very quickly ramp up to seem that they are out of hand," said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.
Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region's hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.
Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system's chief medical officer, Dr. Steven Stites.
But bed space isn't the only hospital resource that's running out. Half of the hospitals in the Kansas City area are now reporting "critical" staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.
"The hospitals are not fine, because people taking care of patients are on the brink," Muhindura said. "We are tired."
This story is from a reporting partnership that includes KCUR, NPRand KHN.
DENVER — In March, Claire Tripeny was watching her dream job fall apart. She'd been working as an intensive care nurse at St. Anthony Hospital in Lakewood, Colorado, and loved it, despite the mediocre pay typicalfor the region. But when COVID-19 hit, that calculation changed.
She remembers her employers telling her and her colleagues to "suck it up" as they struggled to care for six patients each and patched their protective gear with tape until it fully fell apart. The $800 or so a week she took home no longer felt worth it.
"I was not sleeping and having the most anxiety in my life," said Tripeny. "I'm like, 'I'm gonna go where my skills are needed and I can be guaranteed that I have the protection I need.'"
In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a "mass exodus" of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.
Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.
Early in the pandemic, hospitals were competing for ventilators, COVID tests and personal protective equipment. Now, sites across the country are competing for nurses. The fall surge in COVID cases has turned hospital staffing into a sort of national bidding war, with hospitals willing to pay exorbitant wages to secure the nurses they need. That threatens to shift the supply of nurses toward more affluent areas, leaving rural and urban public hospitals short-staffed as the pandemic worsens, and some hospitals unable to care for critically ill patients.
"That is a huge threat," said Angelina Salazar, CEO of the Western Healthcare Alliance, a consortium of 29 small hospitals in rural Colorado and Utah. "There's no way rural hospitals can afford to pay that kind of salary."
Surge Capacity
Hospitals have long relied on traveling nurses to fill gaps in staffing without committing to long-term hiring. Early in the pandemic, doctors and nurses traveled from unaffected areas to hot spots like California, Washington state and New York to help with regional surges. But now, with virtually every part of the country experiencing a surge — infecting medical professionals in the process — the competition for the finite number of available nurses is becoming more intense.
"We all thought, 'Well, when it's Colorado's turn, we'll draw on the same resources; we'll call our surrounding states and they'll send help,'" said Julie Lonborg, a spokesperson for the Colorado Hospital Association. "Now it's a national outbreak. It's not just one or two spots, as it was in the spring. It's really significant across the country, which means everybody is looking for those resources."
In North Dakota, Tessa Johnson said she's getting multiple messages a day on LinkedIn from headhunters. Johnson, president of the North Dakota Nurses Association, said the pandemic appears to be hastening a brain drain of nurses there. She suspects more nurses may choose to leave or retire early after North Dakota Gov. Doug Burgum told healthcare workers to stay on the job even if they've tested positive for COVID-19.
All four of Utah's major healthcare systems have seen nurses leave for traveling nurse positions, said Jordan Sorenson, a project manager for the Utah Hospital Association.
"Nurses quit, join traveling nursing companies and go work for a different hospital down the street, making two to three times the rate," he said. "So, it's really a kind of a rob-Peter-to-pay-Paul staffing situation."
Hospitals not only pay the higher salaries offered to traveling nurses but also pay a commission to the traveling nurse agency, Sorenson said. Utah hospitals are trying to avoid hiring away nurses from other hospitals within the state. Hiring from a neighboring state like Colorado, though, could mean Colorado hospitals would poach from Utah.
"In the wake of the current spike in COVID hospitalizations, calling the labor market for registered nurses 'cutthroat' is an understatement," said Adam Seth Litwin, an associate professor of industrial and labor relations at Cornell University. "Even if the healthcare sector can somehow find more beds, it cannot just go out and buy more front-line caregivers."
Litwin said he's glad to see the labor market rewarding essential workers — disproportionately women and people of color — with higher wages. Under normal circumstances, allowing markets to determine where people will work and for what pay is ideal.
"On the other hand, we are not operating under normal circumstances," he said. "In the midst of a severe public health crisis, I worry that the individual incentives facing hospitals on the one side and individual RNs on the other conflict sharply with the needs of society as whole."
Some hospitals are exploring ways to overcome staffing challenges without blowing the budget. That could include changing nurse-to-patient ratios, although that would likely affect patient care. In Utah, the hospital association has talked with the state nursing board about allowing nursing students in their final year of training to be certified early.
Growth Industry
Meanwhile business is booming for companies centered on healthcare staffing such as Wanderly and Krucial Staffing.
"When COVID first started and New York was an epicenter, we at Wanderly kind of looked at it and said, 'OK, this is our time to shine,'" said David Deane, senior vice president of Wanderly, a website that allows healthcare professionals to compare offers from various agencies. "'This is our time to help nurses get to these destinations as fast as possible. And help recruiters get those nurses.'"
Deane said the company has doubled its staff since the pandemic started. Demand is surging — with Rocky Mountain states appearing in up to 20 times as many job postings on the site as in January. And more people are meeting that demand.
In 2018, according to data from a national survey, about 31,000 traveling nurses worked nationwide. Now, Deane estimated, there are at least 50,000 travel nurses. Deane, who calls travel nurses "superheroes," suspects a lot of them are postoperative nurses who were laid off when their hospitals stopped doing elective surgeries during the first lockdowns.
Competition for nurses, especially those with ICU experience, is stiff. After all, a hospital in South Dakota isn't competing just with facilities in other states.
"We've sent nurses to Aruba, the Bahamas and Curacao because they've needed help with COVID," said Deane. "You're going down there, you're making $5,000 a week and all your expenses are paid, right? Who's not gonna say yes?"
Krucial Staffing specializes in sending healthcare workers to disaster locations, using military-style logistics. It filled hotels and rented dozens of buses to get nurses to hot spots in New York and Texas. CEO Brian Cleary said that, since the pandemic started, the company has grown its administrative staff from 12 to more than 200.
"Right now we're at our highest volume we've been," said Cleary, who added that over Halloween weekend alone about 1,000 nurses joined the roster of "reservists."
With a base rate of $95 an hour, he said, some nurses working overtime end up coming away with $10,000 a week, though there are downsides, like the fact that the gig doesn't come with health insurance and it's an unstable, boom-and-bust market.
Hidden Costs
Amber Hazard, who lives in Texas, started as a traveling ICU nurse before the pandemic and said eye-catching sums like that come with a hidden fee, paid in sanity.
"How your soul is affected by this is nothing you can put a price on," she said.
At a high-paying job caring for COVID patients during New York's first wave, she remembers walking into the break room in a hospital in the Bronx and seeing a sign on the wall about how the usual staff nurses were on strike.
"It said, you know, 'We're not doing this. This is not safe,'" said Hazard. "And it wasn't safe. But somebody had to do it."
The highlight of her stint there was placing a wedding ring back on the finger of a recovered patient. But Hazard said she secured far more body bags than rings on patients.
Tripeny, the traveling nurse who left Colorado, is now working in Kentucky with heart surgery patients. When that contract wraps up, she said, she might dive back into COVID care.
Earlier, in New Jersey, she was scarred by the times she couldn't give people the care they needed, not to mention the times she would take a deceased patient off a ventilator, staring down the damage the virus can do as she removed tubes filled with blackened blood from the lungs.
She has to pay for mental health therapy out-of-pocket now, unlike when she was on staff at a hospital. But as a so-called traveler, she knows each gig will be over in a matter of weeks.
At the end of each week in New Jersey, she said, "I would just look at my paycheck and be like, 'OK. This is OK. I can do this.'"
When Barack Obama was elected president in 2008, the country was in the midst of a dire economic crisis. Twelve years later, his vice president, Joe Biden, has been elected president in the midst of a dire economic crisis and a worldwide, worsening coronavirus pandemic.
In 2008, Obama’s team and that of outgoing President George W. Bush worked together to allow the new administration to be as prepared as possible on Jan. 20, 2009. That’s not happening for Biden, as President Donald Trump continues to fight the election results and block the official transition.
Particularly when it comes to the COVID-19 pandemic, experts say, that delay could cost lives.
“If the new team has to waste time getting up to speed, that’s a huge waste of resources,” said Donald Kettl, a professor at the LBJ School of Public Affairs at the University of Texas-Austin and an expert in presidential transitions.
Until the formal transition begins, there are critical — and usually routine — things the incoming Biden officials cannot do, said Kettl. “Among the things not allowed right now are formal briefings by government officials, including Tony Fauci,” the head of the National Institute of Allergy and Infectious Diseases and the top federal infectious disease expert. In addition, Kettl said, Biden’s landing teams — the handful of people who go inside government agencies to start the actual transition work — “cannot actually land and talk to the people doing front-line planning. And they can’t see some of the front-line documents.”
Biden can — and is — meeting with plenty of people who will be vital to carry out his administration’s fight against COVID. On Thursday, he met remotely with a bipartisan group of governors and vowed afterward to continue to work with state and local officials. He also has his own COVID advisory board, led by former Surgeon General Vivek Murthy; former commissioner of the Food and Drug Administration, David Kessler; and Yale researcher Dr. Marcella Nunez-Smith.
But Kettl warned that it’s not enough for Biden to surround himself with smart, experienced people with good policy ideas. “The biggest risk they face is in managing these details, and that’s where a direct connection with the bureaucracy is so important, and we can’t afford to fumble this handoff,” he said.
So what can Biden do between now and Jan. 20?
Some public health advocates suggest he could set up a shadow COVID effort, to compete with the Trump administration’s task force. “He could do briefings three times a week telling us what we know and what we don’t,” said Dr. Arthur Kellermann, a longtime public health expert who is now CEO of the Virginia Commonwealth University Health System. Without better information for the public, Kellermann said, “we could lose tens of thousands of people between now and” Inauguration Day.
But others worry that Biden needs to be careful not to appear to have more power than he does, lest he end up with the blame if things don’t go well, particularly on the complicated issue of getting a vaccine distributed and accepted by the general public.
“I think we have to have reasonable expectations of what they can do,” said Farzad Mostashari, a senior health official at HHS in the Obama administration. “A lot has got to be planning and creating a ‘whole of government’ approach to tackling COVID.”
Kettl said the incoming Biden administration is better positioned than many others would have been because they have such recent experience running the government. Incoming White House chief of staff Ron Klain, for example, coordinated the federal government’s response to the Ebola outbreak in 2014. “There’s never been a group or team more prepared to run the government than this one,” Kettl said.
But it won’t be as easy as just picking up where they left off, he said, because of how politicized health and science has become. “The places they are walking into are not the same places they walked out of four years ago. The CDC is a shell of itself, the FDA is not the same.”
Mostashari, though, said he is confident the federal government can do more to combat the virus. “There are plenty of experts [still in the government] who are amazing at what they do,” he said. “They just have to unshackle them.”
HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.
Officials at the Centers for Medicare & Medicaid Services confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits.
This article was published on Monday, November 23, 2020 in Kaiser Health News.
The notice from the federal health insurance marketplace grabbed Andrew Schenker’s attention: ACT NOW: YOU’RE AT RISK OF LOSING FINANCIAL ASSISTANCE STARTING JANUARY 1, 2021.
As he read the notice, though, the Blacksburg, Virginia, resident became exasperated. Schenker, his wife and their teenage son have a bronze-level marketplace plan. Based on their income of about $40,000 a year, they receive tax credits that cover the $2,036 monthly premium in full.
When they file their annual taxes they complete an IRS form that reconciles how much they received in advance tax credits against their actual income for the year. The letter from the marketplace said they hadn’t filed for 2019, but Schenker knew they had — just as they have every year.
“I was more annoyed than anything else,” Schenker, 55, said, remembering an earlier enrollment problem that took months to resolve. “I didn’t want to get stuck in some sort of appeals category.”
Schenker’s 25-year-old daughter, Kaily Schenker, who is part owner of the family’s organic farm, got the same letter about her plan. Schenker helps her with her taxes, and she also filed the Form 8962 paperwork, he said.
Officials at the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits. The letters, consumer advocates suggested, may be a result of the IRS extending the deadline for filing income taxes due to the coronavirus to July 15.
State-based marketplaces have similar requirements and likely send some version of this notice as well, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities who works on income tax issues related to the Affordable Care Act.
People who don’t file their taxes and the reconciliation form aren’t eligible for financial assistance with their marketplace coverage next year, including premium tax credits and any cost-sharing reductions they qualify for.
Because of the filing deadline extension, the tax form data may not have yet arrived when the federal marketplace initially asked the IRS for it in the fall, Straw said. Or other issues, including longer processing times for paper tax returns, could be responsible for a delay, Straw said.
“We don’t know how many people are in this boat,” Straw said. “We think it’s higher than in previous years because of anecdotal accounts from marketplace assisters around the country.”
Schenker said he and his daughter both filed paper returns — his family’s, in the spring, while his daughter took advantage of the pandemic extension.
Under ACA rules, people with incomes up to 400% of the poverty level ($86,880 for a family of three) can qualify for advance tax credits to help pay for coverage purchased through state or federal health insurance exchanges. When they sign up for insurance during open enrollment, their tax credits are based on estimates of their income for the coming year, and the exchanges pay insurers that amount directly. Then when people file their income taxes the following year, they use Form 8962 to reconcile their actual income against what they estimated and square off the amount in tax credits they received. If they received too much in subsidies, they must pay that back to the government.
According to the notice Schenker received, people who have already filed their 2019 tax return and Form 8962 don’t need to take any action.
Straw recommends a more hands-on approach.
“It’s really a dangerous thing to just wait and cross your fingers and hope that the data will resolve your issue,” she said.
Consumers who filed and reconciled taxes for 2019 can keep their tax credit in 2021, CMS officials said, by updating their 2021 HealthCare.gov application on or before Dec. 15 and checking the box that says, “Yes, I reconciled premium tax credits for past years.”
Straw encouraged marketplace customers to follow that advice. (State-based marketplaces generally follow the same process as the federal marketplace, perhaps with slight variations.)
Still, that might not be sufficient. Straw also recommends that people contact the IRS directly and ask for a tax transcript that shows their return was received, including Form 8962.
That way, if the marketplace does cut off premium tax credits and people have to appeal, they have documentation proving they filed the necessary forms. (If it comes to this, consumers can elect to continue receiving premium tax credits while they appeal.)
Unfortunately, people who run into this trouble might not get much expert help. Navigators are no longer required to help consumers with problems after they’ve enrolled, though they may still do so, Straw said.
Likewise, insurance brokers generally don’t help people with these problems, said Karen Pollitz, a senior fellow at KFF. (KHN is an editorially independent program of KFF.) Marketplace plan commissions are so low, “they’re much less likely to help people with complex problems,” she said.
After he got the letter, Schenker called marketplace representatives and was told to go ahead and apply for a plan for next year. He did so, making sure to check the box that said he’d filed his taxes, including the reconciliation form. And at the end of the application process, the system told him that, based on his income, his family is eligible for a tax credit of $2,000 a month. He picked a bronze plan.
As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.
This article was published on Monday, November 23, 2020 in Kaiser Health News.
A mom of eight boys, Kim Gudgeon was at her wits' end when she called her family doctor in suburban Chicago to schedule a sick visit for increasingly fussy, 1-year-old Bryce.
He had been up at night and was disrupting his brothers' e-learning during the day. "He was just miserable," Gudgeon said. "And the older kids were like, 'Mom, I can't hear my teacher.' There's only so much room in the house when you have a crying baby."
She hoped the doctor might just phone in a prescription since Bryce had been seen a few days earlier for a well visit. The doctor had noted redness in one ear but opted to hold off on treatment.
To Gudgeon's surprise, that's not what happened. Instead, when she called, her son was referred to urgent care, a practice that has become common for the Edward Medical Group, which included her family doctor and more than 100 other doctors affiliated with local urgent care and hospital facilities. Because of concerns about the transmission of the coronavirus, the group is now generally relying on virtual visits for the sick, but often refers infants and young children to urgent care to be seen in person.
"We have to take into consideration the risk of exposing chronically ill and well patients, staff and visitors in offices, waiting areas or public spaces," said Adam Schriedel, chief medical officer and a practicing internist with the group.
Gudgeon's experience is not unusual. As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.
That policy is troubling to Dr. Arthur "Tim" Garson Jr., a clinical professor in the College of Medicine at the University of Houston who studies community health and medical management issues. "It's a practice's responsibility to take care of patients," Garson said. He worries about patients who can't do video visits if they don't have a smartphone or access to the internet or simply aren't comfortable using that technology.
Garson supports protocols to protect staff and patients, including in some instances referrals to urgent care. In those cases, practices should be making sure their patients are referred to good providers, he said. For instance, children should be seen by urgent care facilities with pediatric specialists.
Referrals for children have become so prevalent that the American Academy of Pediatrics came out with interim guidance on how practices can safely see patients, in an effort to promote patient-centered care and to ease the strain on other medical facilities as the peak of flu season approaches. The academy recommended that pediatricians strive "to provide care for the same variety of visits that they provided prior to the public health emergency."
The academy raises concerns about unintended consequences of referrals, such as the fragmentation of care and increased exposure to other illnesses, both caused by patients seeing multiple providers; higher out-of-pocket costs for families; and an unfair burden shifting to the urgent care system as illnesses surge.
"I think this is all being driven by fear, not really knowing how to do this safely, and not really thinking about all of the sorts of consequences that are going to come as flu and other respiratory illnesses surge this fall and winter," said Dr. Susan Kressly, who recently retired from her practice in Warrington, Pennsylvania, and authored the AAP guidance.
Fear is not unfounded. More than 900 healthcare workers, 20 of them pediatricians and pediatric nurses, have died of COVID-19, according to a KHN-Guardian database of front-line healthcare workers lost to the coronavirus.
For the Edward Medical Group, referrals are a safe way to treat patients by using all the resources of its medical system, Schriedel said.
"We can assure patients, regardless of COVID-19, we have multiple options to provide the care and services they need," he said.
Besides urgent care referrals and virtual visits, doctors have been given guidelines on how to safely see sick patients. That might mean requesting a negative COVID test before a doctor visit or having staff escort a sick patient from the car directly to an exam room. Also, a pilot program is underway with designated offices taking patients with a respiratory illness that could be flu or COVID-19.
It is a balancing act with some risks. In August, friends sent Kressly screenshots of parents' online message boards from states such as Texas, Indiana and Florida that were seeing a summer spike in COVID-19 cases. Mothers felt abandoned by their pediatricians because they were being sent to urgent care and emergency departments. Kressly fears some patients will fall through the cracks if they are seen by several different providers and don't have a continuity of care.
Also, there's the expense. Bryce's case is a good example. Gudgeon reluctantly took him to an urgent care facility, worried about exposure and frustrated because she felt her doctor knew Bryce best. His exam included a COVID test. "They barely looked in his ears, and we went home to wait for the results," she said, and got no medicine to treat Bryce. The next day, she had a negative test and still a fussy, sick baby.
Urgent care facilities across the country are reporting higher numbers of patients, said Dr. Franz Ritucci, president of the American Board of Urgent Care Medicine. His clinic in Orlando, Florida, is seeing twice as many patients, both children and adults, as it did at this time last year.
"In urgent care, we're seeing all comers, whether they are sick with COVID or not," he said.
Meanwhile, ERs are seeing far fewer pediatric patients than usual, said Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians and the director of clinical services at Virtua Our Lady of Lourdes Emergency Department in Camden, New Jersey. Although adult emergency room visits have largely returned to pre-COVID levels, pediatric visits are 30% to 40% lower, he said. Sacchetti suspects several factors are at play, including fewer kids in daycare and school with less opportunity to spread illness and people avoiding emergency rooms for fear of the coronavirus.
"You see parents looking around the department and if someone clears their throat, you can look in their eyes and see the concern," Sacchetti said. "We reassure them" that the precautions taken in hospitals will help keep them safe, he added.
Gudgeon considered taking Bryce to an emergency room, but she felt increasingly uncomfortable both with the thought of exposing him to another healthcare facility and the cost. In the end, she called an out-of-state doctor she had seen often years before moving to Illinois. That doctor phoned in an antibiotic prescription, and Bryce quickly improved, she said.
"I just wish he didn't have to suffer for so long," Gudgeon said.
Kressly hopes doctors become more creative in finding ways to provide direct care. She likes the "Swiss cheese" approach of layering several imperfect solutions to see patients and offer protection from COVID-19: screening for symptoms before the patient comes in, requiring everyone to wear masks, allowing only one caregiver to accompany a sick child and offering parking lot visits for sick kids in their cars.
Most important is good communication, Kressly said. Not only does that help the patient, it can also help protect the doctor from patients who may not want to admit they have COVID symptoms.
"We can't create this barrier to care for uncomplicated, acute illnesses," Kressly said. "This is not temporary. We all have to creatively figure out how to get patients and families connected to the right care at the right place at the right time."