I was a reporter in Rome in 2005 when Italy banned smoking in restaurants. I was skeptical. For many Italians, having a cigarette with after-dinner coffee was simply part of the meal, like dessert. Also, Italians are famously lax about following rules: They dodge their taxes and park on sidewalks. As I wrote back then: "Smokers declared — basta! — they would never comply."
But to my shock (and ease of breathing, since I have asthma), very quickly everyone did.
If the Italians could do it with cigarettes, how come so many people in the United States aren't following relatively simple mandates to prevent the spread of COVID-19, which has killed more than 200,000 Americans?
Thirty-four states and Washington, D.C., have some sort of mask mandate, but many citizens and law enforcement agencies are blatantly ignoring them.
On Sept. 13, President Donald Trump held an indoor rally with thousandsof mostly unmasked supporters in Henderson, Nevada, in violation of a state mandate that prohibits gatherings of more than 50 people. Last week, Trump held a rally in an airport hangar outside Pittsburgh, where thousands of mostly maskless people were crammed, cheering, cheek-to-jowl — even though the governor had asked the campaign to follow the state's COVID-19 rules on mask use and social distancing.
An infectious disease doctor in Florida told me she felt safest when she was in the hospital because, she estimated, fewer than a fifth of the people in her community were masking or social distancing in stores, despite a mask mandate.
Some conservative groups have challenged governors' broad authority to order COVID-19 prevention measures. Last week, a judge appointed by Trump overturned Pennsylvania's limits on gatherings. But the legal standing is relatively clear. "Governors absolutely have the authority during a public health emergency to make laws — to force people to wear masks, to limit gatherings," said Jaime King, an expert on health law at the University of California Hastings College of the Law. "So I'm perplexed at why people say, 'You can't force me.'"
People who act as if these rules are optional might point to a double standard, asking why they should have to obey when others — such as protesters against racial injustice this summer — didn't. But at the protests I observed in Washington and New York City, everyone was wearing masks and mostly kept at least 3 feet apart, outdoors and moving. Yes, some people broke curfews, but there were very visible attempts at enforcement.
Mark Hall, a professor of healthcare law and public health at Wake Forest University, noted that there are what he calls "hortatory laws" — laws that are more about encouraging social norms rather than mandating behavior. But, he said, those involve "trivial" trespasses. "This does seem like a law that has much more serious consequences," he said about the masking measures. "It's not jaywalking or loitering or pooper scooping."
Maybe people just don't like masks. But we routinely obey — and police officers routinely enforce — laws with which we don't entirely agree.
You might think you can drive safely much faster than the speed limit. So maybe you push the boundary a bit, driving 65 in a 55-mph zone. But those who drive 70, 80 or more know they could well get a big ticket and so they (mostly) curb the impulse.
Many people originally objected to seat belt laws as an infringement on personal freedoms, but who doesn't buckle up these days? Not smoking in restaurants and stores is now inviolable. My family had a dog in New York City when the Canine Waste Law took effect in 1978, and it was gratifying to watch women in minks suddenly start doing their pooper-scooping duty.
A big part of the reason adherence has been so variable is that governors generally declare the mandates, and local and city officials are left to decide how to enforce them. And these simple, sensible laws to protect public health have been politicized and wrapped up in controversy as no such laws before.
So now we have some law enforcement officials announcing that they won't enforce masking laws or limits on gatherings imposed by their own governors in states like Ohio and Wisconsin.
"A sheriff or police chief giving advance notice that it's OK to break the law?" said Hall. "There's a new level of lawlessness to that." Imagine the authorities announcing it was fine to ignore stop signs.
The Italians' miraculous turnaround on restaurant smoking offers lessons. There was consistent messaging: The law was there to protect nonsmokers' health. And there were fines: 275 euros, around $320 today, for people smoking, and 220 euros for the restaurant managers or owners. The Italian police, who themselves could frequently be seen smoking while walking their beats, enforced the rule.
Gov. Andrew Cuomo was one of the few American governors who approached the coronavirus edicts almost militaristically (so un-New York) and got a tragic outbreak under control. In Maryland, a state with a Republican governor, a man who had two parties of 50 people at his home was sentenced to a year in jail.
But more governors have enforced these mandates timidly, almost apologetically. In many states, the message was muddled. In Pennsylvania, where disobedience could, on paper, lead to a $300 fine or up to 30 days in prison, state officials announced it wouldn't be enforced against individuals. Officials announced businesses could face citations if they didn't enforce the law, but the state was otherwise relying on citizens' "good sense and cooperative spirit."
The repercussions from the Trump rally that defiantly ignored Nevada's mandate? An angry tweet from the state's Democratic governor criticizing "reckless and selfish actions." Donald Ahern, the businessman who allowed the event to take place in his company's warehouse, was fined $3,000.
Enforcement is difficult when "permission comes from the top," said King. How can we expect Americans to mask up when they're watching a Trump rally and "even he is breaking the law"?
SACRAMENTO, Calif. — Though COVID-19 forced California leaders to scale back their ambitious healthcare agenda, they still managed to enact significant new laws intended to lower consumer healthcare spending and expand access to health coverage.
When Democratic Gov. Gavin Newsom concluded the chaotic legislative year Wednesday what emerged wasn't the sweeping platform he and state lawmakers had outlined at the beginning of the year. But the dozens of healthcare measures they approved included first-in-the-nation policies to require more comprehensive coverage of mental health and addiction, and thrusting the state into the generic drug-making business.
"We had less time, less money and less focus, but COVID makes the causes of expanding coverage and trying to control healthcare costs that much more important," said Anthony Wright, executive director of Health Access California, a Sacramento-based consumer advocacy group.
The governor also signed into law a raft of COVID-related bills intended to address the biggest public health emergency in a century, such as measures to stockpile protective gear for healthcare workers.
This year's legislative season took place against the backdrop of an unprecedented pandemic that sparked a statewide stay-at-home order, back-to-back emergency legislative recesses, the Capitol's first foray into remote voting and a projected $54 billion budget deficit.
Among the most controversial changes Newsom signed into law was the largest expansion of the state's family leaveprogram since it was enacted in 2014, an upgrade opposed by the state's business interests. The tobacco industry also took a hit when Newsom approved a measure banning retail sale of flavored tobacco products, including menthol, with exceptions made for flavored hookah products. And Newsom bucked the powerful doctors' lobby by granting nurse practitioners the ability to practice without physician supervision.
But several contentious health bills stalled in the legislature and never made it to Newsom's desk, including measures that would have given the state attorney general more authority to reject hospital consolidations, expanded the state's Medicaid program, called Medi-Cal, to unauthorized immigrants ages 65 and up, and capped consumers' out-of-pocket costs for insulin.
Among Newsom's vetoeswere a pair of bills that sought to expand telemedicine, as well as legislation to adopt patient privacy protections for COVID-19 genetic testing.
"I think we all wish we'd had more opportunities to move more things forward," said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee. "Under the circumstances, I think we did a good job."
Here's a look at some of the major health measures Newsom signed into law this year. Most will take effect on Jan. 1.
Behavioral Health
Lawmakers made significant changes to mental health coverage, and perhaps the most consequential is a mental health parity bill. SB-855 requires state-regulated health insurers in California to cover all treatment deemed medically necessary for mental health and substance abuse disorders, from depression to opioid addiction. Health insurers opposed the bill, arguing it would drive up healthcare spending.
Mental health parity is already enshrined in state and federal law, but advocates say insurers regularly don't cover the critical care that patients need.
Julie Snyder, a lobbyist for the Sacramento-based Steinberg Institute, which advocates for mental healthcare policy changes, called the new law a model for the rest of the country.
"There's no other state that has anything this comprehensive," Snyder said.
Another bill, SB-803, will allow peer providers — people with their own histories of mental illness or substance abuse who help other Californians navigate behavioral health issues — to be certified by the state. Once certified, they can bill Medi-Cal for their services.
Scope of Practice
Newsom gave nurse practitioners, who are nurses with advanced training and degrees, the power to practice independently, after years of failed attempts and despite major opposition from the California Medical Association, which represents doctors. Supporters say AB-890 will help address healthcare provider shortages, especially in rural and underserved communities.
Certified nurse-midwives will also be allowed to attend low-risk pregnancies in both hospital and home settings without a physician's supervision under SB-1237.
Cutting Healthcare Costs
California will enter the highly competitive generic drug market as a result of SB-852, a first-in-the-nation law that will put the state government in direct competition with private drug manufacturers.
"The cost of healthcare is way too high," Newsom said in a statement upon signing the bill.
By January, California must forge partnerships with one or more drug companies to make or distribute a broad range of generic and biosimilar drugs that are cheaper than brand-name products. The bill specifically calls for the production of the diabetes medicine insulin, because makers have hiked prices sharply in recent years.
Newsom also approved an under-the-radar healthcare transparency measure requiring the state to collect data on the amount state-regulated health insurers pay for specific medical services, from knee replacements to asthma treatments. The data could help policymakers identify excessive spending on certain treatments and provide fodder for proposals to control healthcare costs.
"While the examination of cost has slowed down, it hasn't ended," said state Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee.
Newsom also signed legislation cementing into state law key provisions in the Affordable Care Act, a move guaranteeing Californians will not lose coverage protections should the U.S. Supreme Court strike down the law.
SB-406 will ban health insurers in California from imposing annual or lifetime limits on coverage, and also requires health insurers to cover a range of preventive care services, from cholesterol and blood pressure screenings to immunizations, without charging patients copays or deductibles.
COVID-19
As California continues to grapple with the highest COVID-19 case counts in the country, lawmakers approved a suite of bills in response to the pandemic, largely intended to protect essential workers.
Employers will have to provide written notice within one business day to employees who may have been exposed to the COVID-19 virus at their worksite. They must also report the details of workplace outbreaks to local public health authorities within 48 hours. AB-685 was prompted by major outbreaks this year at food-processing plants.
Newsom also signed legislation making it easier for firefighters, healthcare workers and other front-line workers infected with the coronavirus to get workers' compensation. SB-1159 took effect Sept. 17, the day the governor signed it.
State law now presumes these front-line workers were infected with the virus on the job unless their employers prove otherwise.
Certain employees who have been exposed to the virus will also have more paid sick leave time. Under AB-1867, food-processing companies with at least 500 workers must provide two weeks of paid sick leave to workers who have been exposed to COVID-19 or have been advised to quarantine.
The law also grants healthcare workers and emergency responders two weeks of paid sick leave, closing a loophole in a COVID-relief bill Congress approved this spring.
Two new laws will address another major challenge exposed by the coronavirus pandemic: the lack of adequate personal protective gear for healthcare workers. AB-2537 will require hospitals to stockpile a three-month supply of protective gear by April, while SB-275 mandates that the California Department of Public Health establish an additional stockpile for health and other essential workers to last 90 days during a pandemic.
Nursing homes, which have been at the epicenter of COVID-19 deaths, will be required to have a full-time "infection preventionist" on staff to help stem the spread of disease. The bill, AB-2644, also will require nursing homes to report deaths from a communicable disease to the state within 24 hours during an emergency related to that disease.
And California's roughly 40,000 licensed pharmacists will be allowed to administer COVID-19 vaccines that have been approved by the Food and Drug Administration under AB-1710.
The mixed messages from President Trump and ensuing confusion leave governors, and often state and local health officials, holding the bag of political consequences.
This article was published on Thursday, October 1, 2020 in Kaiser Health News.
While the president and vice president forgo masks at rallies, the White House is quietly encouraging governors to implement mask mandates and, for some, enforce them with fines.
In reports issued to governors on Sept. 20, the White House Coronavirus Task Force recommended statewide mask mandates in Iowa, Missouri and Oklahoma. The weekly memos, some of which have been made public by the Center for Public Integrity, advocate mask usage for other states and have even encouraged doling out fines in Alaska, Idaho and, recently, Montana.
Masks, a political flashpoint since the beginning of the coronavirus pandemic, are considered by public health officials to be a top safeguard against spreading the COVID-19 virus as the country awaits a vaccine. But the president's own actions on masks have wavered: He has called them "patriotic" but often doesn't wear one himself and has contradicted the advice of the Centers for Disease Control and Prevention director. During the presidential debate Tuesday, the president said masks were "OK" and then mocked Democratic presidential candidate Joe Biden's mask-wearing habits. In the audience, some Trump family members and staffers were not wearing masks, despite the rules set by the Cleveland Clinic, which hosted the debate.
The mixed messages and ensuing confusion leave governors, and often state and local health officials, holding the bag of political consequences.
"At some point, we have to turn the corner on this ridiculous separation of what we're being told is best practice and being guided by science and data, and what the actual practices are by the people who issue them," said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials.
So far, 16 states have yet to enact mask mandates for the general public — all of them are run by Republican governors. Three out of 4 Americans support enacting state laws to require mask-wearing in public at all times, according to an August NPR/Ipsos poll.
To be sure, messaging and the science on masks have evolved: U.S. public health officials did not recommend mask-wearing until April. And the White House argues the president has been clear.
"He recommends wearing a mask when you cannot socially distance," White House spokesperson Brian Morgenstern told KHN. "He has worn masks on numerous occasions himself when appropriate and regularly encourages others to do so, as well, when social distancing is not possible."
The pandemic task force sends weekly memos to states to share data and recommendations with leaders to help them make decisions, Morgenstern added. "They're free to share that information as they see fit."
Courtney Parella, a spokesperson for the Trump campaign, said that the staffers check the temperature of every attendee before admission to rallies, provide masks and encourage attendees to wear them, and offer hand sanitizer.
On Sept. 14, Pence stood before a crowdof hundreds in Belgrade, Montana, to stump for the state's Republicans, including Sen. Steve Daines, gubernatorial candidate U.S. Rep. Greg Gianforte and congressional candidate Matt Rosendale. Photos show that most who attended went without masks, including the vice president, despite a mask order in effect for the surrounding county.
Montana calls on everyone to wear masks at outdoor gatherings of 50 or more people in counties with at least four active cases when attendees don't stay 6 feet apart.
Photos show people sitting and standing close together at the event in southwestern Montana. Pence signed hats as people gathered shoulder to shoulder by the rails of a crowd divider.
Six days later, the White House coronavirus reports recommended Montana officials issue fines for those who ignore mask mandates in places the disease is spreading fast.
"What would be helpful from the White House is consistency in their recommendations and their actions," said Matt Kelley, health officer for the Gallatin City-County Health Department. "It's one thing to make a recommendation to state and local health officials to fine people. It's made more difficult to do that when we have the vice president coming here to a rally where no one, very few people, were wearing masks."
During a press call last week, Montana Gov. Steve Bullock said he didn't plan to follow the White House advice to punish those without masks. The Democrat, who is running for Senate, said it's better to encourage people to use masks than rely on fines.
But Bullock said the point of the White House's request was clear. "Even the federal government says we need to be taking wearing masks seriously," he said. "It's not just governors saying that we should do this and it's not just health experts saying we should be wearing masks."
Missouri Gov. Mike Parson is among the Republican governors who have resisted a statewide masking order, despite the White House's recommendation.
"You don't need government to tell you to wear a dang mask," Parson said in July at a Missouri Cattlemen's Association steak fry, according to the Springfield News-Leader. "If you want to wear a dang mask, wear a mask."
Parson and his wife, Teresa, tested positive for COVID-19 last Wednesday.
Spokesperson Kelli Jones said last Thursday that the governor does not plan to enact a mask order, based on an assessment of current COVID data. She added state officials consider the White House reports "really more of an FYI" than a mandate.
"It's kind of a bizarre document, truthfully," she said. "We read them and look at them — and make our own policy."
The reports, which are sent to the governors, also leave local and state public health officials in the dark, said Freeman, of NACCHO.
"If the White House were truly serious about making these — what sounds like solid, scientific-backed, data-backed recommendations — if they were truly serious about it, tell the world, share them, be transparent," she said.
Instead, former CDC director Dr. Tom Frieden said, the White House has fueled the partisan breakdown on masks.
"One of the many failures of this administration is the politicization of masks, and that has really cost lives," Frieden said. "There is no reason masks should be partisan."
Meanwhile back in Montana, Gallatin County appears to be heading toward its third surge in cases since the pandemic began.
"I don't really have a lot of time to worry about inconsistency of messaging from the White House," health officer Kelley said.
The county now has outbreaks in nursing homes and several confirmed cases in schools, he said, and the county's positivity rate is heading toward 10%.
Podiatrist Dr. Mark Lewis greets his first patient of the morning in his suburban Seattle exam room and points to a tiny video camera mounted on the right rim of his glasses. "This is my scribe, Jacqueline," he says. "She can see us and hear us."
Jacqueline is watching the appointment on her computer screen after the sun has set, 8,000 miles away in Mysore, a southern Indian city known for its palaces and jasmine flowers. She copiously documents the details of each visit and enters them into the patient's electronic health record, or EHR.
Jacqueline (her real first name, according to her employer), works for San Francisco-based Augmedix, a startup with 1,000 medical scribes in South Asia and the U.S. The company is part of a growing industry that profits from a confluence of healthcare trends — including, now, the pandemic — that are dispersing patient care around the globe.
Medical scribes first appeared in the 1970s as note takers for emergency room physicians. But the practice took off after 2009, when the federal HITECH Act incentivizedhealthcare providers to adopt EHRs. These were supposed to simplify patient record-keeping, but instead they generated a need for scribes. Doctors find entering notes and data into poorly designed EHR software cumbersome and time-consuming. So scribing is a fast-growing field in the U.S., with the workforce expanding from 15,000 in 2015 to an estimated 100,000 this year.
A 2016 study found that doctors spent 37% of a patient visit on a computer and an average of two extra hours after work on EHR tasks. EHR use contributes to physician burnout, increasingly considered a public health crisis in itself.
Before COVID-19, most scribes — typically young, aspiring health professionals — worked in the exam room a few paces away from the doctor and patient. This year, as the pandemic led patients to shun clinics and hospitals, many scribes were laid off or furloughed. Many have returned, but scribes are increasingly working online — even from the other side of the world.
Remote scribes are patched into the exam room's sound via a tablet or speaker, or through a video connection. Some create doctors' notes in real time; others annotate after visits. And some have help from speech-recognition software programs that grow more accurate with use.
While many remote scribes are based in the United States, others are abroad, primarily in India. Chanchal Toor was a dental school graduate facing limited job opportunities in India when a subcontractor to Augmedix hired her in 2015. Some of her scribe colleagues also trained or aspired to become dentists or other health professionals, she said. Now a manager for Augmedix in San Francisco, Toor said scribing, even remotely, made her feel like part of a healthcare team.
Augmedix recruits people who have a bachelor's degree or the equivalent, and screens for proficiency in English reading, listening comprehension and writing, the company said. Once on board, scribes undergo about three months of training. The curriculum includes medical terminology, anatomy, physiology and mock visits.
Revenue has grown this year, and his sales team has grown from four to 14 members, Augmedix CEO Manny Krakaris said. Sachin Gupta, CEO of IKS Health, which employs Indian doctors as remote scribes for their U.S. counterparts, projects 50% revenue growth this year for its scribing business. He said the company employs 4,000 people but declined to share how many are scribes.
Remote scribe "Edwin" gives internist Dr. Susan Fesmire more time, freeing her from having to finish 20 charts at the end of every day. "It was like constantly having homework that you don't finish," she said. With the help of "Edwin" — Fesmire said he declines to use his real name — she had the time and energy to become chief operating officer of her small Dallas practice. Edwin works for Physicians Angels, which employs 500 remote scribes in India. Fesmire pays $14 an hour for his services.
Doctors with foreign scribes say notes may need minor editing for dialectal differences and scribes may be unfamiliar with local vocabulary. "I had a patient from Louisiana," said Fesmire, "and Edwin said afterward, 'What is chicory, doctor?'" But she also praised his notes as more accurate and complete than her own.
Kevin Brady, president of Physicians Angels, said their scribes start at $500 to $600 per month, plus healthcare and retirement benefits, while senior scribes make $1,000 to $1,500 — middle-class family incomes in India. Employers are requiredto provide employees with health insurance, although many scribes are contractors, and the job site Indeed.com says the average salary for a scribe in India is$500 a month. Scribes in the U.S. get about $2,500.
Remote scribing is still a small part of the market. Craig Newman, chief strategy officer of HealthChannels, parent to ScribeAmerica, the largest scribing company in the U.S., said that the firm's remote scribing business has increased threefold since the pandemic's outset but that "a large majority" of the company's 26,000 U.S. scribes still work in person.
For patients, studies suggest scribes have a positive orneutral effect on satisfaction. Some have privacy concerns, though, and state laws vary on whether a patient must be notified that someone is watching and listening many miles away.
Only 1% of patients refuse a remote scribe when asked by physicians at Massachusetts General Physicians Organization, said Dr. David Ting, the practice's chief medical information officer. His group, an IKS Health client, always seeks patient consent, Ting said.
Scribes aren't for everyone, though. Janis Ulevich, a retiree in Palo Alto, California, declines her primary care doctor's remote scribe. "Conversations with your doctor can be intimate," said Ulevich. "I don't like other people listening in."
Some patients may not have the opportunity to decline. With limited exceptions, federal laws like HIPAA, the Health Insurance Portability and Accountability Act of 1996, don't require doctors to seek a patient's consent before sharing their health information with a company that supports the practice's work (like a scribe firm), as long as that company signed a contract agreeing to protect the patient's data, said Chris Apgar, a former HIPAA compliance officer.
About one-quarter of U.S. states require all parties in a conversation to agree to be recorded, meaning they require a patient's permission. Some states also have special privacy protections for certain groups, like people with HIV/AIDS, or very strict informed-consent or privacy laws, said Matt Fisher, a partner at Massachusetts law firm Mirick O'Connell.
Remote scribing also raises cybersecurity concerns. Reported data breaches are rare, but some scribe companies have lax security, said Cliff Baker, CEO of the healthcare cybersecurity firm Corl Technologies.
The next step in the trend could be no human scribes at all. Tech giants like Google, EHR companies and venture-backed startups are developing or already marketing artificial intelligence tools aimed at reducing or eliminating the need for humans to document visits.
AI and scribes won't eliminate physician burnout that stems from the nature of the healthcare system, said Dr. Rebekah Gardner, an associate professor of medicine at Brown University who researches the issue. Neither can take on burnout-driving EHR tasks like submitting requests for insurance company approval of procedures, drugs and tests, she said.
Clarence Troutman survived a two-month hospital stay with COVID-19, then went home in early June. But he's far from over the disease, still suffering from limited endurance, shortness of breath and hands that can be stiff and swollen.
"Before COVID, I was a 59-year-old, relatively healthy man," said the broadband technician from Denver. "If I had to say where I'm at now, I'd say about 50% of where I was, but when I first went home, I was at 20%."
He credits much of his progress to the "motivation and education" gleaned from a new program for post-COVID patients at the University of Colorado, one of a small but growing number of clinics aimed at treating and studying those who have had the unpredictable coronavirus.
As the election nears, much attention is focused on daily infection numbers or the climbing death toll, but another measure matters: Patients who survive but continue to wrestle with a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression.
"We need to think about how we're going to provide care for patients who may be recovering for years after the virus," said Dr. Sarah Jolley, a pulmonologist with UCHealth University of Colorado Hospital and director of UCHealth's Post-Covid Clinic, where Troutman is seen.
That need has jump-started post-COVID clinics, which bring together a range of specialists into a one-stop shop.
One of the first and largest such clinics is at Mount Sinai in New York City, but programs have also launched at the University of California-San Francisco, Stanford University Medical Center and the University of Pennsylvania. The Cleveland Clinic plans to open one early next year. And it's not just academic medical centers: St. John's Well Child and Family Center, part of a network of community clinics in South Central Los Angeles, said this month it aimsto test thousands of its patients who were diagnosed with COVID since March for long-term effects.
The general idea is to bring together medical professionals across a broad spectrum, including physicians who specialize in lung disorders, heart issues and brain and spinal cord problems. Mental health specialists are also involved, along with social workers and pharmacists. Many of the centers also do research studies, aiming to better understand why the virus hits certain patients so hard.
"Some of our patients, even those on a ventilator on death's door, will come out remarkably unscathed," said Dr. Lekshmi Santhosh, an assistant professor of pulmonary critical care and a leader of the post-COVID program at UC-San Francisco, called the OPTIMAL clinic. "Others, even those who were never hospitalized, have disabling fatigue, ongoing chest pain and shortness of breath, and there's a whole spectrum in between."
'Staggering' Medical Need
It's too early to know how long the persistent medical effects and symptoms will linger, or to make accurate estimates on the percentage of patients affected.
Some early studies are sobering. An Austrian report released this month found that 76 of the first 86 patients studied had evidence of lung damage six weeks after hospital discharge, but that dropped to 48 patients at 12 weeks.
Some researchers and clinics say about 10% of U.S. COVID patients they see may have longer-running effects, said Dr. Zijian Chen, medical director of the Center for Post-COVID Care at Mount Sinai, which has enrolled 400 patients so far.
If that estimate is correct — and Chen emphasized that more research is needed to make sure — it translates to patients entering the medical system in droves, often with multiple issues.
How health systems and insurers respond will be key, he said. More than 6.5 million U.S. residents have tested positive for the disease. If fewer than 10% — say 500,000 — already have long-lasting symptoms, "that number is staggering," Chen said. "How much medical care will be needed for that?"
Though startup costs could be a hurdle, the clinics themselves may eventually draw much-needed revenue to medical centers by attracting patients, many of whom have insurance to cover some or all of the cost of repeated visits.
Chen at Mount Sinai said the specialized centers can help lower health spending by providing more cost-effective, coordinated care that avoids duplicative testing a patient might otherwise undergo.
"We've seen patients that when they come in, they've already had four MRI or CT scans and a stack of bloodwork," he said.
The program consolidates those earlier results and determines if any additional testing is needed. Sometimes the answer to what's causing patients' long-lasting symptoms remains elusive. One problem for patients seeking help outside of dedicated clinics is that when there is no clear cause for their condition, they may be told the symptoms are imagined.
"I believe in the patients," said Chen.
About half the clinic's patients have received test results showing damage, said Chen, an endocrinologist and internal medicine physician. For those patients, the clinic can develop a treatment plan. But, frustratingly, the other half have inconclusive test results yet exhibit a range of symptoms.
"That makes it more difficult to treat," said Chen.
Experts see parallels to a push in the past decade to establish special clinics to treat patients released from ICU wards, who may have problems related to long-term bed rest or the delirium many experience while hospitalized. Some of the current post-COVID clinics are modeled after the post-ICU clinics or are expanded versions of them.
The ICU Recovery Center at Vanderbilt University Medical Center, for instance, which opened in 2012, is accepting post-COVID patients.
There are about a dozen post-ICU clinics nationally, some of which are also now working with COVID patients, said James Jackson, director of long-term outcomes at the Vanderbilt center. In addition, he's heard of at least another dozen post-COVID centers in development.
The centers generally do an initial assessment a few weeks after a patient is diagnosed or discharged from the hospital, often by video call. Check-in and repeat visits are scheduled every month or so after that.
"In an ideal world, with these post-COVID clinics, you can identify the patients and get them into rehab," he said. "Even if the primary thing these clinics did was to say to patients, 'This is real, it is not all in your head,'" he added, "that impact would be important."
A Question of Feasibility
Financing is the largest obstacle, program proponents say. Many hospitals lost substantial revenue to canceled elective procedures during stay-at-home periods.
"So, it's not a great time to be pitching a new activity that requires a startup subsidy," said Glenn Melnick, a professor of health economics at the University of Southern California.
At UCSF, a select group of faculty members staff the post-COVID clinics and some mental health professionals volunteer their time, said Santhosh. Mount Sinai's Chen said he was able to recruit team members and support staff from the ranks of those whose elective patient caseload had dropped.
Jackson, at Vanderbilt, said unfortunately there's not been enough research into the cost-and-clinical effectiveness of post-ICU centers.
"In the early days, there may have been questions about how much value does this add," he noted. "Now, the question is not so much is it a good idea, but is it feasible?"
Right now, the post-COVID centers are foremost a research effort, said Len Nichols, an economist and nonresident fellow at the Urban Institute.
"If these guys get good at treating long-term symptoms, that's good for all of us," said Nichols. "There's not enough patients to make it a business model yet, but if they become the place to go when you get it, it could become a business model for some of the elite institutions."
The federal government did a quick pivot on the threat of the coronavirus spreading through the air, changing a key piece of guidance over the weekend.
On Sept. 18, the Centers for Disease Control and Prevention warned that tiny airborne particles, not just the bigger water droplets from a sneeze or cough, could infect others. It cited growing "evidence."
The move put the CDC in the middle of a debate over how the coronavirus infects people. Its guidelines could make the difference between restaurants, bars and other places where people gather fully reopening sooner or much later.
And it raised more questions about politics at the public health agency and whether White House officials are dictating policy to health authorities.
So what does the science on airborne transmission actually say?
The emerging picture is a work-in-progress, but many of the pieces do point toward the potential for airborne transmission.
The Challenge of Proving Airborne Transmission
The CDC's retracted language said, "There is growing evidence that droplets and airborne particles can remain suspended in the air and be breathed in by others, and travel distances beyond 6 feet (for example, during choir practice, in restaurants, or in fitness classes)."
Why is this a big deal? It means the guidelines for proper physical distancing might need to be increased.
Six feet is the benchmark for safety that has helped shape the reopening of schools and businesses nationwide. The number is based on the long-held finding that larger water drops from a cough are so heavy that most of them fall to the ground before the 6-foot mark.
But much smaller droplets can hang in the air longer. The debate is whether they carry enough of the virus to infect another person. If the answer is yes, the implications for everyday life could be substantial.
University of Maryland Medical School professor Donald Milton sees plenty of evidence that airborne transmission is a major factor, but he emphasized that a definitive answer is hard to come by.
No one disagrees that being near someone with the disease is the main threat. But Milton said what happens during that time is tough to untangle.
"It could be they cough and you get infected by getting a direct hit on your eye or mouth," Milton said. "Or could it be through an airborne particle that you inhale. Or you might have touched something and then touched your nose or your mouth. It's fiendishly difficult to sort that out."
That said, many incidents and studies point toward the idea that airborne particles play a bigger role than has been thought.
A study published in the Proceedings of the National Academy of Sciences reported that one minute of loud talking could produce "1,000 virus-containing droplet nuclei that could remain airborne for more than eight minutes."
The authors' conclusion? "These are likely to be inhaled by others and hence trigger new infections."
Public transit is a key testing ground.
In China, scientists looked at 126 passengers on two buses making a trip that lasted about an hour and a half. One bus was virus-free, the other had one infected rider. The people on the bus with the virus were 41.5 times more likely to be infected.
Many other researchers have noted the super-spreading event at the 2½-hour-long choir practice of the Skagit Valley Chorale in Mount Vernon, Washington. Of the 61 people who attended, there were 53 confirmed and potential cases and two deaths.
A University of Florida study sampled the air in the hospital rooms of two COVID patients. They found aerosol particles carrying enough viral load to infect someone more than 15 feet away from the patients.
In July, 239 researchers co-signed an open letter that called on national and international health agencies to "recognize the potential for airborne spread" of COVID-19.
Credible studies, they wrote, "have demonstrated beyond any reasonable doubt that viruses are released during exhalation, talking, and coughing in microdroplets small enough to remain aloft in air and pose a risk of exposure."
Still, a July World Health Organization report found while airborne transmission was possible, more robust research was needed to confirm that it presents an appreciable risk.
If public health leaders take airborne transmission more seriously, Milton said, there are a few implications. Most business activity could continue, but restaurants and bars — because masks don't fit with eating and drinking — would face a higher hurdle.
Beyond that, more attention to ventilation in more closed spaces becomes important, as does the supply of N95 masks. Those masks continue to be in short supply.
Daniel Prude's family knew he needed psychiatric care and tried to get it for him. Instead, his encounter with police hours after he was released from Strong Memorial Hospital in Rochester, New York, proved fatal.
This article was published on Tuesday, September 29, 2020 in Kaiser Health News.
When Joe Prude called Rochester, New York, police to report his brother missing, he was struggling to understand why Daniel Prude had been released from the hospital hours earlier. Joe Prude described his brother's suicidal behavior.
"He jumped 21 stairs down to my basement, headfirst," Joe said in a video recorded by the responding officer's body camera in the early hours of March 23. Joe's wife, Valerie, described Daniel nearly jumping in front of a train on the tracks that run behind their house the previous day.
"The train missed him by this much," Joe said, holding his thumb and pointer finger a few inches apart.
"When the doctor called me and told me that they released him, I'm saying, 'How you going to sit here and tell me you're going to release him when he was hurting himself? Come on. You weren't sworn to do that,'" he said on the body camera footage.
At the point of this recorded conversation just after 3 a.m., Joe and Valerie Prude knew only that Daniel was missing, delusional and vulnerable. They didn't know his next encounter with the police would be fatal.
Police would find Daniel minutes later ― naked, acting irrationally. Because he spat in the direction of officers and allegedly said he had the novel coronavirus, officers placed a white hood, called a "spit hood," over his head. When he started trying to stand up, despite being restrained by handcuffs, an officer placed much of his body weight over Daniel's head and pushed it into the pavement.
Daniel died a week later when his family took him off life support. The county medical examiner's autopsy described his death as a homicide and listed the immediate cause of death as "complications of asphyxia in the setting of physical restraint." The incident garnered widespread attention as another example of a Black man killed after an encounter with police.
Less attention has been paid to what happened to Daniel Prude in the preceding hours, when he was treated and released after a psychiatric assessment at Strong Memorial Hospital, run by the University of Rochester Medical Center.
Joe Prude called police at about 7 p.m. on March 22 because he needed help getting Daniel to the hospital. Daniel had been having problems with a PCP addiction, Joe told officers. Now he had begun telling Joe and Valerie that people were out to get him, and he wanted to die.
By about 11 p.m., Daniel was released from the hospital, according to Joe and police records. "He was calm as hell when he got back here," Joe told police.
That didn't last.
"He was fine for a little bit, then all of a sudden started acting crazy," Joe said. He told police that Daniel asked him for a cigarette, and when he went to get one, Daniel took off running. He was barefoot, wearing only a tank top and long johns in 30-degree weather.
"He was gone. Track star status. Hauled ass like Carl Lewis," Joe told the officer.
Around 3 a.m. the next day, four hours after his release from the hospital, emergency dispatchers started fielding calls about Daniel Prude. His brother reported him missing, and a tow truck driver spotted him, naked and bloodied, on West Main Street, police records show.
Police body camera footage shows that by 3:20 a.m., officer Mark Vaughn was pressing Daniel Prude's head into the pavement.
While restrained, Prude stopped breathing. An ambulance crew resuscitated him, but he was in critical condition. His brain was damaged after being deprived of oxygen. He died a week later at Strong Memorial after being taken off life support.
The University of Rochester Medical Center said patient privacy laws bar it from discussing the specifics of Prude's treatment and release, but, in general terms, spokesperson Chip Partner said, the hospital is bound by a New York state law that requires patients to be released within 24 hours unless they have a mental illness that is likely to result in serious harm to themselves or others and that requires immediate observation, care and hospital treatment.
The details of Prude's encounters with law enforcement and the healthcare system offer a look into the practice of emergency psychiatry, and how, as inmanybranches ofmedicine in the U.S., mistakes in that field are disproportionately borne by Black people.
Medical decisions in a case like Daniel Prude's are high-stakes, with little margin for error, said Dr. Ken Duckworth, chief medical officer of the National Alliance on Mental Illness.
"Emergency psychiatric assessment is very challenging, and the potential for catastrophic outcomes following your decision is very real," he said.
The hospital where Prude died has faced scrutiny over its treatment of psychiatric patients and discharge procedures before.
In April 2018, federal inspectors found security officers at the hospital had used law enforcement restraint techniques against a pediatric psychiatry patient, breaking her arm and sending her to the emergency room.
Months later, inspectors found the hospital discharged a patient who was in the emergency room with a history of dementia and multiple medical problems despite a discrepancy in her address between her medical record and the information she gave hospital staff.
Two years earlier, inspectors found that hospital staff had placed patients in ankle and wrist restraints without an order to do so, and placed another patient in restraints without documenting when the restraints were released. Restraints are meant to be used only with a physician's order, and federal rules require precise documentation of their use.
None of these incidents at Strong Memorial Hospital garnered media attention at the time they happened or at the time the reports were made public.
Strong spokesperson Partner said that immediately after the April 2018 inspection the hospital changed its public safety protocol to eliminate the use of law enforcement techniques to manage a violent patient unless that patient is being arrested.
He said updated staff training and discharge protocol after these incidents now mitigates the risk of discharging someone who was not ready to be released. "These protocols were well established in 2020 and had absolutely no bearing on the evaluation or treatment of Daniel Prude on March 22," Partner said.
Prude's case is unusual because the consequences of the decision by doctors to release him have played out so publicly, said Duckworth. Usually, emergency room psychiatrists never find out what happened to their patients.
"You make a very big decision, which usually has no known outcome. You put this person in the hospital, you go on to the next patient. You send this person home, you go on to the next patient," he said.
Duckworth said he would not second-guess the actions of Prude's hospital team in the moment, but with the benefit of hindsight, "there's overwhelming evidence that he had a psychotic illness and was quite vulnerable," he said. "He didn't need to die."
In a statement, URMC said its treatment of Prude was "medically appropriate and compassionate."
Several oversight organizations are investigating.
The Joint Commission, which certifies hospitals to receive federal funding, saidit's reviewing Prude's treatment at Strong. New York state's Justice Center is investigating on behalf of the state Office of Mental Health.
The university medical center itself is still conducting an internal clinical review.
In response to questions from NPR and KHN about whether the hospital's treatment of Prude could have been affected by his race, Partner said the medical center asked Dr. Altha Stewart, past president of the American Psychiatric Association, "to conduct a third-party independent review through her lens as a national expert on racism and bias in psychiatric care."
In a separate interview before the request from URMC, she described how unconscious bias can cloud clinicians' judgment and make it difficult for them to make the best possible decisions for their patients.
"It is very clear that in today's healthcare system, bias is built in structurally," Stewart said. "Seeing a tall, imposing Black man who is behaving aggressively puts in place a series of ideas and thoughts and assumptions that direct decision-making."
Psychiatric disorders in Black patients are less likely to be taken seriously than in white patients, Stewart said. Unequal treatment starts early.
"So a Black child with a meltdown is described as aggressive, obstinate, oppositional," she said, "as opposed to traumatized, depressed, anxious."
Those expectations follow Black boys through adulthood and in the healthcare system, increasing the odds that doctors will view Black men as a lost cause and provide subpar care, Stewart said.
She stressed that she does not have any direct knowledge of deficiencies in the care of Daniel Prude, but she said that Black men, like Prude, are disproportionately likely to be misdiagnosed, mistreated and written off as a result of structural bias and unconscious racism.
A group of medical students at the University of Rochester wrote in an open letter that Daniel Prude was "sentenced to death by our failed healthcare system."
"Not only do our current models of healthcare leave gaping holes for individuals such as Daniel to fall through, but they do so in manners which are fraught with racism," the students wrote.
Partner, the medical center spokesperson, said the psychiatry department's Office of Diversity, Inclusion, Culture and Equity will evaluate Daniel's treatment for potential bias. He said the medical center "recognizes that we have a long way to go before we can confidently say that our policies and practices are universally culturally appropriate to the populations we serve."
Both Stewart and Duckworth said reducing the role that police play in addressing mental health crises would increase the odds of survival for a person released too early from psychiatric care.
Federal inspection reports show that hospitals across the country have released patients who, like Prude, ended up in grave danger only shortly thereafter.
In March 2018, a patient with a history of schizophrenia, post-traumatic stress disorder and suicide attempts arrived at Russell County Hospital in Kentucky complaining of alcohol withdrawal, depression, anxiety and pain. An hour and a half later, the patient was discharged with instructions to "follow up with his/her primary care provider and take medications as prescribed." Two hours later, the patient was back in the same hospital. A physician's notes said the patient had drunk a bottle of Benadryl "in effort to kill self."
In August 2018, federal inspectors found that UT Health East Texas Pittsburg Hospital discharged a patient who had verbalized a plan for suicide. The patient got a ride to his truck from the county sheriff. Later that day, the patient was found dead in the truck from a self-inflicted gunshot wound.
Last summer at Stafford County Hospital in Kansas, a patient arrived in the emergency room saying she had drunk half a liter of vodka because she was upset and wanted to die. She told hospital staff that she started drinking that day after two years of sobriety and that she "did not feel safe to go home due to the presence of alcohol." The hospital discharged her 11 minutes later.
Earlier this year, inspectors found that a patient with a history of psychosis went to the emergency room at Mercy Hospital in St. Louis and told staff she needed to get back on her medication. She was delusional, disoriented, homeless and unable to give her name. She was discharged with a voucher for cab fare but no follow-up appointments or services and no plan to ensure she got her medication.
A spokesperson for UT Health East Texas said the health system has since implemented a process for staff to more thoroughly document mental health concerns in patient records. Mercy Hospital in St. Louis said it takes the health and safety of each patient very seriously "regardless of race, ethnicity or ability to pay."
Neither of the other hospitals responded to emails or calls seeking comment.
For a term that's at least 100 years old, "herd immunity" has gained new life in 2020.
It starred in many headlines last month, when reports surfaced that a member of the White House Coronavirus Task Force and adviser to the president, Dr. Scott Atlas, recommended it as a strategy to combat COVID-19. The Washington Post reported that Atlas, a healthcare policy expert from the Hoover Institution of Stanford University, suggested the virus should be allowed to spread through the population so people build up immunity, rather than trying to contain it through shutdown measures.
At a town hall event a few weeks later, President Donald Trump raised the idea himself, saying the coronavirus would simply "go away," as people developed "herd mentality" — a slip-up that nonetheless was understood to reference the same concept.
And as recently as last week, Sen. Rand Paul (R-Ky.) sparked a heated debate at a committee hearing when he suggested that the decline in COVID cases in New York City was due to herd or community immunity in the population rather than public health measures, such as wearing masks and social distancing. Dr. Anthony Fauci, the top U.S. infectious disease official, rebuked Paul, pointing out that only 22% of the city's residents have COVID antibodies.
"If you believe 22% is herd immunity, I believe you're alone in that," Fauci told the senator.
All this talk got us thinking: People seem pretty confused about herd immunity. What exactly does it mean and can it be used to combat COVID-19?
An Uncertain Strategy With Great Cost
Herd immunity, also called community or population immunity, refers to the point at which enough people are sufficiently resistant to a disease that an infectious agent is unlikely to spread from person to person. As a result, the whole community — including those who don't have immunity — becomes protected.
People generally gain immunity in one of two ways: vaccination or infection. For most diseases in recent history — from smallpox and polio to diphtheria and rubella —vaccines have been the route to herd immunity. For the most highly contagious diseases, like measles, about 94% of the population needs to be immunized to achieve that level of protection. For COVID-19, scientists estimate the percentage falls between 50% to 70%.
Before the COVID pandemic, experts can't recall examples in which governments intentionally turned to natural infection to achieve herd immunity. Generally, such a strategy could lead to widespread illness and death, said Dr. Carlos del Rio, an expert in infectious disease and vaccines at the Emory University School of Medicine.
"It's a terrible idea," del Rio said. "It's basically giving up on public health."
A new, large study found fewer than 1 in 10 Americans have antibodies to SARS-CoV-2, the virus that causes COVID-19. Even in the hardest-hit areas, like New York City, estimates of immunity among residents are about 25%.
To reach 50% to 70% immunity would mean about four times as many people getting infected and an "incredible number of deaths," said Josh Michaud, associate director of global health policy at KFF. Even those who survive could suffer severe consequences to their heart, brain and other organs, potentially leaving them with lifelong disabilities. (KHN is an editorially independent program of KFF.)
"It's not a strategy to pursue unless your goal is to pursue suffering and death," Michaud said.
What's more, some scientists say natural immunity may not even be feasible for COVID-19. While most people presumably achieve some degree of protection after being infected once, cases of people who recovered from the disease and were reinfectedhave raised questions about how long natural immunity lasts and whether someone with immunity could still spread the virus.
Even the method scientists are using to measure immunity — blood tests that detect antibodies to the coronavirus — may not be an accurate indicator of who is protected against COVID-19, said Dr. Stuart Ray, an infectious disease expert at the Johns Hopkins University School of Medicine.
With so many unanswered questions, he concluded: "We can't count on natural herd immunity as a way to control this epidemic."
Vaccines, on the other hand, can be made to trigger stronger immunity than natural infection, Ray said. That's why people who acquire a natural tetanus infection, for example, are still advised to get the tetanus vaccine. The hope is that vaccines being developed for COVID-19 will provide the same higher level of immunity.
But What About Sweden?
In the political debate around COVID-19, proponents of a natural herd immunity strategy often point to Sweden as a model. Although the Scandinavian country imposed fewer economic shutdown measures, its death rate is less than a fraction of that in the U.S., Paul said at Wednesday's Senate hearing.
But health experts — including Fauci during the same hearing — argue that's a flawed comparison. The U.S. has a much more diverse population, with vulnerable groups like Black and Hispanic Americans being disproportionately affected by the coronavirus, said Dr. Jon Andrus, an epidemiology expert at the George Washington University Milken Institute School of Public Health. The U.S. also has greater population density, especially on the coasts, he said.
When compared with other Scandinavian countries, Sweden's death toll is much higher. It has had 5,880 deaths linked to COVID-19 so far, according to data from Johns Hopkins University. That's nearly 58 deaths per 100,000 residents — several times higher than the death rates of 5 or 6 per 100,000 in Norway and Finland. In fact, as a result of COVID-19, Sweden has recorded its highest death toll since a famine swept the country 150 years ago. And cases are on the rise.
Despite that level of loss, it's still unclear if Sweden has reached the threshold for herd immunity. A study by the country's public health agency found that by late April only 7% of residents in Stockholm had antibodies for COVID-19. In other Swedish cities, the percentage was even lower.
Those findings mirror other studies around the globe. Researchers reported that in several cities across Spain, Switzerland and the U.S. — with the exception of New York City — less than 10% of the population had COVID-19 antibodies by June, despite months of exposure and high infection rates. The results led commentators in the medical research journal The Lancet to write, "In light of these findings, any proposed approach to achieve herd immunity through natural infection is not only highly unethical, but also unachievable."
Herd Immunity Is Still Far Off
The bottom line, medical experts say, is that natural herd immunity is an uncertain strategy, and attempts to pursue it could result in a slew of unnecessary deaths. A vaccine, whenever one becomes available, would offer a safer route to community-wide protection.
Until then, they emphasize there is still plenty to do to counter the pandemic. Wearing masks, practicing social distancing, hand-washing and ramping up testing and contact tracing have all proven to help curb the virus's spread.
"As we wait for new tools to be added to the toolbox," Andrus said, "we have to keep reminding ourselves that there are measures in this very moment that we could be using to save lives."
KHN reporter Victoria Knight contributed to this article.
"No Mercy" is Season One of "Where It Hurts," a podcast about overlooked parts of the country where cracks in the health system leave people without the care they need. Our first destination is Fort Scott, Kansas.
Each season, "Where It Hurts" takes you somewhere new — to an overlooked part of the country to explore cracks in the American health system that leave people frustrated — and without the care they need. The story begins in Fort Scott, Kansas. Rural. Deeply Christian. And sicker than other parts of the state. When Mercy Hospital shut its doors, the town's sense of identity wavered.
Season One "No Mercy" is about the people who remain, surviving the best way they know how. Host and investigative journalist Sarah Jane Tribble spent more than a year revisiting southeastern Kansas, where she grew up, to document the sparking tensions, anger and fear many people felt as they struggled to come to terms with the hospital's closure.
Chapter 1: 'It Is What It Is'
Midwesterners aren't known for complaining. But after Mercy Hospital Fort Scott closed, hardship trickled down to people whose lives were already hard. Pat Wheeler has emphysema. Her husband, Ralph, has end-stage kidney failure, and the couple are barely making ends meet as they raise their teenage grandson. Pat is angry with hospital executives who she said yanked a lifeline from residents. "They took more than a hospital from us," she said.
"Where It Hurts" is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble's award-winning series, "No Mercy."
STERLING, Colo. — Tonja Jimenez is far from the only person driving an RV down Colorado’s rural highways. But unlike the other rigs, her 34-foot-long motor home is equipped as an addiction treatment clinic on wheels, bringing lifesaving treatment to the northeastern corner of the state, where patients with substance use disorders are often left to fend for themselves.
As in many states, access to addiction treatment remains a challenge in Colorado, so a new state program has transformed six RVs into mobile clinics to reach isolated farming communities and remote mountain hamlets. And, in recent months, they’ve become more crucial: During the coronavirus pandemic, even as brick-and-mortar addiction clinics have closed or stopped taking new patients, these six-wheeled clinics have kept going, except for a pit stop this summer for air conditioning repair.
Their health teams perform in-person testing and counseling. And as broadband access isn’t always a given in these rural spots, the RVs also provide a telehealth bridge to the medical providers back in the big cities. Working from afar, these providers can prescribe medicine to fight addiction and the ever-present risk of overdose, an especially looming concern amid the isolation and stress of the pandemic.
Mobile health clinics have been around for years, bringing vision tests, asthma treatment and dentistry to places without adequate care. But using health care on wheels to treat addiction isn’t as common. Nor is equipping such motor homes with telehealth capability that expands the reach of prescribing providers to treat hard-to-reach patients in these hard-to-reach rural areas.
“We really believe we bring treatment to our patients and we meet them where they’re at,” said Donna Goldstrom, clinical director for Front Range Clinic, a Fort Collins, Colorado, practice that operates four of the RVs. “So meeting them where they’re at physically is not a long leap from meeting them where they’re at motivationally and psychologically.”
Each RV has a nurse, a counselor and a peer specialist who has personal experience with addiction — and all had to be trained to drive a vehicle that size.
“I never thought when I went to nursing school that I’d be doing this,” Christi Couron, a licensed practical nurse, said as she pumped 52 gallons of diesel fuel into the motor home she works on with Jimenez.
The crew has driven their RV more than 30,000 miles since January, much of it viewed through a cracked windshield courtesy of a summer afternoon hailstorm. Four days a week, they ply the roads from Greeley to the smaller towns near the Nebraska border, as the view goes from mile-high to miles-wide.
Don a Mask, Pee in a Cup
On a dusty lot outside a halfway house in Sterling, Jimenez, the peer specialist, activates the leveling jacks to balance the RV, and the team readies the unit for the day’s slate of patients. The passenger-side captain’s chair flips around to face a table where Jimenez will check in patients. The tabletop is crowded with a printer, a scanner, a laptop and a label-maker. Underneath lie a box of specimen cups and a gallon of windshield washer fluid. The vehicle now has plenty of masks and cleaning supplies on hand, too.
After patients check in, they go to the RV’s snug bathroom to provide a urine sample. With test strips built into the sides of the cup, results show instantly whether any of 13 categories of drugs — from opiates to antidepressants — are in the urine. The sample is later dropped off at a lab to confirm the results and determine which specific drug is involved. The results help the team understand how best to treat the patients and make sure they use the prescriptions they’re given.
Patients then head to a small exam room in the back, where they connect via video to a nurse practitioner or physician assistant in a brick-and-mortar clinic.
If all goes well, the provider will send over a prescription for Suboxone (a combination medicine containing buprenorphine, which reduces cravings for opioids) or for Vivitrol (a monthly injectable version of naltrexone, which blocks opioid receptors). Once the staffers have the prescription in hand, the RV nurse can give those Vivitrol shots directly and distribute Narcan, a medication that will reverse an opioid overdose. Suboxone prescriptions must be called into a local pharmacy.
Patients also can drop used needles into a sharps container for disposal, but the staffers are not allowed to distribute clean needles. Some patients will talk with counselor Nicky McLean in a room just large enough to fit a table and two chairs.
Within minutes, a couple, who asked not to be identified by name because of the stigma surrounding addiction, arrive early for their appointments. They’ve brought the staff homemade chicken enchiladas. They had been spending $8,000 a month buying OxyContin on the street, and their lives and finances were a wreck. He lost his house. She needs clean urine tests to see her son. The couple started their addiction treatment only three weeks earlier, after he learned about the RV clinic from a friend.
They no longer have a car, so they walked a half-hour to get to their appointment.
“We would’ve done anything to get our drugs,” she said. “Walking 30 minutes to get better, it’s worth it.”
Even before they’ve finished, another patient is at the door. Spencer Nash, 29, has been using opioids since he was 18. Nine years ago, when his wife got pregnant, the couple decided to get clean, driving two hours each way, six days a week, to a methadone clinic in Fort Collins. Now, he walks to the RV, outside the halfway house where he lives, to get his Suboxone prescription.
Filling the Gaps
A few years ago, Robert Werthwein, director of Colorado’s Office of Behavioral Health, heard about a project using RVs for addiction treatment in rural upstate New York. He thought it would work in his state, too. The agency crunched the numbers to see which regions recorded the highest levels of opioid prescriptions and overdoses but lacked addiction treatment.
“We hear too often that in rural Colorado and the mountain regions of Colorado they don’t have the same access to services as the Denver metro and the Front Range regions,” Werthwein said. The state secured a $10 million federal grant for the program. His team brought in health care providers, such as Front Range Clinic, to staff and operate the RVs.
Once the RVs were ready, the staff had to be trained to drive them, which necessitated “a couple of repairs,” Werthwein said. The vehicles first started rolling out in December, eventually serving six regions — and in a seventh area, a place where narrow mountain roads precluded a large RV, one of Werthwein’s teams travels by SUV.
In some communities, the local doctors and others have been less than thrilled, feeling the RVs would attract drug users to their town.
“We’re hoping to address stigma, not just from a public standpoint, but we’re hoping to show providers ‘there is a demand in your community for medication-assisted treatment,’” Werthwein said.
Once the federal grant runs out in September 2022, Front Range Clinic and the other mobile unit operators will inherit and continue to operate the RVs, billing Medicaid and private insurance as they do now for the appointments.
As the RV crew’s 1 p.m. departure time in Sterling approached, one patient remained. The woman, who asked that her name not be published because she didn’t want to be publicly identified as a drug user, arrived at the mobile clinic without an appointment. But they couldn’t take her as a new patient without a urine sample. For two hours, she was in and out of the bathroom, drinking bottles of water, but unable to fill the little plastic cup. Through the bathroom door, the staffers could hear her crying and cursing at herself.
With the battery power on the RV winding down, they coaxed her out of the bathroom. Perhaps tomorrow would work better, they told her. She could continue to rehydrate through the night and then meet the mobile unit at its next stop, Fort Morgan, some 45 minutes away.
The next day, she was still unable to produce a urine sample, whether because of dehydration from her substance use or simply nerves. They asked her to come back again when the RV returned to Sterling the next week, but she never showed up.