Managing the condition requires other essential, often lifesaving medical supplies. And patients frequently face hurdles in getting access to those supplies — hurdles put in place by insurance companies.
This story was first published on Tuesday, September 24, 2019 inKaiser Health News.
In the first three months after getting his Dexcom continuous glucose monitor, Ric Peralta said, he reduced his average blood sugar level by 3 percentage points.
"It took me from not-very-well-managed blood sugar to something that was incredibly well managed," said Peralta, a 46-year-old optician in Whittier, Calif., who was diagnosed with Type 1 diabetes in 2008.
Peralta was so enthused that he became a "Dexcom Warrior," a sort of grassroots spokesman for the product. It became hard to imagine life without his new monitor, a device that lets him track the trends in his blood sugar 24 hours a day on his smartphone. And yet, he has spent weeks at a time without the device over the past year because of insurance restrictions. Physician groups and patients consider those rules burdensome, but insurers defend them as necessary.
Diabetes activistsand legislatorshave started to focus attention on the surging price of insulin, leading to legislative pushes, lawsuits and congressional hearings. But insulin isn't the only thing people with Type 1 diabetes are struggling to get. Managing the condition requires other essential, often lifesaving medical supplies. And patients frequently face hurdles in getting access to those supplies — hurdles put in place by insurance companies.
A Life-Changing Device
Peralta learned about the latest version of the Dexcom continuous glucose monitor from the mother of one of his patients. He visited the company's website and, within two weeks, the device was shipped to his front door.
"I still didn't 100% appreciate exactly how it was going to change my life," Peralta said. "It was amazing."
Typically, people with Type 1 diabetes check their blood sugar by drawing a drop of blood from a finger and placing it on a disposable test strip that's read by a blood glucose meter. Doctors suggest checking blood sugar this way between four and 10 times a day. These readings are crucial for helping people with diabetes manage their blood sugar — keeping it from getting too low, which can lead to sudden seizures and loss of consciousness, as well as from getting too high, which can cause vision loss and nerve damage and can even, over time, lead to amputations.
Instead, Peralta's continuous glucose monitor gave accurate blood sugar readings every five minutes. That's 288 readings a day, or about 278 more readings than even the most conscientious patients get the old-fashioned way.
"When I had to do the old-fashioned finger prick test, I was only doing that right before I ate, so I could see how much [insulin] I was supposed to take," Peralta said. (People with Type 1 diabetes have to take multiple daily shots of insulin to keep their blood sugar within the normal range because their bodies stop producing the naturally occurring hormone.)
"I didn't realize that I had rather severe [blood sugar] peaks and valleys in between my mealtimes," Peralta said.
Tighter control of blood sugar can reduce the risk of heart disease, kidney failure and nerve damage. For Peralta, it also offered peace of mind.
The monitor sounds an alarm when his blood sugar gets dangerously low; Peralta said his co-workers have started bringing him sugary snacks when they hear the alarm, to help him raise his blood sugar back to normal. When he takes his family on road trips — a favorite activity — he no longer has to worry about the possibility of passing out while driving.
"It even syncs with my car so I can just say, 'Siri, what's my blood sugar?' And it will come over the car stereo system," Peralta said. "I'm safe for my family."
Prior-Authorization Requirements
When common chronic conditions such as diabetes are well controlled, it prevents worsening disease and saves money for the health system and the patient.
But Peralta said his efforts to use this new tool consistently to manage his diabetes have been stymied by insurance problems that began about a year ago.
The newest Dexcom continuous glucose monitor has three parts: a sensor that measures glucose levels, a transmitter that sends out the sensor's readings wirelessly and a receiver that displays those readings on a screen.
For each of these parts, Peralta needs "prior authorization" — a requirement that his physician get approval from his insurance company before prescribing the device.
The Dexcom sensors last about 10 days each, and Peralta's insurance allows him to buy a three-month supply at a time. But he also has to get prior authorization for each supply, meaning every three months his doctor needs to reconfirm with his insurance company that the sensors are medically necessary. Same goes for the device's transmitters — which last about six months each.
"I have to jump through hoops and they have to jump through hoops to get information from my insurance to get authorization," Peralta said in frustration, adding that "for the last year, basically every time there's been something that's gone wrong."
"Prior authorizations are in place to protect patients, to improve safety and to try to make sure that the care they receive is as safe as possible and also as affordable as possible," said Kate Berry of the trade group America's Health Insurance Programs.
But to Ric Peralta, the requirement is a burden.
The most recent snafu happened in March. Peralta ordered a new supply of sensors directly from Dexcom but said the company submitted a request for approval of a new transmitter as well. And because his insurance approves the sensors and transmitters on different authorization timelines, the whole claim was denied. Peralta estimates he spent four hours on the phone with Dexcom and his insurer over the next month and a half to sort it all out. During that time he had to revert to finger-stick tests.
"It's maddening," Peralta said. "If I do not have my proper management of this disease, I'm going to die from it. And they're making it as difficult as possible."
A Burden On Doctors, Too
Prior authorizations have become a major concern of physicians across the U.S. health care system, as evidenced by a December survey by the American Medical Association.
Of the 1,000 physicians surveyed, 91% said prior authorizations "have a negative impact on patient clinical outcomes"; 75% said the requirements "can at least sometimes lead to patients abandoning a recommended course of treatment"; and 28% said the prior-authorization process had "led to serious or life-threatening events" for their patients.
"In my practice, we have five individual physicians, and we hired five full-time employees whose primary duty is obtaining prior authorization and dealing with insurance companies," said Dr. Bruce Scott, an otolaryngologist from Kentucky and speaker of the AMA House of Delegates.
"Prior authorization is a burden on providers and diverts valuable resources," Scott said. "That's a problem."
The AMA has even created a website that catalogs stories of patients and providers who say they've struggled to gain access to important medical products and procedures because of problems with getting prior authorization from insurers — everything from pain medication for a cancer patient to X-rays in the ER. Scott said the AMA doesn't expect insurers to completely do away with requirements for prior authorization, "but we believe that it should be focused and that it should be better planned."
The American Association of Clinical Endocrinologists — an organization of the physicians whose specialty is often associated with diabetes treatment — goes further.
"We feel that physicians that are specialists in endocrine disease should not be required to fill out prior authorizations for endocrine treatments," said Dr. Scott Isaacs, an endocrinologist from Atlanta and a member of the board of directors of AACE.
"It's a huge burden for the patients trying to get this sorted out. Sometimes it's red tape; sometimes it's a true denial," Isaacs said. "It's a huge burden for the doctors as well, and the doctors resent it."
Berry, of America's Health Insurance Programs, acknowledges there's room for improvement in the prior-authorization process. In fact, in January 2018, the AMA and AHIP signed a consensus statementidentifying five areas for improvement. It was co-signed by the American Hospital Association, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association.
Who Bears The Greatest Burden?
For Ric Peralta, the ultimate burden of getting all these prescriptions filled falls on him and other patients like him.
After his latest mix-up with the sensors in March, he discovered the battery in his transmitter had died.
Peralta made another frustrated call to Dexcom, and recently got a complimentary transmitter to get him back on the system while his formal order goes through the approval process.
"I'm quite nervous about what's going to happen again in two months when I am needing to call in orders again," Peralta said.
"Am I going to have to go through this whole thing over again?"
This story is part of NPR's reporting partnership with Kaiser Health News.
HILLSBORO, Ore. — On Kimberly Repp's office wall is a sign in Latin: Hic locus est ubi mors gaudet succurrere vitae. This is a place where the dead delight in helping the living.
For medical examiners, it's a mission. Their job is to investigate deaths and learn from them, for the benefit of us all. Repp, however, isn't a medical examiner; she's a Ph.D. microbiologist. And as the Washington County epidemiologist, she was most accustomed to studying infectious diseases like flu or norovirus outbreaks among the living.
But in 2012 she was asked by county officials to look at suicide. The request led her into the world of death investigations, and also appears to have led to something remarkable: In this suburban county of 600,000 just west of Portland, the suicide rate now is going down. It's remarkable because national suicide rates have risen despite decades-long efforts to reverse the deadly trend.
While many factors contribute to suicide, officials here believe they've chipped away at this problem through Repp's initiative to use data — very localized data that any jurisdiction could collect. Now Repp's mission is to help others learn how to gather and use it.
New York state has just begun testing a system like hers. Humboldt County, Calif., is implementing it. She's gotten inquiries from Utah and Kentucky. Colorado, meanwhile, is using its own brand of data collection to try to achieve the same kind of turnaround.
Following The Death Investigators
Back in 2012, when Repp looked at the available data — mostly statistics reported periodically to the federal Centers for Disease Control and Prevention — she could see that suicide was a big problem and that rates were highest among older white men. But, beyond that, the data didn't offer a lot of guidance. Plus, it lagged two years behind.
She returned to her bosses. "I can tell you who has the highest suicide rate, but I can't tell you what to do about it," she recalled telling them. "It's too broad."
So she turned to the county medical examiner's death investigators. They gather information at every unnatural death scene to determine the cause (say, drowning or gunshot) and manner (homicide, suicide, accident). It's an important job, but a grim one, and it tends to attract unusual personalities.
Repp mustered the courage to introduce herself to one of the investigators, Charles Lovato. "I said, 'Hi, my name is Kim and I was hoping to go on a death investigation with you.' And he's like, 'You're that weirdo that does outbreak investigations, aren't you?' And I'm like, 'You're the weirdo that does death investigations.'"
The gambit worked. Repp accompanied Lovato on his grim rounds for more than a year. "Nothing can prepare you for what you're going to see," she said. "It gave me a very healthy dose of respect for what they do."
She studied the questions Lovato asked friends and family of the deceased. She watched how he recorded what he saw at the scene. And she saw how a lot of data that helped determine the cause and manner of death never made it into the reports that state and federal authorities use to track suicides. It was a missed opportunity.
Collecting Data On The Dead To Save Lives
Repp worked with Lovato and his colleagues to develop a new data collection tool through which investigators could easily record all those details in a checklist. It included not only age and cause of death, but also yes/no questions on things like evidence of alcohol abuse, history of interpersonal violence, health crises, job losses and so on.
In addition, the county created a procedure, called a suicide fatality review, to look more closely at these deaths. The review is modeled on child fatality reviews, a now-mandatory concept that dates to the 1970s. After getting the OK from family members, key government and community representatives meet to investigate individual suicides with an eye toward prevention. The review group might include health care organizations to look for recent visits to the doctor; veterans' organizations to check service records; law enforcement; faith leaders; pain clinic managers; and mental health support groups.
The idea, Repp said, isn't to point fingers. It's to look for system-level interventions that might prevent similar deaths.
"We were able to identify touchpoints in our community that we had not seen before," Repp said.
For example, data revealed a surprising number of suicides at hotels and motels. It also showed a number of those who killed themselves had experienced eviction or foreclosure or had a medical visit within weeks or days of their death. It revealed that people in crisis regularly turn their pets over to the animal shelter.
But what to do with that information? Experts have long believed that suicide is preventable, and there are evidence-based programs to train people how to identify and respond to folks in crisis and direct them to help. That's where Debra Darmata, Washington County's suicide prevention coordinator, comes in. Part of Darmata's job involves running these training programs, which she described as like CPR but for mental health.
The training is typically offered to people like counselors, educators or pastors. But with the new data, the county realized they were missing people who may have been the last to see the decedents alive. They began offering the training to motel clerks and housekeepers, animal shelter workers, pain clinic staffers and more.
It is a relatively straightforward process: Participants are taught to recognize signs of distress. Then they learn how to ask a person if he or she is in crisis. If so, the participants' role is not to make the person feel better or to provide counseling or anything of the sort. It is to call a crisis line, and the experts will take over from there.
Since 2014, Darmata said, more than 4,000 county residents have received training in suicide prevention.
"I've worked in suicide prevention for 11 years," Darmata said, "and I've never seen anything like it."
The sheriff's office has begun sending a deputy from its mental health crisis team when doing evictions. On the eviction paperwork, they added the crisis line number and information on a county walk-in mental health clinic. Local health care organizations have new procedures to review cases involving patient suicides, too.
Taking The Idea Elsewhere
Repp cautions that the findings can't be generalized. What's true in suburban Portland may not be true in rural Nebraska or the city of San Francisco or even suburban New Jersey, for that matter. Every community needs to look at its own data.
Still, Jay Carruthers, who runs New York's Office of Suicide Prevention, saw the potential. "To be able to close the loop and connect [the data] to prevention? That's the beauty," he said. This year, the state is beginning to test a similar system in several counties.
In Northern California's Humboldt County, public health manager Dana Murguía had been frustrated for some time that local prevention plans weren't making a dent. "I said, 'We don't need another plan. We need an operations manual.' That's what I feel Dr. Repp has given us."
Humboldt began using a Washington County-style checklist this year, and county officials have identified several unexpected touchpoints, including public parks and motels where people have died by suicide. Now, those sad facts can become action plans.
In Colorado, a different effort to reduce suicides also began with extensive data analysis. There, they realized that while youth suicide has understandably been a focus, the biggest numbers are among older men. They've not only crafted materials specifically for men in crisis, but they've also created materials for specialized groups, such as veterans, farmers and construction workers.
"What was unexpected to me was how empowering these data would be to so many different people to make change," Repp said — including Lovato and the other death investigators. "To know that they're actually keeping the living alive is really powerful."
IF YOU NEED HELP If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.
Dr. Wesley Boyd, an associate professor of psychiatry at Harvard, has spent years working with state programs that help doctors, nurses and other health care workers who have become addicted to opioids get back on their feet professionally.
He supports these non-disciplinary programs, in which doctors and nurses enroll for a number of years and are closely monitored by addiction specialists and state authorities as they seek to maintain or restore their medical licenses. But, he said, he is perplexed as to why these programs and other efforts to help health care providers generally do not stress a recovery method that has long been shown to be effective: the use of drugs like buprenorphine and methadone, known as opioid agonists, to relieve cravings.
"Obviously the data are clear that medication-assisted treatment is the best course of action," said Boyd, who worked for Massachusetts' Physician Health Services (previously known as the Society to Help Physicians) from 2004 to 2010. "Whether they're doctors, nurses or anybody else, [they] can function perfectly well at work and in their lives generally while they're using medication-assisted treatment."
Furthermore, he said, "the odds that they're going to stay clean and sober while using medications for treatment are better."
Clinical studies showmedication-assisted treatment significantlydecreases the rate of relapse and overdose more than other interventions alone. Most advocates advise using it in conjunction with regular therapy or counseling. Legal and medical researchers also made this point in the New England Journal of Medicine last month, calling it "ironic that clinicians, who are better positioned than most people to acquire and afford opioid-agonist therapy, are often denied it."
But some health care professionals believe opioid agonists are just a substitute for the drugs a doctor is addicted to, and, since they bind to the same brain receptors as opioids, may affect providers' ability to do their jobs. The opioid agonists help reduce relapses and cravings by stimulating the same pathways opioids do, but in a controlled manner that prevents a person from feeling high.
Non-Disciplinary Treatment Programs For Addiction
Non-disciplinary treatment programs have been operating in most states since the 1970s to help health professionals overcome their addiction. Instead of revoking the license of an individual who is found to be impaired on the job, these peer-run programs try to get participants back to work with mandated treatment plans that include intensive therapy, monitoring their behavior in and out of the workplace and, of course, drug testing. Throughout treatment, participants are actively discouraged, if not outright banned from, using opioid agonists that could aid their recovery.
Members of the non-disciplinary program may advocate for a participant's return to work when they believe the individual is ready, but, ultimately, it is the state board that determines when an individual is fit to care for patients.
Bill Kinkle, a registered nurse in Pennsylvania, developed an addiction to opioids more than a decade ago and lost his license. He tried several recovery programs but relapsed and overdosed several times.
He has been working with the state's Peer Nurse Assistance Program to get his license back. When he asked if he could use Suboxone, a brand name for a combination of buprenorphine and naloxone, he was told that the nurse assistance program would not allow it unless he had a detailed plan for tapering off the drug.
So he is treating his addiction through the state program without the medication. He was required to participate in a 30-day inpatient program, undergo partial hospitalization (in which a participant is treated for several hours a day but can go home in the evenings) for an additional three weeks, receive three months of intensive outpatient therapy, attend Alcoholics Anonymous meetings three to five times a week and pay for expensive random urine screenings.
The Peer Nurse Assistance Program did not respond to requests for comment.
Some state officials are beginning to consider the use of drugs like methadone and buprenorphine. The North Carolina Medical Board, which handles physician licensing and discipline, is encouraging the state program for doctors with opioid addictions to introduce these medications.
Critics argue that the non-disciplinary programs can, in fact, feel more disciplinary than supportive and don't help as many people as they could if opioid agonists were made available.
The programs "have no independent oversight and patients don't have a recourse," said Dr. Peter Grinspoon, an internist in Boston who had an opioid addiction and was both a participant in, and eventually a board member of, Massachusetts' Physician Health Services program for addicted doctors.
Grinspoon, who also teaches at Harvard, said that although he was unaware of any formal state policy against medication-assisted treatments, none of the program's participants with opioid addictions used opioid agonists while he served.
Impairment in Safety-Sensitive Positions
Scott Teitelbaum, medical director at the University of Florida Recovery Center, which treats health care professionals from all over the country, said he sometimes prescribes the medicines to the half of his patients who don't work in "safety-sensitive positions."
But, he said, it makes sense to have a different strategy for patients in those positions. When the programs ask him if a person should return to practice, they're not asking what's best for the individual; they're asking whether it's safe for the public. And when patients are using agonist therapies, Teitelbaum, who also was treated for cocaine and marijuana use, said he isn't sure it is.
A review in Mayo Clinic Proceedings of several studies in 2012 showed small effects of both methadone and suboxone on performance in measures such as reaction time and memory. The review was criticized for weak evidence and a lack of appropriate control groups.
Grinspoon noted that doctors could be taking other medications that affect their performance but face no repercussions. For example, he said, they may take benzodiazepines for anxiety or Ambien to help them sleep.
"There are tons of pharmaceuticals that could affect our performance — all of which doctors are allowed to take," he said. "And it's just because of the stigma that they're singling out addiction."
Success Rates
Critics of medication-assisted treatment often point to the overwhelming five-year success rates reported by the non-disciplinary programs — generally between 70% and 90%.
But Boyd is wary of those rosy statistics. First, he noted, they rarely count people who dropped out of the program or died by suicide. He said some professionals who never suffered from substance use disorder are forced into the program by bad evaluations.
So far, Kinkle, the nurse in Pennsylvania, has stayed on track, "white-knuckling it" without Suboxone. If all goes according to plan, his license will be reinstated in another 13 months.
"My wife found me multiple times after an overdose lying on the floor unconscious," said Kinkle. "All that could have been prevented had I been offered" Suboxone.
FORT SCOTT, Kan. — On a hot June day as the Good Ol' Days festival was in full swing, 7-year-old Kaidence Anderson sat in the shade with her family, waiting for a medevac helicopter to land.
A crowd had gathered to see the display prearranged by staff at the town's historic fort.
"It's going to show us how it's going to help other people because we don't have the hospital anymore," the redheaded girl explained.
Since the hospital closed, air ambulance advertising has become a more common sight in mailboxes and at least one company's representative has paid visits to a local nursing home and the Chamber of Commerce, offering memberships. A prepaid subscription would guarantee that if an AirMedCare Network helicopter comes to your rescue, you will pay nothing.
Nationwide, though, state insurance leaders, politicians and even one of the nation's largest air ambulance companies have raised alarms about the slickly marketed membership campaigns.
The air ambulance industry expanded by more than a hundred bases nationwide from 2012 to 2017 and prices increased as well, according to a recent federal report. The median price charged for a medevac helicopter transport was $36,400 in 2017 — a 60% increase compared with the roughly $22,100 charged in 2012, according to the March report from the U.S. Government Accountability Office.
Insurance seldom covers the trips and consumers often are surprised to get a bill showing they are responsible for the bulk of the cost. However, both Medicare and Medicaid control the price of the service, so enrollees in those government insurance programs face much lower out-of-pocket costs or have none.
AirMedCare Network, which includes 340 bases across mostly rural America, has more than 3 million people enrolled in memberships, said Seth Myers, president of Air Evac Lifeteam, one of the medevac companies under the AirMedCare Network umbrella.
One brightly colored AirMedCare advertisement mailed in southeastern Kansas promised entry in a summer vacation giveaway as an incentive to sign up. A one-year membership is $85 — unless you are 60 or older, which qualifies you for a discount. Buying multiyear memberships increases the odds of winning that summer trip.
"We're a safety net for people in rural areas," Myers said. "Generally, if I tell you the names of the towns that most of our bases are located in, you wouldn't know them unless you lived in that state."
Increasingly, though, state regulators have a skeptical view.
North Dakota Insurance Commissioner Jon Godfread called the memberships "another loophole" that air ambulance companies use to "essentially exploit our consumers." The state banned the memberships in 2017, noting that the subscription plans don't solve the problem of surprise medical bills as promised.
Too often, the company responding to a patient's call for help is not the one the patient signed up with, Godfread said. North Dakota has nine different air ambulance operators who respond to calls and patients have no control over who will be called, he explained.
Air Evac's Myers said his company, which operates mostly in the Midwest and Texas, doesn't get many complaints from customers about other companies picking them up. He counted three this year.
Texas Rep. Drew Springer, a Republican, introduced a bill passed by the state legislature this year that would require companies to honor the subscriptions or memberships of other air ambulance companies.
But Texas Gov. Greg Abbott, also a Republican, vetoed Springer's reciprocity bill, saying it would unnecessarily intrude on the operations ofprivate businesses.
Myers said that AirMedCare Network was "very careful to educate the legislature and the governor's office" in Texas. A letter signed by Myers and other industry executives noted that the 1978 Airline Deregulation Act — a law created for the commercial airline industry — protects them. The federal law limits states' ability to regulate rates, routes or services. The law is at the core of the industry's defense of its prices.
Like North Dakota, though, Montana used insurance regulations to limit the memberships. A 2017 law requires air ambulance subscriptions to be certified by the state's insurance department. As of August, no company had applied for certification — essentially opting out of the state.
Air Methods, one of the nation's largest private air ambulance companies, decided memberships "aren't right for patients," according to Megan Smith, a spokeswoman for the company.
While membership programs promise customers will avoid out-of-pocket expenses, in reality the contractual fine print "isn't as cut and dry," she said in an email.
Patients who sign up for memberships and have private insurance would still receive a bill and then must work through their insurance company's claims, denial and appeal processes.
And while Air Evac's Myers said the AirMedCare Network memberships or subscription fees replace copays and deductibles, Air Method's email highlighted in bold print that "a membership is not necessary" for Medicare patients because federal law prohibits companies from charging more than copays and deductibles. Myers said having a membership offers peace of mind, particularly to those Medicare enrollees who do not have an added supplemental insurance plan that covers transportation.
Also, because the memberships are not officially insurance or a covered benefit, air ambulance companies can end them at any time "without obligation to notify the customer," stated the Air Methods email. This means a patient could believe his or her emergency air transport was taken care of, only to face a rude awakening when the bill came.
Air Methods is the preferred helicopter service for Fort Scott's dispatch service, according to city officials. Yet, Midwest AeroCare operated the helicopter that dropped in during the Good Ol' Days festival.
Midwest AeroCare is part of the AirMedCare Network — not Air Methods. Families like the Andersons were there looking for reassurance that someone would come for them if needed, said Dawn Swisher-Anderson, Kaidence's mom. Her son, Connor, has frequent and severe asthma attacks that require hospitalization.
"It's obviously scary with a young one when he's having breathing complications," Swisher-Anderson said.
Once the helicopter landed, a tall pilot and two crewmembers stepped out and the onlookers quickly formed a line on the grass. Susan Glossip, who brought her grandchildren to see the helicopter, encouraged them to pose for a picture.
Midwest AeroCare representative Angela Warner stood nearby and asked if she could post the picture on the company's Facebook page.
After Glossip said yes, Warner began talking about the membership program emphasizing that "with Fort Scott losing its hospital … having a helicopter be able to fly in can mean the difference between living and dying for some people."
Glossip agreed and asked for a membership brochure.
A month ago, during a visit to her doctor's office in Sequim, Wash., Sue Christensen fell to her knees in the bathroom when her legs suddenly gave out.
The 74-year-old was in an accessible stall with her walker, an older model that doesn't have brakes. On her left side was a grab bar; there was nothing to hold onto on the right.
Christensen tried to pull herself up but couldn't. With difficulty, she rearranged her clothing and, inching forward on her knees, exited the stall. There, she tried calling the front desk on her cellphone but was placed on hold by the automated phone system.
Altogether, Christensen, who has a herniated disk in her back, was on the floor for almost half an hour before a nurse and her husband, who'd been parking the car, lifted her to her feet.
"I just wish there had been a button that I could have pushed indicating that someone in the restroom needs assistance," she said.
For older adults, especially those who are frail, who have impaired cognition, or who have trouble seeing, hearing and moving around, health care facilities can be difficult to navigate and, occasionally, perilous.
Grab bars may not be placed where they're needed. Doors may be too heavy to open easily. Chairs in waiting rooms may lack arms that someone can use to help them stand up.
Toilets may be too low to rise from easily. Examination tables may be too high to get onto. Lettering on signs may be too small to read. And there may not be a place to sit down while walking down a hallway if a break is needed.
"Most hospitals and clinics have been designed for 40- or 50-year-olds, not 70- or 80-year-olds," said Dr. Lee Ann Lindquist, chief of geriatrics at Northwestern University's Feinberg School of Medicine in Chicago. "Additional thought has to be given to seniors who have functional disabilities."
What changes could be made to better accommodate older adults' needs? I asked geriatric specialists and seniors to identify practical issues that should be addressed. Here are a number of suggestions that came up repeatedly.
Parking
Difficulties start in the parking lot, which may not be adjacent to the medical center.
That's the case at Long Island Jewish Medical Center, a large teaching hospital in New Hyde Park, N.Y. Every day, Dr. Maria Torroella Carney, a geriatrician at the hospital, crosses a busy road from the parking lot to the hospital's entrance.
"It's challenging. There isn't clear signage indicating where to cross safely, and if you need to stop and rest there aren't any benches nearby," said Carney, who is also chief of geriatrics at Hofstra/Northwell School of Medicine.
Dr. Michael Wasserman, a California geriatrician on the board of the American Geriatrics Society's Health in Aging Foundation, observed that accessible parking spaces are often in short supply. "Even then, not all older adults who need help have a handicap sticker," he noted.
The University of Florida's Senior Care Clinic has a solution: valet services. "When an older patient comes by themself, if they need help, the valet will call our clinic and someone will come down and take the patient up," said Dr. Bhanuprasad Sandesara, division chief of geriatrics.
Signage
All too often, easy-to-read signs indicating where patients should go can't be found, either inside or outside medical centers. For older patients, this can lead to confusion and unnecessary wandering, accompanied by pain, fatigue and annoyance.
Last year, a committee examining how Long Island Jewish Medical Center should handle patients with special needs (for instance, people with cognitive impairments or hearing or speech problems) identified better signage as a priority.
Now, signs in the parking lot and outside the medical center are bigger, with larger type. Inside the medical center, large signs have been placed at bathrooms, showing clearly if they're accessible to those with disabilities. And the staff is creating a comprehensive map of the hospital campus — a handout — to help patients find their way more easily, according to Roseanne O'Gara-Shubinsky, associate executive director for quality management at Long Island Jewish.
Appointment cards were also altered: Carney persuaded the hospital to print phone numbers in large type on cards for seven geriatricians at its senior clinic.
At Northwestern, Lindquist realized that older patients were having trouble seeing whiteboards in their hospital rooms listing scheduled procedures and the names of physicians and nurses responsible for their care. Upon Lindquist's urging, the hospital bought whiteboards that are more than double the normal size.
Getting Around
At a recent talk in the San Francisco Bay Area to promote her new book, "Elderhood," Dr. Louise Aronson was approached by an older woman who uses a portable oxygen tank to breathe and relies on a rollator walker (with a seat and basket attached).
The woman was new to the area and had been visiting various medical facilities. "Some of these places have ramps, but the angle is so steep I can't push my rollator up," she complained. "Whoever designed them wasn't thinking of someone like me."
At the University of Arkansas for Medical Sciences, Dr. Jeanne Wei, who heads the geriatrics department and the Donald W. Reynolds Institute on Aging, has seen many older adults injure themselves while pushing someone in a wheelchair up an incline. She has insisted that parking lots be on the same level as medical buildings and that sidewalks around facilities be kept in good shape to minimize older adults' risk of falling.
Also, at the University of Arkansas' Thomas and Lyon Longevity Clinic for older adults, examination tables are wider than usual and their height can be adjusted electronically. "Sometimes, it's difficult to navigate lying in a narrow strip" and many older adults are afraid of falling, Wei said.
The staff at Long Island Jewish didn't realize there weren't enough walkers and wheelchairs at the hospital's entrance until the issue came to light during deliberations by the special needs committee. Now, "we've made sure that we have plenty of these available," O'Gara-Shubinsky said.
Something as simple as having a hook to hang up a cane can be a thoughtful touch. "You see this a lot: An older patient sits down, there's nowhere to put a cane, and it falls on the floor," said Dr. Diana Anderson, a geriatric medicine fellow at the University of California-San Francisco, who's also a board-certified architect.
Doors
Diane Ashkenaz, 68, has fibromyalgia, chronic pain and a ruptured tendon. She also has undergone two knee replacements. Most of the time, she uses a walker when she visits doctors in the Washington metropolitan area.
Doors are often a problem. "Neither my primary care doctor nor my orthopedic surgeon have doors to their offices that open automatically," Ashkenaz said.
Not long ago, she said, the staff at a pain clinic's front desk handed her a pen and clipboard and asked, "Can you fill this out please?" How was Ashkenaz supposed to hold those items while finding her way to a chair? No one seemed to realize there was a problem.
At the clinic Sue Christensen visits in Washington, the front doors open wide automatically and a nursing assistant helps her into the exam room. But once her appointment is over, she's directed to an exit door that she must open herself.
"It's pretty heavy and hard to manage while trying to clunk my walker through," Christensen said. "I don't know why they don't have a door system that would be easier for people who don't have much strength or dexterity."
Seats
Ashkenaz has another pet peeve: chairs in waiting rooms with seats that are too low or without arms that she can grab to push herself up into a standing position.
At her cardiologist's office, there's a sofa with deep seats. "It looks nice, but I'd do anything not to sit there," Ashkenaz said. "I just can't get up from it."
Wei's clinic at the University of Arkansas has brought in chairs that are 4 inches taller than usual, with arms, for older patients. "These chairs are always occupied," she said.
Also, exam rooms at the clinic are large enough to accommodate chairs for multiple family members. "We'll bring everyone in to talk about Mom or Dad so they can hear what the other person is saying," Wei said.
We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or suggestions for how medical facilities could become more age-friendly.
Gov. Ralph Northam and the president of the University of Virginia committed to changing UVA Health System's collections practices a day after Kaiser Health News detailed its aggressive and widespread pursuit of former patients for unpaid medical bills.
At the same time, the health system announced the departure of CEO Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president.
Her exit "is in no way related" to the billing and collections problems, James Ryan, UVA's president, said in a message to employees Tuesday.
UVA sued former patients for unpaid bills more than 36,000 times over six years, seeking repayment of over $106 million and often pushing families into onerous payment plans or bankruptcy, according to KHN's investigation, published with The Washington Post.
Both Ryan and Northam expressed ignorance about UVA practices that were an open secret in Charlottesville, with hundreds of medical lawsuits often filed in a week.
Northam "was only just made aware of these practices," said spokeswoman Alena Yarmosky, adding that he "is not involved" in day-to-day university operations.
Northam, a pediatric neurologist who oversees UVA's board and often speaks about the need for affordable health care, said he is "absolutely concerned" about what the health system has been doing.
"I am glad to hear that UVA Health System is in the process of changing their policies and practices," Northam said Tuesday in a prepared statement. He declined to offer remedies or agree to an interview.
Ryan said in a tweet late Monday that he had asked Sutton-Wallace last month to look into collection and litigation practices. KHN informed UVA of its findings Aug. 1.
Fixing the problem "is complicated," in part because "we are legally obligated as a state agency to collect debts," he said. "But we have discretion within those legal constraints to make our system more generous and more humane."
Ryan and Sutton-Wallace also declined interview requests through spokesmen.
The health system is making a "comprehensive review" of its indigent care and financial assistance policies and will announce changes by the end of the week, said spokesman Eric Swensen.
"I learned about our aggressive billing and collection practices within the medical center a little over a month ago," Ryan said in his tweet. "Part of striving to be both a great and good university is honestly facing problems you encounter and doing what you can to address them."
The departure of Sutton-Wallace, named CEO five years ago, leaves the prestigious medical system with two top vacancies. Richard Shannon, executive vice president for health affairs, left in May.
UVA Health System, which is taxpayer-supported and state-funded, is the latest medical center to face withering scrutiny over patient collections as insurance coverage continues to leave consumers financially vulnerable—despite passage of the Affordable Care Act in 2010.
High-deductible health plans, unaffordable premiums, short-term insurance that doesn't cover preexisting illness and narrow provider networks all expose patients to unexpected bills of thousands or hundreds of thousands of dollars.
In recent months, journalists and academics have exposed collections practices in Baltimore, Memphis and New Mexico and at another Virginia hospital. A top federal health care regulator made a pointed reference to the coverage in a speech to hospital executives Tuesday.
"We are learning the lengths to which certain not-for-profit hospitals go to collect the full list price from uninsured patients," Medicare administrator Seema Verma said in a speech before members of the American Hospital Association. "These hospitals are referring patients to debt collectors, garnishing wages, placing liens on property and even suing patients into bankruptcy."
Phil Galewitz and Emmarie Huetteman contributed to this report. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
The force behind the multimillion-dollar effort against banning surprise medical bills is not only medical professionals, but also private equity and venture capital firms.
As proposals to ban surprise medical bills move through Congress and state legislatures with rare bipartisan support, physician groups have emerged as the loudest opponents.
Often led by doctors with the veneer of noble concern for patients, physician-staffing firms — third-party companies that employ doctors and assign them out to health care facilities — have opposed efforts to limit the practice known as balance billing. They claim such bans would rob doctors of their leverage in negotiating, drive down their payments and push them out of insurance networks.
Opponents have been waging well-financed campaigns. Slick TV ads and congressional lobbyists seek to stop legislation that had widespread support from voters. Nearly 40% of patients said they were "very worried" about surprise medical bills, which generally arise when an insured individual inadvertently receives care from an out-of-network provider.
But as lobbyists purporting to represent doctors and hospitals fight the proposals, it has become increasingly clear that the force behind the multimillion-dollar crusade is not only medical professionals, but also investors in private equity and venture capital firms.
In the past eight years, in such fields as emergency medicine and anesthesia, investors have bought and now operate many large physician-staffing companies. And key to their highly profitable business strategy is to not participate in insurance networks, allowing them to send surprise bills and charge patients a price they set — with few limitations.
"We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.
"They have money to burn," said a Democratic congressional aide with knowledge of the lobbying efforts "They're in take-the-bill-down mode."
Private equity firms and the staffing companies they own have a lot to lose, too. While doctors largely once worked for hospitals or had individual contracts, many hospitals now rely on these huge staffing businesses to provide doctors for various departments. Companies like Envision Physician Services and TeamHealth provide doctors to dozens, sometimes hundreds of hospitals. Private equity firms back these ever-growing outsourced staffing companies.
Because patients have no effective way to protect themselves from unexpected medical bills, even knowledgeable, proactive people with comprehensive insurance can find themselves whisked away to an out-of-network hospital in an emergency or treated by an out-of-network anesthesiologist at the in-network hospital they selected.
Several lawmakers have adopted the issue, one seemingly ready-made for campaign season: In fighting surprise bills, they are attacking a practice both reviled by the public and easy to explain.
What's harder to explain is where the money on the other side of the campaign comes from. Coalitions like Physicians for Fair Coverage and dark-money groups with innocuous names like Doctor Patient Unity have flooded the airwaves with ads urging people to call their lawmakers and voice opposition to ending surprise bills. And those lawmakers are overwhelmingly senators facing difficult reelection fights next year, who might be hesitant to vote for change — especially if it means more expensive ad campaigns aimed at taking them down.
To understand the power and size of private equity in the U.S. health care system, one must first understand physician-staffing firms.
Increasingly, hospitals have turned to third-party companies to fill their facilities with doctors. Among driving factors: physician shortages, a bigger insured population because of the Affordable Care Act and an aging population, according to research from the investment firm Harris Williams & Co.
In some areas, doctors have few options but to contract with a staffing service, which hires them out and helps with the billing and other administrative headaches that occupy much of a doctor's time. Staffing companies often have profit-sharing agreements with hospitals, so some of the money from billing patients is passed back to the hospitals.
The two largest staffing firms, EmCare and TeamHealth, together make up about 30% of the physician-staffing market.
That's where private equity comes in. A private equity firm buys companies and passes on the profits they squeeze out of them to the firm's investors. Private equity deals in health care have doubled in the past 10 years. TeamHealth is owned by Blackstone, a private equity firm. Envision and EmCare are owned by KKR, another private equity firm.
With affiliates in every state, these privately owned, profit-driven companies staff emergency rooms, own dialysis facilities and operate physician practices. Research from 2017 shows that when EmCare entered a market, out-of-network billing rates went up between 81 and 90 percentage points. When TeamHealth began working with a hospital, its rates increased by 33 percentage points.
A study by the Kaiser Family Foundation found that 1 in 6 Americans with insurance were surprised by a medical bill after treatment at a hospital in 2017.
That is no coincidence: In many states, balance billing — when a provider charges a patient the difference between their fee and what their insurance company paid — is legal, so physician-staffing services have little incentive to contract with insurance companies and provide in-network doctors.
"These physician-staffing companies are benefiting tremendously from the ability to bill out-of-network," said Zack Cooper, an associate professor of public health at Yale, who has studied physician-staffing firms and balance billing. "It's a small but profitable sliver of the health care system that these firms are using to make pretty significant amounts of money."
Cooper said the business models are built on the ability to get profits from balance billing.
"Private equity firms are buying up physician practices that allow them to bill out-of-network, cloaking themselves in the halo that physicians generally receive and then actively watering down any legislation that would both protect patients but affect their bottom line," Cooper said.
The staffing firm Envision disputed this assessment of its business model. An emailed statement said more than 90% of its business comes from in-network agreements and that the company continues "actively advocating for a federal solution to surprise medical bills."
The two possible solutions on the table in congressional legislation are arbitration and benchmarking.
Arbitration sends the insurers and health care providers through an independent review to determine a fair price in the event of a balance bill.
Under benchmarking, out-of-network physician charges are paid by the patient's health plan based on an average of what other in-network doctors in the area are paid. Money is being spent on all sides of the debate, but for the physicians and private equity firms, it's weighted most heavily on the side of arbitration.
Assorted groups have organized themselves into different coalitions and mega-groups to pool resources for lobbying and ads. On the side of benchmarking, there is the Coalition Against Surprise Medical Billing, made up of employers and insurers like Blue Cross Blue Shield, the Association of Health Insurance Plans and ERIC, which represents large employers.
On the arbitration side, there is Out of the Middle, Physicians for Fair Coverage, SOAR and Doctor Patient Unity, to name a few. Ostensibly, these are composed of doctor and hospital groups.
"It's important that federal legislation to end surprise billing also incentivizes all providers and insurers to negotiate in good faith in order to increase the number of in-network providers and ensure patients' continued access to high-quality medical care," added Megan Taylor, a spokeswoman for Physicians for Fair Coverage.
Yet these groups are dominated by private equity and hedge-fund-backed organizations. Physicians for Fair Coverage is made up of ApolloMD (a staffing firm owned in part by the investment firm ValorBridge), Radiology Partners (a staffing firm owned in part by the investment firm New Enterprise Associates) and a trio of staffing firms called US Acute Care Solutions, US Radiology Specialists and US Anesthesia partners (all partly owned by the investment firm Welsh, Carson, Anderson and Stowe).
Among the groups listed as lobbying on surprise bills are hospital groups like Christus Health (which usesEmCare) and Wellstar Health Systems (which uses ApolloMD). In addition, HCA, a large hospital chain that has had a joint venture with EmCare, has also been active on these issues.
Even the groups that appear to represent independent doctors are tied to private equity and staffing firms. Out of the Middle consists of trade organizations for specialty doctors, like the American College of Emergency Physicians (ACEP) and the American Society of Anesthesiologists and many others. It's mostly run by ACEP, whose immediate past president, Dr. Rebecca Parker, was also a senior vice president at Envision.
Spending on lobbying around this issue has been generous, according to disclosures from the Center for Responsive Politics. The staffing firm Mednax spent $180,000 on lobbying the House and Senate. TeamHealth and TeamHealth Inc. together spent $100,000. Physicians for Fair Coverage spent $145,000. US Physician Partners, an "informal lobbying group" that never lobbied before 2019, spent $130,000.
"There's no way we can match them," said Gelfand, from ERIC. "We're entering this debate knowing we're being horrifically outspent."
Over six years, the state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds.
This article was first published on Tuesday, September 10, 2019 in Kaiser Health News.
Heather Waldron and John Hawley are losing their four-bedroom house in the hills above Blacksburg, Va. A teenage daughter, one of their five children, sold her clothes for spending money. They worried about paying the electric bill. Financial disaster, they say, contributed to their divorce, finalized in April.
Their money problems began when the University of Virginia Health System pursued the couple with a lawsuit and a lien on their home to recoup $164,000 in charges for Waldron's emergency surgery in 2017.
The family has lots of company: Over six years ending in June 2018, the health system and its doctors filed 36,000 lawsuits against patients seeking a total of more than $106 million, seizing wages and bank accounts, putting liens on property and homes and forcing families into bankruptcy, a Kaiser Health News analysis has found.
Unpaid hospital bills are a leading cause of personal debt and bankruptcy across the nation, with hospitals from Memphis to Baltimorecriticized for their role in pushing families over the financial edge. But UVA stands out for the scope of its collection efforts and how persistently it seeks payment, pursuing poor as well as middle-class patients for almost all they're worth.
KHN's findings, based on court records, documents and interviews with hospital officials and dozens of patients, show UVA:
Sued patients for as much as $1 million and as little as $13.91, and garnished thousands of paychecks, largely from workers at lower-pay employers such as Walmart, where UVA took wages more than 800 times.
Seized $22 million over six years in state tax refunds owed to patients with outstanding bills, most of it without court judgments, under a program intended to help state and local governments collect debts.
Sued about 100 patients every year who also happened to be UVA Health System employees and filed thousands of property liens over the years, from Albemarle County all the way to Georgia.
Dunned some former patients an additional 15% for legal costs, plus 6% interest on their unpaid bills, which over years can add up to more than the original bill.
Has the most restrictive eligibility guidelines for patient financial assistance of any major hospital system in Virginia. Savings of only $4,000 in a retirement account can disqualify a family from aid, even if its income is barely above the poverty level.
The hospital ranked No. 1 in Virginia by U.S. News & World Report is taxpayer-supported and state-funded, not a company with profit motives and shareholder demands. Like other nonprofit hospitals, it pays no federal, state or local taxes on the presumption it offers charity care and other community benefits worth at least as much as those breaks. Democratic Gov. Ralph Northam, a pediatric neurologist, oversees its board.
UVA defended the institution's practices as legally required and necessary "to generate positive operating income" to invest in medical education, new facilities, research and the latest technology. They point to the Virginia Debt Collection Act of 1988, which requires state agencies to "aggressively collect" money owed.
"Sending unpaid bills to a collection agency or pursuing a civil claim is a last resort," said UVA Health System spokesman Eric Swensen. Two years ago, he said, the health system limited lawsuits to cases in which patients owe more than $1,000. "For the vast majority of patients, we are able to agree upon workable payment plans without filing a legal claim," he said.
In addition, UVA is "making a comprehensive review" of its charity care rules and "considering policies to provide additional financial assistance to low-income patients not covered by our existing charity care policies," he said.
Swensen declined to discuss individual cases, saying the hospital was bound by patient confidentiality. UVA Health CEO Pamela Sutton-Wallace declined an interview request. A spokeswoman for Northam did not respond to repeated requests for comment.
Though there is no national data on hospital debt collection, UVA's pursuit of patients goes beyond that of a number of institutions. Johns Hopkins Hospital in Baltimore has sued patients 240 times a year on average, according to a May report in The Baltimore Sun. UVA, by comparison, often sues that many former patients in a week and averages more than 6,000 cases annually, court data show.
Private, nonprofit Yale New Haven Health System files liens only if a bill is over $10,000 and then only if the property is worth at least $300,000, a spokesman said. Falls Church, Va.-based Inova Health says it does not file liens on patient homes or garnish wages.
Industry standards are few and vague. The American Hospital Association says its members follow Internal Revenue Service guidelines, which merely require hospitals to have a financial assistance policy and to make "reasonable efforts" to determine whether a patient qualifies for help before initiating collections.
Patients find themselves unable to pay UVA bills for many reasons: They are uninsured or sometimes have short-term coverage that does not pay for treatment of preexisting illnesses. Or they are out-of-network, or have a "high-deductible" plan — increasingly common coverage that can require patients to pay more than $6,000 before insurance kicks in. Virginia's Medicaid expansion, effective this year, covers families with low income but is still projected to leave hundreds of thousands uninsured.
Patients also have trouble because, like many U.S. hospitals, UVA bills people lacking coverage at rates far higher than what insurance companies pay on behalf of members. In addition, experts say such bills often have little connection to the cost of care. Insurers obtain huge discounts off hospital sticker prices — 70% on average in UVA's case, according to documents it files with Medicare.
UVA offers uninsured patients 20% off to start and an additional 15% to 20% if they pay promptly, Swensen said. Few are able to do that. Patients are subject to collections and lawsuits if they do not pay or arrange to do so within four months, he said.
The $164,000 billed to Heather Waldron for intestinal surgery was more than twice what a commercial insurer would have paid for her care, according to benefits firm WellRithms, which analyzed bills for Kaiser Health News using cost reports UVA files with the government. Charges on her bill included $2,000 for a $20 feeding tube.
UVA would not disclose basic information about patient lawsuits, liens and garnishments. Reporters reconstructed the hospital's practices by talking directly with patients, analyzing court documents and hospital bills and observing the legal process in court. They gathered records in Charlottesville, where the UVA Health System is located, to supplement a courts database compiled by the nonprofit Code for Hampton Roads, which works to improve government technology.
The picture that emerges is of a trusted institution whose practices violate its stated public mission, with little accountability or redress for its patients.
Waldron, 38, an insurance agent and former nurse, appreciates the treatment she received for an intestinal malformation that almost killed her. But, she said, "UVA has ruined us."
'Here For A Hospital Case?'
UVA sues so many patients that District Court Judge William Barkley doesn't announce the cases as he takes the bench each Thursday in the historic brick courthouse in Charlottesville. On this day, he waves a thick stack of litigation at defendants, asking, "Is anybody here for a hospital case?" Nobody needs to ask which hospital.
A recent NPR report noted that nonprofit Mary Washington Healthcare, in Fredericksburg, Va., had 300 cases in court in one month. (Following that report the hospital announced that it would suspend the practice of suing patients for unpaid bills.)
Barkley's court often handles 300 UVA suits in a week, data shows.
The court often operates like a UVA billing office. UVA sends collections representatives, not lawyers, who sit near the judge's bench. They give patients two weeks to commit to an interest-free payment plan, according to courtroom meetings witnessed by a reporter. Otherwise, "we're already going to be reviewing it for garnishment," a UVA official tells a car accident victim. With bills often in the tens of thousands of dollars, even the five-year, interest-free plans are unaffordable, patients said.
Swensen said patients in court would have already received "four to five" bills over several months and notifications about potential financial assistance.
Zann Nelson — who is 70, lives in Reva, Va., and was sued by UVA for $23,849 a few years ago — is a rare patient who fought back. Admitted with a newly diagnosed uterine cancer, she was bleeding and in pain when she signed an open-ended payment agreement. In court, she argued it was so vague as to be unenforceable. (C-Ville Weekly, a local paper, wrote about her case in 2014.)
She lost. The judge, according to court records, said that Nelson had "the ability to decline the surgery" if she didn't like the terms of the deal. She lived with a lien on her farm until she managed to pay off the debt.
'Can't Afford To Go Back'
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UVA Medical Center, the flagship of UVA Health System, earned $554 million in profit over the six years ending in June 2018 and holds stocks, bonds and other investments worth $1 billion, according to financial statements. CEO Sutton-Wallace earns a salary of $750,000, with bonus incentives that could push her annual pay close to $1 million, according to a copy of her employment contract, obtained under public information law.
Yet UVA offers financial assistance that's more limited than any other major health system in Virginia, according to an analysis of policies at organizations including Inova, Sentara Healthcare, Riverside Health and Carilion Clinic.
To qualify for help, UVA patients must earn less than 200% of federal poverty guidelines ($34,000 for a couple) and own less than about $3,000 in assets, not counting a house, according to the hospital's website and guidelines UVA files with the state.
Carilion Clinic, by contrast, provides aid to families with income up to 400% of poverty guidelines and assets of less than $100,000, other than a house. If bills at Riverside Health exceed household income over 12 months, the hospital forgives the whole amount.
Sentara slashed lawsuit volume by using software to rule out patients who were unlikely to pay, said spokesman Dale Gauding. "We write off a lot of bad debt rather than put someone through a judgment they can't pay and an additional black mark on their credit," he said.
The only other policy in Virginia similar to UVA's is that of VCU Health, a sister state hospital system with the same income and asset guidelines. In July, VCU started offering help to some patients with "catastrophic" and "prohibitively expensive" bills who don't otherwise qualify, a spokesman said.
"We are considering those updates," Swensen said of VCU's changes. He noted that for the most recent fiscal year UVA approved almost 10,000 applications for charity care. Most of the patients who qualify pay nothing beyond a $6 copay, he said.
UVA sued Carolyn Davis, 55, of Halifax County, for $7,448 to pay for nerve injections to treat back pain that she hadn't realized would be out-of-network.
Her husband is a cook at Hardee's, taking home $500 to $600 a week, she said. UVA refused their application for financial assistance because his Hardee's 401(k) balance of $6,000 makes them too well-off, she said.
"We don't have that kind of money," Davis said. The hospital insisted on a monthly payment of $75. She was meeting it by charging it to her credit card at 22% interest.
Charges for Davis' treatment were about twice what a commercial insurer would have paid, according to an estimate by WellRithms.
Sometimes patients who are prepared to pay cash for UVA treatment find they can't afford the charges. Wayne Williams, 43, of Charlottesville, is a custodian at a community college. He was uninsured but feared he had strep throat last year.
"I thought they were going to give me some antibiotics," he said.
Instead, UVA's emergency department gave him a CT scan, a bill for $6,931 and, when he didn't pay, a lawsuit. UVA did give him a 30% discount based on his financial circumstances, he said — meaning the sore throat would cost about $4,800.
WellRithms calculated that a commercial insurance company would have paid $992 for the care Williams received, which would have covered costs and generated a profit.
Leigh Ann Beach, 37, of Palmyra, experienced how differently hospitals treat those who cannot pay after hurting her ankle in a bike accident.
Rising premiums left her uninsured when she fell off a bike and hurt her ankle last year. Her husband works in construction to provide for their family with seven children. A rainy 2018 washed out working days and his income. They couldn't afford their $667 monthly insurance premium.
Sentara Martha Jefferson Hospital, which first treated her, canceled the entire $4,650 bill in light of her family's income, her paperwork shows. UVA, where she got surgery and metal implants, sued her for $9,505 and rejected her request for financial help.
A UVA representative said she could sell some acreage from her small rural home to pay the bill, she said. She limps and is in pain, but "I can't afford to go back," she said.
Resorting To Bankruptcy
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When Jesse Lynn, 42, of Orange County, bought short-term coverage as a bridge between policies, he and wife Renee didn't realize the plan considered Jesse's old back problems a preexisting illness, and therefore would not pay for treatment.
After back surgery at Culpeper Medical Center, a UVA affiliate, he came out with a bill for about $230,000, Renee Lynn said.
The surgeon reduced his portion of the charges — from $32,000 to $4,500, which they thought was reasonable. They asked for a similar break or a payment delay from UVA. "We are not a lending institution," the billing office told her, she said.
The Lynns decided bankruptcy was their only option.
"I probably see at least a couple a month," said Marshall Slayton, a Charlottesville bankruptcy lawyer, holding up a new file. "This is the third case this week."
UVA said it doesn't foreclose on primary residences. But often a UVA lawsuit leads to home loss because patients' credit is downgraded and they cannot keep up with hospital payment plans and mortgages.
Property liens do give UVA a claim on the equity in patients' homes.
"We see a lot of them," said Tina Merritt, a partner with True North Title in Blacksburg. "And a lot of people don't even know until they go to sell the property."
It took Priti Chati, 62, of Roanoke six years to pay a $44,000 UVA bill for brain surgery and have a home lien removed last year, court records show. She had had a pre-Obamacare policy that did not cover preexisting illness. The health system seized bank funds intended for her daughters' college costs, she said. She sold jewelry and borrowed from friends, eventually paying more than $70,000 including interest, she said.
Paul Baker, 41, of Madison County ran a small lawn service and with his wife owes more than $500,000 for treatment after their truck rolled over. He is grateful to UVA "for saving my life," he said. But he is "frustrated they are ultimately taking my farm" when he sells or dies, a result of UVA's lawsuit.
Indigent Care
Swensen said the medical center gave $322 million in financial assistance and charity care in fiscal 2018. But legal and finance experts said that's not a reliable estimate.
The $322 million "merely indicates the amount they would have charged arbitrarily" before negotiated insurer discounts, said Ge Bai, an accounting and health policy associate professor at the Johns Hopkins Carey Business School.
The figure is "based on customary reporting standards used by hospitals across the U.S.," Swensen said.
Insurers would have paid UVA only $88 million for that care, according to an accounting of unpaid bills presented in September 2018 to the UVA Health board. Even that unpaid figure did not come out of UVA's purse since federal and state governments provided "funding earmarked to cover indigent care" for almost all of it — $83.7 million, according to Bai.
The real, "unfunded" cost of UVA indigent care: $4.3 million, or 1.3% of what it claims, according to the document.
"That's nothing," given how much money UVA makes, Bai said. "Nonprofit hospitals advance their charitable mission primarily through providing indigent care."
The hospital recorded an additional $109 million in uncollectible debts not considered indigent care, the document shows.
Nacy Sexton, who is in his 30s and lives outside Richmond, hoped he might get a break on his medical bills as a student enrolled at Virginia. He was close to graduation in 2015 when he was hospitalized for lupus. After he was unable to cover the reduced bill offered by the hospital, the university blocked his enrollment, a notice he received from student financial services shows.
"The university places enrollment holds on student accounts for many reasons, including unpaid tuition and medical bills," said university spokesman Wesley Hester. This semester the university has "active holds" on 20 students because of unpaid medical center bills, which might or might not block their attendance depending on when the hold was placed, he said.
Sexton still has about $4,000 to go on a bill that he said was more than $30,000 before UVA's discount, a fundraising campaign and other payments. He hopes to re-enroll and finish his degree in education next year.
"When you get sick, why should it affect your education?" he asked.
Shirley Perry was a registered nurse at the medical center who was "so proud of working at UVA," said her mother, Vera Perry. She became chronically ill, lost her job and insurance, and then needed treatment from her former employer. UVA sued her for $218,730 plus $32,809 in legal fees. She died last year at age 51, with a UVA lien on her townhouse. It was auctioned off on Aug. 7 at the Albemarle County Courthouse.
For Heather Waldron, the path from "having everything and being able to buy things and feeling pretty good" to "devastation" began when she learned after her UVA hospitalization that a computer error involving a policy bought on healthcare.gov had led to a lapse in her insurance.
She is now on food stamps and talking to bankruptcy lawyers. A bank began foreclosure proceedings in August on the Blacksburg house she shared with her family. The home will be sold to pay off the mortgage.
She expects UVA to take whatever is left.
Methodology
KHN analyzed Virginia civil case records from both the district and circuit courts from July 2012 through June 2018, based on the date a case was filed. These case records were acquired from Ben Schoenfeld, a volunteer for Code for America, a nonprofit focused on improving government technology. Schoenfeld compiles court records that are available directly from Virginia's court system (from bothcircuit anddistrict courts) and posts them on the website VirginiaCourtData.org.
The Circuit Courts of Alexandria and Fairfax do not use the statewide case management system and are not included in this analysis.
The online circuit court cases do not include the amount for which the plaintiff sued. KHN went to the Albemarle Circuit Court (where most of the UVA circuit cases were filed) and looked up each of over 900 cases by hand to obtain the dollar amount, which totaled over $60 million.
The online district court cases do include a principal amount sought in a "Warrant in Debt" case. However, if the case is settled or dismissed, the principal amount is zero. Therefore, KHN's reporting of the total for which UVA has sued its patients during this period is likely a low estimate.
KHN focused on district cases that were "Warrant in Debt" cases and circuit cases that were "Complaint — Catch-all" or "Contract Action." UVA sues to recover patient debt from all three categories. For cases brought by the University of Virginia, the plaintiff names (as entered by the court) vary widely: "University of Virginia," "Rectors and Visitors of UVA" or just "UVA" are some examples. We included cases that mentioned the UVA Physicians Group and Health Services Foundation (although these were much less prevalent). In some cases, the UVA Medical Center was named specifically; in others, it was not. KHN analyzed cases brought by the university whether or not the case specifically mentioned the medical center, knowing that some cases omit this detail. We took a random sample of 30 "Warrant in Debt" cases from the Albemarle District Court in 2017 that were filed by "Rectors and Visitors" but did not specify the medical center. We looked up the original records at the courthouse; each one was related to the medical center.
KHN also found several 2012 cases filed in the Albemarle Circuit Court by UVA that were not in the public data available online, which suggests that the data is not necessarily complete.
KHN contacted UVA directly on multiple occasions. We filed several public records requests for the number of cases involving medical debt and the total amount sought, as well as the total amount recovered. Each time our request was denied.
SAN FRANCISCO — Economists and researchers long have blamed the high cost of health care in Northern California on the giant medical systems that have gobbled up hospitals and physician practices — most notably Sutter Health, a nonprofit chain with 24 hospitals, 34 surgery centers and 5,000 physicians across the region.
Now, those arguments will have their day in court: A long-awaited class-action lawsuit against Sutter is set to open Sept. 23 in San Francisco Superior Court.
The hospital giant, with $13 billion in operating revenue in 2018, stands accused of violating California's antitrust laws by leveraging its market power to drive out competition and overcharge patients. Health care costs in Northern California, where Sutter is dominant, are 20% to 30% higher than in Southern California, even after adjusting for cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley cited in the complaint.
The case was initiated in 2014 by self-funded employers and union trusts that pay for worker health care. It since has been joined with a similar case brought last year by California Attorney General Xavier Becerra. The plaintiffs seek up to $900 million in damages for overpayments that they attribute to Sutter; under California's antitrust law, the award can be tripled, leaving Sutter liable for up to $2.7 billion.
The case is being followed closely by industry leaders and academics alike.
"This case could be huge. It could be existential," said Glenn Melnick, a health care economist at the University of Southern California. If the case is successful, he predicted, health care prices could drop significantly in Northern California. It also could have a "chilling effect" nationally for large health systems that have adopted similar negotiating tactics, he said.
The case already has proved controversial: In November 2017, San Francisco County Superior Court Judge Curtis E.A. Karnow sanctioned Sutter after finding it had intentionally destroyed 192 boxes of documents sought by plaintiffs, "knowing that the evidence was relevant to antitrust issues." He wrote: "There is no good explanation for the specific and unusual destruction here."
Antitrust enforcement is more commonly within the purview of the Federal Trade Commission and U.S. Department of Justice. "One of the reasons we have such a big problem [with consolidation] is that they've done very little. Enforcement has been very weak," said Richard Scheffler, director of the Nicholas C. Petris Center. From 2010 to 2017, there were more than 800 hospital mergers, and the federal government has challenged just a handful.
"We feel very confident," said Richard Grossman, lead counsel for the plaintiffs. "Sutter has been able to elevate their prices above market to the tune of many hundreds of millions of dollars."
Or, as Attorney General Becerra put it at a news conference unveiling his 2018 lawsuit: "This is a big 'F' deal."
Sutter vigorously denies the allegations, saying its large, integrated health system offers tangible benefits for patients, including more consistent high-quality care. Sutter also disputes that its prices are higher than other major health care providers in California, saying its internal analyses tell a different story.
"This lawsuit irresponsibly targets Sutter's integrated system of hospitals, clinics, urgent care centers and affiliated doctors serving millions of patients throughout Northern California," spokeswoman Amy Thoma Tan wrote in an emailed statement. "While insurance companies want to sell narrow networks to employers, integrated networks like Sutter's benefit patient care and experience, which leads to greater patient choice and reduces surprise out-of-network bills to our patients."
There's no dispute that for years Sutter has worked aggressively to buy up hospitals and doctor practices in communities throughout Northern California. At issue in the case is how it has used that market dominance.
According to the lawsuit, Sutter has exploited its market power by using an "all-or-none" approach to contracting with insurance companies. The tactic — known as the "Sutter Model" — involves sitting down at the negotiating table with a demand: If an insurer wants to include any one of the Sutter hospitals or clinics in its network, it must include all of them. In Sutter's case, several of its 24 hospitals are "must-haves," meaning it would be almost impossible for an insurer to sell an insurance plan in a given community without including those facilities in the network.
"All-or-none" contracting allows hospital systems to demand higher prices from an insurer with little choice but to acquiesce, even if it might be cheaper to exclude some of the system's hospitals that are more expensive than a competitor's. Those higher prices trickle down to consumers in the form of higher premiums.
The California Hospital Association contends such negotiations are crucial for hospitals struggling financially. "It can be a great benefit to small hospitals and rural hospitals that don't have a lot of bargaining power to have a larger group that can negotiate on their behalf," said Jackie Garman, the CHA's legal counsel.
Sutter also is accused of preventing insurers and employers from tiering benefits, a technique used to steer patients to more cost-effective options. For example, an insurer might charge $100 out-of-pocket for a procedure at a preferred surgery center, but $200 at a more expensive facility. In addition, the lawsuit alleges that for years Sutter restricted insurers from sharing information about its prices with employers and workers, making it nearly impossible to compare prices when selecting a provider.
Altogether, the plaintiffs allege, such tactics are anti-competitive and have allowed Sutter to drive up the cost of care in Northern California.
Hospitals in California and other regions across the country have watched the success of such tactics and taken note. "All the other hospitals want to emulate [Sutter] to get those rates," said Anthony Wright, executive director of the advocacy group Health Access.
A verdict that finds such tactics illegal would "send a signal to the market that the way to compete is not to be the next Sutter," said Wright. "You want them to compete instead by providing better quality service at a lower price, not just by who can get bigger and thus leverage a higher price."
Along with damages, Becerra's complaint calls for dismantling the Sutter Model. It asks that Sutter be required to negotiate prices separately for each of its hospitals — and prohibit officials at different hospitals from sharing details of their negotiations. While leaving Sutter intact, the approach would give insurers more negotiating room, particularly in communities with competing providers.
Consolidation in the health care industry is likely here to stay: Two-thirds of hospitals across the nation are part of larger medical systems. "It's very hard to unscramble the egg," said Melnick.
California legislators have attempted to limit the "all or nothing" contracting terms several times, but the legislation has stalled amid opposition from the hospital industry.
Louis Rocco has lived with diabetes for decades but, until he met with a registered dietitian in August, he didn't know eating too much bread was dangerous for him.
"I'm Italian, and I always eat a lot of bread," he said. After two hour-long visits with a dietitian — including a session at his local grocery store in Philadelphia — Rocco, 90, has noticed a difference in his health.
"It's helped bring down my sugar readings," he said of changes in his diet including eating less bread. "I wish I knew I could have had this help years ago."
After getting a referral this summer from his doctor, Rocco learned that Medicare covers personal nutritional counseling for people with diabetes or kidney disease.
The estimated 15 million Medicare enrollees with diabetes or chronic kidney disease are eligible for the benefit, but the federal health insurance program for people 65 and older and some people with disabilities paid for only about 100,000 recipients to get the counseling in 2017, the latest year billing data is available. The data does not include the20 million enrollees in private Medicare Advantage plans.
Health experts say the little-used benefit represents a lost opportunity for beneficiaries to improve their health — and for the program to save money by preventing costly complications from the diseases.
An estimated1 in 4 people 65 and older have diabetes and 1 in 3 have chronic kidney disease. Kidney disease is often a complication of diabetes.
The prevalence of diabetes has risen markedly in the past 20 years and the condition is more common as people age.
Nationwide, there are 100,000 registered dietitians — more than enough to meet demand, said Krista Yoder Latortue, executive director of Family Food in Philadelphia, which employs about 50 dietitians including the one who visited Rocco. Medicare data showed about 3,500 dietitians billed the program for nutritional counseling in 2017.
The problem may be that not enough physicians know about the Medicare benefit. Doctors have to refer patients to a dietitian.
Congress approved the benefit, which began in 2002, after studies found medical nutrition counseling leads to improved health outcomes and fewer complications for older patients. Under the preventive health provisions of the Affordable Care Act, the counseling has been available without out-of-pocket costs to Medicare beneficiaries since 2011.
Medicare pays for three hours of dietary counseling during the first year the benefit is used and two hours in subsequent years. A doctor can appeal to Medicare for additional nutritional therapy if the physician believes it is medically necessary.
Larry Lipman, 70, of Falls Church, Va., said he was shocked to learn he had diabetes earlier this year because he's relatively thin and is an avid cyclist.
When his doctor recommended meeting with a dietitian, he not only said yes but also brought along his wife, who does most of the cooking.
"It was great because I could ask specific questions and get into the nitty-gritty about how I eat, what I eat and when I eat," said Lipman, a retired journalist.
"I've learned I needed to cut down on portion sizes of rice and other things to keep my carbohydrates down," he said. "I'm thinking more about what I eat every time and staying away from Doritos and ice cream."
Doctors shoulder some of the blame for patients not getting dietary counseling by failing to refer them to dietitians.
"It's a lot easier to prescribe a medication than it is to discuss the importance of nutrition and get patients to meet with a registered dietitian," said Dr. Holly Kramer, a Chicago nephrologist and president of the National Kidney Foundation.
"I don't understand how we have this burgeoning obesity and diabetes epidemic and we are not using dietitians in our clinics for all these patients, yet we are paying for all these things that mediate from the disease process such as arthritis, dialysis and amputations," she said.
Jennifer Weis, a registered dietitian in Philadelphia, said the limited hours Medicare covers is frustrating given how difficult it is to change behaviors in older adults.
"It's better than nothing, but in my mind is not sufficient," she said.
Doctors might not be aware of the Medicare option since "it's a challenge to keep up with what is a covered benefit and what is not," said Dr. Michael Munger, chairman of the American Academy of Family Physicians who practices in Overland Park, Kan. He said that many doctors who don't practice with a large health system may not be familiar with dietitians in their community.
For convenience, Munger said, he refers his diabetes patients to a nurse practitioner in his office for nutritional counseling. But only registered dietitians are covered under the Medicare benefit, so his Medicare patients face a copayment for that service.
Nutritional counseling is not the only underused Medicare benefit that can prevent health complications.
Part of the problem, said Yoder Latortue in Philadelphia, is there is a lot of misinformation about whom the public can trust on nutrition advice.
"Everyone eats and everyone has an opinion," Yoder Latortue said.
Lauri Wright, a Jacksonville, Fla., registered dietitian and spokeswoman for the Academy of Nutrition and Dietetics, said the federal Centers for Medicare & Medicaid Services sends out notices to health providers once a year but more information is needed.
About 10,600 registered dietitians have enrolled to treat Medicare patients, a CMS spokeswoman said. She said the agency has been advising health providers about the benefit and promoting it to enrollees on its website and its annual handbook that it sends to beneficiaries.
Still, "I think because only two diseases are covered by Medicare and the rest aren't, it falls off everybody's radar," Wright said.