When a Doctor No Longer Accepts Medicare, Patients Left Holding the Bag

KFF Health News, June 9, 2020

Many primary care doctors have argued that Medicare doesn't reimburse them adequately and requires too much paperwork.

This article was first published on Tuesday, June 9, 2020 in Kaiser Health News.

By Carmen Heredia Rodriguez June 9, 2020

Pneumonia. Heart problems. High cholesterol. Betsy Carrier, 71, and her husband, Don Resnikoff, 79, relied on their primary care doctor in Montgomery County, Maryland, for help managing their ailments.

But after seven years, the couple was surprised when the doctor informed them she was opting out of Medicare, the couple's insurer.

"It's a serious loss," Resnikoff said of their doctor.

Patients can lose doctors for a variety of reasons, including a physician's retirement or when either patient or doctor moves away. But economic forces are also at play. Many primary care doctors have long argued that Medicare, the federal health insurance program for seniors and people with disabilities, doesn't reimburse them adequately and requires too much paperwork to get paid.

These frustrations have prompted some physicians to experiment with converting their practices to more lucrative payment models, such as concierge medicine, in which patients pay a fee upfront to retain the doctor. Patients who cannot afford that arrangement may have to search for a new physician.

The exact number of physicians with concierge practices is unknown, health care experts said. One physician consulting company, Concierge Choice Physicians, estimates that roughly 10,000 doctors practice some form of membership medicine, although it may not strictly apply to Medicare patients.

Shawn Martin, senior vice president of the American Academy of Family Physicians, estimated that fewer than 3% of their 134,000 members use this model but the number is slowly growing.

The move to concierge medicine may be more prevalent in wealthier areas.

Travis Singleton, executive vice president for the medical staffing company Merritt Hawkins, said doctors switching to other payment systems or those charging Medicare patients a higher price for care are likely "in more affluent, well-to-do areas where, frankly, they can get fees."

It is far easier for physicians than hospitals to opt out of taking Medicare patients. Most hospitals have to accept them since they rely on Medicare payments to fund inpatient stays, doctor training and other functions.

The majority of physicians do still accept Medicare, and most people insured by the federal program for seniors and people with disabilities have no problem finding another health care provider. But that transition can be tough, particularly for older adults with multiple medical conditions.

"When transition of care happens, from one provider to another, that trust is often lost and it takes time to build that trust again," said Dr. Fatima Sheikh, a geriatrician and the chief medical officer of FutureCare, which operates 15 rehabilitation and skilled nursing centers in Maryland.

Shuffling doctors also heightens the risk of mishaps.

A study of at least 2,200 older adults published in 2016 found that nearly 4 in 10 were taking at least five medications at the same time. Fifteen percent of them were at risk of drug-to-drug interaction.

Primary care providers mitigate this risk by coordinating among doctors on behalf of the patient, said Dr. Kellie Flood, a geriatrician at the University of Alabama-Birmingham.

"You really need the primary care physicians to serve as the quarterback of the health care team," said Flood. "If that's suddenly lost, there's really not a written document that can sum all that up and just be sent" to the new doctor.

Finding a physician who accepts Medicare depends partly on workforce demographics. From 2010 to 2017, doctors providing primary care services to Medicare beneficiaries increased by 13%, according to the Medicare Payment Advisory Commission (MedPAC), a nonpartisan group that advises Congress.

However, the swell of seniors who qualify for Medicare has outpaced the number of doctors available to treat them. Every day, an estimated 10,000 Americans turn 65 and become eligible for the government program, the Census Bureau reported.

The impact: In 2010, MedPAC reported, there were 3.8 primary care doctors for every 1,000 Medicare enrollees. In 2017, it was 3.5.

Authors of a MedPAC report out last June suggested that the number of available primary care providers could be an overestimate. Their calculation assumed all internal medicine doctors provided these services when, in reality, many specialize in certain medical conditions, or accept only a limited number of Medicare patients into their practices.

But MedPAC concluded seniors are not at a disadvantage finding a doctor.

"We found that beneficiaries have access to clinician services that is largely comparable with (or in some cases better) access for privately insured individuals, although a small number of beneficiaries report problems finding a new primary care doctor," the MedPAC researchers wrote.

The coronavirus outbreak has complicated the ability for many Americans to access care, regardless of their insurer. However, many older patients now have an opportunity to connect with their doctors virtually after the Centers for Medicare & Medicaid Services (CMS) broadened access to telemedicine services under Medicare.

Experts said the long-term effects of the virus on doctors and Medicare remain unknown. But Martin said the shortage of cash that many doctors are experiencing because of the coronavirus epidemic has revealed the shortcomings of how primary care doctors are paid.

"The COVID crisis really brought to life the challenges of fee for service," said Martin.
Despite these challenges, the number of doctors choosing to opt out of Medicare has been on the decline, according to data from CMS.

Singleton, of Merritt Hawkins, said concern about doctors leaving the Medicare system is part of larger workforce issues. Those include the need to recruit more medical students to concentrate on primary care.

One estimate predicts the nation will face a shortage of 23,600 primary care physicians by 2025. The majority of residents in internal medicine ― those who care for adults — are choosing a subspecialty such as cardiac care or gastroenterology, MedPAC reported.

In 2017, MedPAC reported, the median compensation for all doctors was $300,000 a year. Among primary care doctors, it was $242,000.

Creative business models can make up that difference. Under the concierge model, the doctor charges patients an annual fee — akin to a gym membership ― to access their practice. The provider still bills the insurer ― including Medicare — for all patient care.

Another model ― called direct primary care — charges the patient an annual fee for access and care; doctors do not bill health insurance plans.

Proponents say that the model enables them to take more time with their patients without dealing with the bureaucracy of getting paid by health insurers.

"I think what is most attractive to direct primary care is that they just practice medicine," Martin said.

The size of a physician practice can also determine whether it accepts Medicare. Large practices can better offset the lower Medicare payment rates by leveraging their influence with private insurers to raise those reimbursements, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. But small, independent clinics may not have the same clout.

"If you're a large primary care practice, private insurers are really going to want to have you in their network," he said. "And they're willing to pay more than they might pay an individual solo practitioner who they're not as concerned [with] because it's only one physician."

Luckily, after more than a dozen calls to physicians, Carrier and Resnikoff said they found another primary care doctor. They said she accepts Medicare and impressed them during their meet-and-greet with her knowledge of their medical history. She also met their criteria for age and expertise.

"At this point in our lives, I'd be eager to find somebody who's young enough that they might be in practice for the next 10 years," Carrier said.

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

Rapid Changes to Health System Spurred By COVID Might Be Here to Stay

KFF Health News, June 8, 2020

But the COVID-19 pandemic has forced sudden major changes to the nation's health care system that are unlikely to be reversed.

This story was first published on Monday, June 8, 2020 in Kaiser Health News.

By Julie Rovner June 8, 2020

The U.S. health care system is famously resistant to government-imposed change. It took decades to create Medicare and Medicaid, mostly due to opposition from the medical-industrial complex. Then it was nearly another half-century before the passage of the Affordable Care Act.

But the COVID-19 pandemic has done what no president or social movement or venture capitalist could have dreamed of: It forced sudden major changes to the nation's health care system that are unlikely to be reversed.

"Health care is never going back to the way it was before," said Gail Wilensky, a health economist who ran the Medicare and Medicaid programs for President George H.W. Bush in the early 1990s.

Wilensky is far from the only longtime observer of the American health care system to marvel at the speed of some long-sought changes. But experts warn that the breakthroughs may not all make the health system work better, or make it less expensive.

That said, here are three trends that seem likely to continue.Bottom of Form

Telehealth For All

Telehealth is not new; medical professionals have used it to reach patients in rural or remote settings since the late 1980s.

But even while technology has made video visits easier, it has failed to reach critical mass, largely because of political fights. Licensing has been one main obstacle – determining how a doctor in one state can legally treat a patient in a state where the doctor is not licensed.

The other obstacle, not surprisingly, is payment. Should a video visit be reimbursed at the same rate as an in-person visit? Will making it easier for doctors and other medical professionals to use telehealth encourage unnecessary care, thus driving up the nation's $3.6 trillion health tab even more? Or could it replace care once provided free by phone?

Still, the pandemic has pushed aside those sticking points. Almost overnight, by necessity, every health care provider who can is delivering telemedicine. A new survey from Gallup found the number of patients reporting "virtual" medical visits more than doubled, from 12% to 27%, from late March to mid-May. That is due, at least in part, to Medicare having made it easier for doctors to bill for virtual visits.

It's easy to see why many patients like video visits ― there's no parking to find and pay for, and it takes far less time out of a workday than going to an office.

Doctors and other practitioners seem more ambivalent. On one hand, it can be harder to examine a patient over video and some services just can't be done via a digital connection. On the other hand, they can see more patients in the same amount of time and may need less support staff and possibly smaller offices if more visits are conducted virtually.

Of course, telemedicine doesn't work for everyone. Many areas and patients don't have reliable or robust broadband connections that make video visits work. And some patients, particularly the oldest seniors, lack the technological skills needed to connect.

Primary Care Doctors In Peril

Another trend that has suddenly accelerated is worry over the nation's dwindling supply of primary care doctors. The exodus of practitioners performing primary care has been a concern over the past several years, as baby boomer doctors retire and others have grown weary of more and more bureaucracy from government and private payers. Having faced a difficult financial crisis during the pandemic, more family physicians may move into retirement or seek other professional options.

At the same time, fewer current medical students are choosing specialties in primary care.

"I've been trying to raise the alarm about the kind of perilous future of primary care," said Farzad Mostashari, a top Health and Human Services Department official in the Obama administration. Mostashari runs Aledade, a company that helps primary care doctors make the transition from fee-for-service medicine to new payment models.

The American Academy of Family Physicians reports that 70% of primary care physicians are reporting declines in patient volume of 50% or more since March, and 40% have laid off or furloughed staff. The AAFP has joined other primary care and insurance groups in asking HHS for an infusion of cash.

"This is absolutely essential to effectively treat patients today and to maintain their ongoing operations until we overcome this public health emergency," the groups wrote.

One easy way to help keep primary care doctors afloat would be to pay them not according to what they do, but in a lump sum to keep patients healthy. This move from fee-for-service to what's known as capitation or value-based care has unfolded gradually and was championed in the Affordable Care Act.

But some experts argue it needs to happen more quickly and they predict that the coronavirus pandemic could finally mark the beginning of the end for doctors who still charge for each service individually. Mostashari, who spends his time helping doctors make the transition, said in times like these, it would make more sense for primary care doctors to have "a steady monthly revenue stream, and [the doctor] can decide the best way to deliver that care. Unlimited texts, phone calls, video calls. The goal is to give you satisfactory outcomes and a great patient experience."

Still, many physicians, particularly those in solo or small practices, worry about the potential financial risk ― particularly the possibility of getting paid less if they don't meet certain benchmarks that the doctors may not be able to directly control.

But with many practices now ground to a halt, or just starting to reopen, those physicians who get paid per patient rather than per service are in a much better position to stay afloat. That model may be gain traction as doctors ponder the next pandemic, or the next wave of this one.

Hospitals On The Decline?

The pandemic also might lead to less emphasis on hospital-based care. While hospitals in many parts of the country have obviously been full of very sick COVID patients, they have closed down other nonemergency services to preserve supplies and resources to fight the pandemic. People with other ailments have stayed away in droves even when services were available, for fear of catching something worse than what they already have.

Many experts predict that care won't just snap back when the current emergency wanes. Dr. Mark Smith, former president of the California Health Care Foundation, said among consumers, a switch has been flipped. "Overnight it seems we've gone from high-touch to no-touch."

Which is not great for hospitals that have spent millions trying to attract patients to their labor-and-delivery units, orthopedic centers and other parts of the facility that once generated lots of income.

Even more concerning is that hospitals' ability to weather the current financial shock varies widely. Those most in danger of closing are in rural and underserved areas, where patients could wind up with even less access to care that is scarce already.

All of which underscores the point that not all these changes will necessarily be good for the health system or society. Financial pressures could end up driving more consolidation, which could push up prices as large groups of hospitals and doctors gain more bargaining clout.

But the changes are definitely happening at a pace few have ever seen. Said Wilensky, "When you're forced to find different ways of doing things and you find out they are easier and more efficient, it's going to be hard to go back to the old way."

Julie Rovner: jrovner@kff.org, @jrovner

Exclusive: Nearly 600 — And Counting — US Health Workers Have Died Of COVID-19

KFF Health News, June 8, 2020

The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers.

This story was first published on Saturday, June 6, 2020 in Kaiser Health News.

By Christina Jewett and Melissa Bailey and Danielle Renwick, The Guardian  

Nearly 600 front-line health care workers appear to have died of COVID-19, according to Lost on the Frontline, a project launched by The Guardian and KHN that aims to count, verify and memorialize every health care worker who dies during the pandemic.

The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers, who have put their own lives at risk during the pandemic to help care for others. Lost on the Frontline has now published the names and obituaries for more than 100 workers.

A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander. Profiles of more victims, and an updated count, will be added to our news sites twice weekly going forward.

There is no other comprehensive accounting of U.S. health care workers' deaths. The Centers for Disease Control and Prevention has counted 368 COVID deaths among health care workers, but

The Guardian and KHN are building an interactive, public-facing database that will also track factors such as race and ethnicity, age, profession, location and whether the workers had adequate access to protective gear. The database — to be released this summer — will offer insight into the workings and failings of the U.S. health care system during the pandemic.

In addition to tracking deaths, Lost on the Frontline reports on the challenges health care workers are facing during the pandemic. Many were forced to reuse masks countless times amid widespread equipment shortages. Others had only trash bags for protection. Some deaths have been met with employers' silence or denials that they were infected at work.

The number released today reflects the 586 names currently in the Lost on the Frontline internal database, which have been collected from family members, friends and colleagues of the deceased, health workers unions, media reports, unions, among other sources. Reporters at KHN and The Guardian are independently confirming each death by contacting family members, employers, medical examiners and others before publishing names and obituaries on our sites. More than a dozen journalists across two newsrooms — as well as student journalists ― are involved in the project.

Many of the health care workers included here studied physiology and anatomy for years. They steeled themselves against the long hours they'd endure. Emergency medical technicians raced by ambulance to help. Others did the cleanup, maintenance, security or transportation jobs needed to keep operations running smoothly.

They undertook their work with passion and dedication. They were also beloved spouses, parents, friends, military veterans and community activists.

None started 2020 knowing that simply showing up to work would expose them to a virus that would kill them.

This project aims to capture the human stories, compassion and heroism behind the statistics. Among those lost were Dr. Priya Khanna, a nephrologist, who continued to review her patients' charts until she was put on a ventilator. Her father, a retired surgeon, succumbed to the disease just days after his daughter.

Susana Pabatao, one of thousands of Philippine health providers in the United States, became a nurse in her late 40s. Susana died just days after her husband, Alfredo, who was also infected with COVID-19.

Dr. James Goodrich, a renowned pediatric neurosurgeon, acclaimed for separating conjoined twins, was also remembered as a renaissance man who collected antique medical books, loved fine wines and played the didgeridoo.

Some of the first to die faced troubling conditions at work. Rose Harrison, 60, a registered nurse, wore no mask while taking care of a COVID-19 patient at an Alabama nursing home, according to her daughter. She felt pressured to work until the day she was hospitalized. The nursing home did not respond to requests for comment.

Thomas Soto, 59, a Brooklyn radiology clerk faced delays in accessing protective gear, including a mask, even as the hospital where he worked was overwhelmed with COVID-19 patients, his son said. The hospital did not respond to requests for comment.

The Lost on the Frontline team is documenting other worrying trends. Health care workers across the U.S. said failures in communication left them unaware they were working alongside people infected with the virus. And occupational safety experts raised alarms about CDC guidance permitting workers treating COVID patients to wear surgical masks ― which are far less protective than N95 masks.

The Occupational Safety and Health Administration, the federal agency responsible for protecting workers, has launched dozens of fatality investigations into health workers' deaths. But recent agency memos raise doubts that many employers will be held responsible for negligence.

As public health guidelines have largely prevented traditional gatherings of mourners, survivors have found new ways to honor the dead: In Manhattan, a medical resident played a violin tribute for a fallen co-worker; a nurses union placed 88 pairs of shoes outside the White House commemorating those who had died among their ranks; fire departments have lined up trucks for funeral processions and held "last call" ceremonies for EMTs.

The Lost on the Frontline death toll includes only health care workers who were potentially exposed while caring for or supporting COVID-19 patients. It does not, for example, include retired doctors who died from the virus but were not working during the pandemic.

The number of reported deaths is expected to grow. But as reporters work to confirm each case, individual deaths may not meet our criteria for inclusion — and, therefore, may be removed from our count.

You can read our first 100 profiles here. And if you know of a health care worker who died of COVID-19, please share their story with us.

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

Melissa Bailey: @mmbaily

Nearly 600 — And Counting — U.S. Health Workers Have Died Of COVID-19

KFF Health News, June 6, 2020

A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander.

By Christina Jewett and Melissa Bailey and Danielle Renwick, The Guardian

Nearly 600 front-line health care workers appear to have died of COVID-19, according to Lost on the Frontline, a project launched by The Guardian and KHN that aims to count, verify and memorialize every health care worker who dies during the pandemic.

The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers, who have put their own lives at risk during the pandemic to help care for others. Lost on the Frontline has now published the names and obituaries for more than 100 workers.

A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander. Profiles of more victims, and an updated count, will be added to our news sites twice weekly going forward.

There is no other comprehensive accounting of U.S. health care workers’ deaths. The Centers for Disease Control and Prevention has counted 368 COVID deaths among health care workers, but acknowledges its tally is an undercount. The CDC does not identify individuals.

The Guardian and KHN are building an interactive, public-facing database that will also track factors such as race and ethnicity, age, profession, location and whether the workers had adequate access to protective gear. The database — to be released this summer — will offer insight into the workings and failings of the U.S. health care system during the pandemic.

In addition to tracking deaths, Lost on the Frontline reports on the challenges health care workers are facing during the pandemic. Many were forced to reuse masks countless times amid widespread equipment shortages. Others had only trash bags for protection. Some deaths have been met with employers’ silence or denials that they were infected at work.

The number released today reflects the 586 names currently in the Lost on the Frontline internal database, which have been collected from family members, friends and colleagues of the deceased, health workers unions, media reports, unions, among other sources. Reporters at KHN and The Guardian are independently confirming each death by contacting family members, employers, medical examiners and others before publishing names and obituaries on our sites. More than a dozen journalists across two newsrooms — as well as student journalists ― are involved in the project.

Many of the health care workers included here studied physiology and anatomy for years. They steeled themselves against the long hours they’d endure. Emergency medical technicians raced by ambulance to help. Others did the cleanup, maintenance, security or transportation jobs needed to keep operations running smoothly.

They undertook their work with passion and dedication. They were also beloved spouses, parents, friends, military veterans and community activists.

None started 2020 knowing that simply showing up to work would expose them to a virus that would kill them.

This project aims to capture the human stories, compassion and heroism behind the statistics. Among those lost were Dr. Priya Khanna, a nephrologist, who continued to review her patients’ charts until she was put on a ventilator. Her father, a retired surgeon, succumbed to the disease just days after his daughter.

Susana Pabatao, one of thousands of Philippine health providers in the United States, became a nurse in her late 40s. Susana died just days after her husband, Alfredo, who was also infected with COVID-19.

Dr. James Goodrich, a renowned pediatric neurosurgeon, acclaimed for separating conjoined twins, was also remembered as a renaissance man who collected antique medical books, loved fine wines and played the didgeridoo.

Some of the first to die faced troubling conditions at work. Rose Harrison, 60, a registered nurse, wore no mask while taking care of a COVID-19 patient at an Alabama nursing home, according to her daughter. She felt pressured to work until the day she was hospitalized. The nursing home did not respond to requests for comment.

Thomas Soto, 59, a Brooklyn radiology clerk faced delays in accessing protective gear, including a mask, even as the hospital where he worked was overwhelmed with COVID-19 patients, his son said. The hospital did not respond to requests for comment.

The Lost on the Frontline team is documenting other worrying trends. Health care workers across the U.S. said failures in communication left them unaware they were working alongside people infected with the virus. And occupational safety experts raised alarms about CDC guidance permitting workers treating COVID patients to wear surgical masks ― which are far less protective than N95 masks.

The Occupational Safety and Health Administration, the federal agency responsible for protecting workers, has launched dozens of fatality investigations into health workers’ deaths. But recent agency memos raise doubts that many employers will be held responsible for negligence.

As public health guidelines have largely prevented traditional gatherings of mourners, survivors have found new ways to honor the dead: In Manhattan, a medical resident played a violin tribute for a fallen co-worker; a nurses union placed 88 pairs of shoes outside the White House commemorating those who had died among their ranks; fire departments have lined up trucks for funeral processions and held “last call” ceremonies for EMTs.

The Lost on the Frontline death toll includes only health care workers who were potentially exposed while caring for or supporting COVID-19 patients. It does not, for example, include retired doctors who died from the virus but were not working during the pandemic.

The number of reported deaths is expected to grow. But as reporters work to confirm each case, individual deaths may not meet our criteria for inclusion — and, therefore, may be removed from our count.

You can read our first 100 profiles here. And if you know of a health care worker who died of COVID-19, please share their story with us.

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.

Tear-Gassing Protesters During An Infectious Outbreak 'A Recipe For Disaster'

KFF Health News, June 6, 2020

Their widespread use in recent weeks while an infectious disease — for which there is no vaccine — continues to spread across the U.S., has stunned experts and physicians.

This article was first published on Friday, June 5, 2020 in Kaiser Health News.

By Will Stone

In nationwide demonstrations sparked by the killing of George Floyd in police custody, protesters have been frequently pepper-sprayed or enveloped in clouds of tear gas. These crowd-control weapons are rarely lethal, but in the middle of the coronavirus pandemic, there are strong calls for police to stop using these chemical irritants because they can damage the body in ways that can spread the coronavirus and increase the severity of COVID-19.

Even before the coronavirus pandemic, some experts said additional research was needed on the risks of tear gas — an umbrella term for several chemical “riot-control agents” used by law enforcement. It’s known that the chemicals can have both immediate and long-term health effects.

Their widespread use in recent weeks while an infectious disease — for which there is no vaccine — continues to spread across the U.S., has stunned experts and physicians. The coronavirus that causes the disease COVID-19 is highly contagious, spreads easily through the air via droplets, and can lead to severe or fatal respiratory illness. Deploying these corrosive, inhalable chemicals could harm people in several ways: exposing more people to the virus, compromising the body’s ability to fight off the infection and even causing mild infections to become more severe illnesses.

“This is a recipe for disaster,” said associate professor Sven Eric Jordt, a researcher at the Duke University School of Medicine who studies the effects of tear gas.

Jordt refers to these chemicals as “pain gases” because they activate certain pain-sensing nerves on the skin and in the mucous membranes of the eyes, mouth and nose.

“You have this excruciating pain, sneezing, coughing, the production of a lot of mucus that obstructs breathing,” Jordt said.

People who have been exposed describe a burning and stinging sensation, even a sense of asphyxiation and drowning. Sometimes the chemicals cause vomiting or allergic reactions. In law enforcement, officers generally use two types of chemicals for crowd control: CS gas and pepper spray.

The active ingredient in pepper spray, called capsaicin, is derived from chiles. It is often sprayed from cans at close quarters or lobbed into crowds in the form of “pepper balls.”

CS gas (o‐chlorobenzylidene malononitrile) is a chlorinated, organic chemical that can induce “very strong inflammation” and “chemical injury” by burning the skin and airways when inhaled, Jordt said.

“Using it in the current situation with COVID-19 around is completely irresponsible,” he added. “There are sufficient data proving that tear gas can increase the susceptibility to pathogens, to viruses.”

Jordt said research on the harms of tear gas has not kept up with its escalating use in the U.S and around the world in recent years. Many of the safety studies that law enforcement officials rely on date to the 1950s and ’60s, he said.

But a 2014 study from the U.S. Army offers an alarming glimpse into how the chemical could escalate the pandemic. The study found that recruits who were exposed to tear gas as part of a training exercise were more likely to get sick with respiratory illnesses like the common cold and the flu.

“We have a lot of antiviral defenses that can inactivate viruses and prevent them from entering cells,” he said. “These are depleted by inhalation of tear gas and also compromised.”

The findings of the Army study led the U.S. military to significantly reduce how much recruits were being exposed to the chemical.

“Even the Army realized they had done something wrong and that this was more toxic than they thought before,” Jordt said.

Even though there is a limited amount of research on this new coronavirus, there are studies from China and Italy about how other irritants, such as smoking and air pollution, affect COVID-19. These studies indicate that tear gas could also make people more likely to develop severe illness, said Dr. John Balmes, a pulmonologist at the University of California-San Francisco and an expert with the American Thoracic Society.

“I actually think we could be promoting COVID-19 by tear-gassing protesters,” said Balmes. “It causes injury and inflammation to the lining of the airways.”

Balmes said this period of inflammation sets back the body’s defenses, and makes it more likely that someone who already harbors the virus will become sick.

“It’s adding fuel to the fire,” said Balmes. “These exposures to tear gas would increase the risk of progression from the asymptomatic infection, to a symptomatic disease.”

Growing evidence shows many people who have the coronavirus are asymptomatic and don’t know they are infected, or are “presymptomatic” — infected with the virus and able to infect others, but not yet showing symptoms.

With thousands of people jammed together at mass protests, the demonstrations are already primed to be “superspreading events,” which can lead to an explosion of new cases. Outdoor gatherings typically decrease the chance of spreading the coronavirus. But activities like singing and yelling can increase the risk.

Tear gas and pepper spray can also sow confusion and panic in a crowd. People may rip off their masks and touch their faces, leading to more contamination.

Dr. Amesh Adalja, with Johns Hopkins University, said the body’s reaction to the chemicals causes people to shed more of the virus.

“If they’re coughing, the particles actually emanate and are projectiles that travel about 6 feet or so and could land on other people,” said Adalja, who is also a spokesperson for the Infectious Diseases Society of America.

“This is a way to almost induce the virus to be expelled from people when they are exposed to these agents.”

Adalja anticipates the protests will inevitably lead to a spike in infections.

“We know that any kind of social unrest, especially in the midst of an outbreak, is only going to make things worse,” he said.

He said the most recent example would be bombings in Yemen that exacerbated a cholera outbreak.

Dr. Rohini Haar, an emergency physician in Oakland, California, has studied the use of riot-control agents around the world.

“These weapons don’t actually deescalate tensions in peaceful community policing,” said Haar who is a lecturer at the University of California-Berkeley.

Haar has also been treating COVID-19 patients. She recognizes there is a danger of spreading the virus at these gatherings, but she would not discourage people from attending the protests and exercising their right to free speech.

“It’s a really tough situation,” said Haar. “I think the irony is that people are rightfully and justifiably protesting police violence and are being met with violence that is worsening the pandemic conditions we’re living under right now.”

This week, more than a thousand physicians and health care professionals signed an open letter in support of the demonstrations.

Dr. Jade Pagkas-Bather, an infectious disease expert at the University of Chicago, is one of them. She said it will be difficult to determine whether any spike in cases was a direct result of the protests, because they’re happening at a time when many states are also allowing businesses to reopen.

“In everyday life, we weigh the risks and benefits of our actions. People who are going out to protests are clearly at a critical juncture where they are saying this state-sanctioned violence is unacceptable, and I am willing to put myself and others potentially at risk,” she said.

The open letter she signed recommends ways that protesters, police and local officials can reduce the transmission of the virus. Among the major recommendations: Police should not use tear gas or pepper spray.

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.

Efforts To Curb Congenital Syphilis Falter In COVID's Shadow

KFF Health News, June 4, 2020

A new report, released Thursday by the federal Centers for Disease Control and Prevention, aims to pinpoint the reasons so many women aren’t getting the care they need.

This article was first published on Thursday, June 4, 2020 in Kaiser Health News.

By Anna Maria Barry-Jester

U.S. public health officials are closer to identifying a road map for curbing the rising rates of syphilis infections in newborn babies, but with so many resources diverted to stopping the spread of COVID-19, many fear the rate of deadly infections will only get worse.

Congenital syphilis — the term used when a mother passes the infection to her baby during pregnancy — is often a devastating legacy, potentially leaving babies blind or in excruciating pain or with bone deformities, blood abnormalities or organ damage. It’s one of the most preventable infectious diseases, experts say. Prevention, which means treating Mom so she doesn’t pass it on to her baby, requires just a few shots of penicillin.

Yet rates of infection and death from congenital syphilis have been on the rise for years. In 2018, 1,306 babies acquired syphilis from their mothers, a 40% increase over 2017 and the largest number since 1995. Nearly 100 were stillborn or died soon after birth. Federal researchers say 2019 data will show yet another jump.

A new report, released Thursday by the federal Centers for Disease Control and Prevention, aims to pinpoint the reasons so many women aren’t getting the care they need. It found that nationally 28% of women who gave birth to a baby with syphilis in 2018 had no prenatal care and weren’t tested in time for treatment. Nearly a third of the mothers were diagnosed but didn’t receive timely or thorough treatment.

How women slip through the cracks of the public health system varies by race and geography. Syphilis rates are highest in the South and West but have been rising across the nation, particularly in rural areas of the Midwest and West.

The burden of the disease falls disproportionately on African American women and families. Nearly 40% of moms who gave birth to babies with syphilis in 2018 were black, even though they made up about 15% of deliveries.

“That falls on public health as an institution,” said Matthew Prior, communications director for the National Coalition of STD Directors. “We need to think about why we do what we do, and we need to hear from the voices we are trying to serve.”

The CDC researchers identified four core reasons that mothers who gave birth to babies with syphilis weren’t treated: lack of prenatal care; prenatal care that did not include testing; improper treatment after a positive diagnosis; and getting infected during pregnancy.

In the South, a lack of prenatal care was the most common reason white women who gave birth to infected babies didn’t get treatment, while black women tended to have been diagnosed but not treated. In the West, 41% of women of all races who gave birth to infected babies had no prenatal care.

The CDC study provides clues for how to prevent infections, but taking advantage of that information will be a challenge for many local health departments. The COVID-19 pandemic has strained the nation’s frayed public health system.

In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services.

“COVID-19 is an obstacle to a lot of the interventions that we will try to roll out,” said Rebekah Horowitz, a senior program analyst with the National Association of County and City Health Officials (NACCHO).

In mid-March, the National Coalition of STD Directors surveyed a panel of its members; 83% of responding STD programs said they had deferred services. Nearly two-thirds said they cannot keep up with their HIV and syphilis caseloads.

“A lot of our enhancement projects have been scaled back,” said Amanda Reich, congenital syphilis coordinator for Texas. “Our staff are doing the best that they can do.”

Shuttered clinics and delayed prenatal care — yet another consequence of COVID-related shutdowns — are likely to exacerbate rates of congenital syphilis and sexually transmitted diseases in general. Testing for syphilis is key since there’s often a lag between contracting the disease and developing symptoms, said Dr. Anne Kimball, a pediatrician in the Epidemic Intelligence Service of the CDC and lead author of the study. “You can have it and give it to your unborn child without knowing you have it,” she said.

Because syphilis is so easy to test for, treat and prevent, it’s often seen as the canary in the coal mine, signaling a warning about what’s happening with other infectious diseases. Cases of syphilis, gonorrhea and chlamydia combined reached an all-time national high in 2018.

“It is a symptom of under-supporting public health and STD programs for decades,” Prior said. “It’s not surprising.”

Even before the global coronavirus pandemic, many health departments around the country were working with bare-bones staffing and aggressively tracking and treating syphilis only among pregnancy-age women. Men who have sex with men have the highest rate of the disease nationally.

Arkansas reorganized its disease investigation unit after a spike in cases in 2018, assigning one person to follow up with all pregnant women with syphilis, said Brandi Roberts, the state’s STD Prevention Program Manager. She said the reorganization has been successful, and even as resources have been redeployed to COVID-19, that employee’s assignment hasn’t changed. But like many states, Arkansas has seen a decrease in reported STD cases, which Roberts believes is likely a sign of reduced testing, not a drop in cases.

NACCHO and the CDC are helping to fund and evaluate programs at six health departments — ranging from New York City to rural Tulare County, California — that they hope will offer further clues for how to curb the spread of disease.

But their success will rely on resources, said Horowitz.

“This was true two years ago, it is true now, and it will be true in the future: These missed opportunities will continue as long as we are not investing in a robust way in our public health infrastructure,” she said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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.

In Hard-Hit Areas, COVID's Ripple Effects Strain Mental Health Care Systems

KFF Health News, June 4, 2020

The pandemic enveloping the hospitals had a ripple effect on mental health programs and facilities.

This article was first published on Thursday, June 4, 2020 in Kaiser Health News.

By Cheryl Platzman Weinstock June 4, 2020

In late March, Marcell's girlfriend took him to the emergency room at Henry Ford Wyandotte Hospital, about 11 miles south of Detroit.

"I had [acute] paranoia and depression off the roof," said Marcell, 46, who asked to be identified only by his first name because he wanted to maintain confidentiality about some aspects of his illness.

Marcell's depression was so profound, he said, he didn't want to move and was considering suicide.

"Things were getting overwhelming and really rough. I wanted to end it," he said.

Marcell, diagnosed with schizoaffective disorder seven years ago, had been this route before but never during a pandemic. The Detroit area was a coronavirus hot spot, slamming hospitals, attracting concerns from federal public health officials and recording more than 1,000 deaths in Wayne County as of May 28. Michigan ranks fourth among states for deaths from COVID-19.

The crisis enveloping the hospitals had a ripple effect on mental health programs and facilities. The emergency room was trying to get non-COVID patients out as soon as possible because the risk of infection in the hospital was high, said Jaime White, director of clinical development and crisis services for Hegira Health, a nonprofit group offering mental health and substance abuse treatment programs. But the options were limited.

Still, the number of people waiting for beds at Detroit's crisis centers swelled. Twenty-three people in crisis had to instead be cared for in a hospital.

This situation was hardly unique. Although mental health services continued largely uninterrupted in areas with low levels of the coronavirus, behavioral health care workers in areas hit hard by COVID-19 were overburdened. Mobile crisis teams, residential programs and call centers, especially in pandemic hot spots, had to reduce or close services. Some programs were plagued by shortages of staff and protective supplies for workers.

At the same time, people battling mental health disorders became more stressed and anxious.

"For people with preexisting mental health conditions, their routines and ability to access support is super important. Whenever additional barriers are placed on them, it could be challenging and can contribute to an increase in symptoms," said White.

After eight hours in the emergency room, Marcell was transferred to COPE, a community outreach program for psychiatric emergencies for Wayne County Medicaid patients.

"We try to get patients like him into the lowest care possible with the least restrictive environment," White said. "The quicker we could get him out, the better."

Marcell was stabilized at COPE over the next three days, but his behavioral health care team couldn't get him a bed in one of two local residential crisis centers operated by Hegira. Social distancing orders had reduced the beds from 20 to 14, so Marcell was discharged home with a series of scheduled services and assigned a service provider to check on him.

However, Marcell's symptoms ― suicidal thoughts, depression, anxiety, auditory hallucinations, poor impulse control and judgment ― persisted. He was not able to meet face-to-face with his scheduled psychiatrist due to the pandemic and lack of telehealth access. So, he returned to COPE three days later. This time, the staff was able to find him a bed immediately at a Hegira residential treatment program, Boulevard Crisis Residential in Detroit.

Residents typically stay for six to eight days. Once they are stabilized, they are referred elsewhere for more treatment, if needed.

Marcell ended up staying for more than 30 days. "He got caught in the pandemic here along with a few other people," said Sherron Powers, program manager. "It was a huge problem. There was nowhere for him to go."

Marcell couldn't live with his girlfriend anymore. Homeless shelters were closed and substance abuse programs had no available beds.

"The big problem here is that all crisis services are connected to each other. If any part of that system is disrupted you can't divert a patient properly," said Travis Atkinson, a behavioral consultant with TBD Solutions, which collaborated on a survey of providers with the American Association of Suicidology, the Crisis Residential Association and the National Association of Crisis Organization Directors.

White said the crisis took a big toll on her operations. She stopped her mobile crisis team on March 14 because, she said, "we wanted to make sure that we were keeping our staff safe and our community safe."

Her staff assessed hospital patients, including Marcell, by telephone with the help of a social worker from the emergency room.

People like Marcell have struggled during the coronavirus crisis and continue to face hurdles because emergency preparedness measures didn't provide enough training, funds or thought about the acute mental health issues that could develop during a pandemic and its aftermath, said experts.

"The system isn't set up to accommodate that kind of demand," said Dr. Brian Hepburn, a psychiatrist and executive director of the National Association of State Mental Health Program Directors.

"In Detroit and other hard-hit states, if you didn't have enough protective equipment you can't expect people to take a risk. People going to work can't be thinking 'I'm going to die,'" said Hepburn.

For Marcell, "it was bad timing to have a mental health crisis," said White, the director at Hegira.

At one time Marcell, an African American man with a huge grin and a carefully trimmed goatee and mustache, had a family and a "pretty good job," Marcell said. Then "it got rough." He made some bad decisions and choices. He lost his job and got divorced. Then he began self-medicating with cocaine, marijuana and alcohol.

By the time he reached the residential center in Detroit on April 1, he was at a low point. "Schizoaffective disorder comes out more when you're kicked out of the house and it increases depression," said Powers, the program manager who along with White was authorized by Marcell to talk about his care. Marcell didn't always take his medications and his use of illicit drugs magnified his hallucinations, she said.

While in the crisis center voluntarily, Marcell restarted his prescription medications and went to group and individual therapy. "It is a really good program," he said while at the center in early May. "It's been one of the best 30 days."

Hepburn said the best mental health programs are flexible, which allows them more opportunities to respond to problems such as the pandemic. Not all programs would have been able to authorize such a long stay in residential care.

Marcell was finally discharged on May 8 to a substance abuse addiction program. "I felt good about having him do better and better. He had improved self-esteem to get the help he needed to get back to his regular life," Powers said.

But Marcell left the addiction program after only four days.

"The [recovery] process is so individualized and, oftentimes, we only see them at one point in their journey. But, recovering from mental health and substance use disorders is possible. It can just be a winding and difficult path for some," said White.

Seeking Help

If you or someone you know is in immediate danger, call 911. Below are other resources for those needing help:

— National Helpline: 1-800-662-HELP (4357) or https://findtreatment.samhsa.gov.

— National Suicide Prevention Lifeline: 1-800-273-TALK (8255).

— Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746.

Correction: This story was updated on June 4 at 7:50 a.m. ET to correct an attribution. It was Marcell who said that he had  a family and a "pretty good job" before his illness got severe.

Cheryl Platzman Weinstock: @CherylWeinstock

ICUs Become A 'Delirium Factory' For COVID Patients

KFF Health News, June 3, 2020

When doctors suspect a stroke, they usually order a brain MRI. But many ICU patients with COVID-19 are too sick to be wheeled across the hospital to a scanner.

This article was first published on Wednesday, June 3, 2020 in Kaiser Health News.

By Liz Szabo June 3, 2020

Doctors are fighting not only to save lives from COVID-19, but also to protect patients' brains.

Although COVID-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, as well as starve the organ of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.

Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.

And while COVID-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.

When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with COVID-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.

Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.

"Our hands are much more tied right now than before the pandemic," said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.

In many cases, doctors can't even examine patients' reflexes and coordination because patients are so heavily sedated.

"We may not know if they've had a stroke," Sheth said.

A study from Wuhan, China — where the first COVID-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.

A smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.

Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.

New York's Northwell Health is using a mobile MRI machine for COVID patients, said Dr. Richard Temes, the health system's director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.

Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain's electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.

To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.

The Brain Under Attack

"Right now, we actually don't know enough to say definitely how COVID-19 affects the brain and nervous system," said Chou, who is leading an international study of neurological effects of the virus. "Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments."

Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.

Authors of a recent study from Germany found the novel coronavirus in patients' brains.

But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.

That's because performing autopsies on patients who died of COVID-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.

Some of the best-known symptoms of COVID-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.

Research shows that the coronavirus may enter a cell through a gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also on organs throughout the body, including many parts of the brain.

In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.

Some of the most surprising symptoms of COVID-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.

A study from Europe published in May found that 87% of patients with mild or moderate COVID-19 lost their sense of smell. Patients' loss of smell couldn't be explained by inflammation or nasal congestion, the study said. Stevens said it's possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.

A new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a COVID-19 patient who lost her sense of smell.

Many COVID patients develop "silent hypoxia," in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.

When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with COVID-19 could indicate the brain stem is impaired.

Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.

Collateral Damage

Well-intentioned efforts to save lives can also cause serious complications.

Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.

Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.

Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.

Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often "don't realize they're in the hospital," Singh said. "They don't recognize their family."

In the French study in the New England Journal of Medicine, one-third of discharged COVID-19 patients suffered from "dysexecutive syndrome," which can be characterized by inattention, disorientation or poorly organized movements in response to commands.

Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.

Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.

Just allowing a family member to hold a patient's hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they're in the hospital.

"You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort," Fleisher said.

These and other innovative practices — such as helping patients to move around and get off a ventilator as soon as possible — can reduce the rate of delirium to 50%.

Hospitals have banned visitors, however, to avoid spreading the virus. That leaves COVID-19 patients to suffer alone, even though it's well known that isolation increases the risk of delirium, Fleisher said.

Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.

Doctors are also positioning patients with COVID-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.

But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.

All of these factors make COVID-19 patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a "delirium factory."

"The way we're having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself," said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. "A lot of the things we'd like to do are just very difficult."

Liz Szabo: lszabo@kff.org, @LizSzabo

Pandemic Presents New Hurdles, And Hope, For People Struggling With Addiction

KFF Health News, June 2, 2020

Rosalind Pichardo advertises a daily food giveaway service in the heart of Philadelphia's Kensington neighborhood, where more people die of drug overdoses than in any other area in the city.

This article was first published on Tuesday, June 2, 2020 in Kaiser Health News.

By Nina Feldman, WHYY

Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.

He’s still living on the streets.

“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”

KHN agreed not to use his last name because he uses illegal drugs.

Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.

When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.

“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.

Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.

She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.

When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.

So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.

After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.

That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.

To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.

“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.

In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.

“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”

Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.

“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.

More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.

Police resumed arrests at the beginning of May.

Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.

“It’s like the survival kit of the ’hood,” she said.

For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.

During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.

“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.

Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

California AG Seeks More Power To Battle Merger-Hungry Health Care Chains

KFF Health News, June 2, 2020

California Attorney General Xavier Becerra has made battling healthcare consolidation a signature issue since he took office in 2017.

This article was first published on Tuesday, June 2, 2020 in Kaiser Health News.

By Rachel Bluth

California’s health care industry has a consolidation problem.

Independent physician practices, outpatient clinics and hospitals are merging or getting gobbled up by private equity firms or large health care systems. A single company can dominate an entire community, and in some cases, vast swaths of the state.

Such dominance can inflate prices, and consumers end up facing higher insurance premiums, more expensive outpatient services and bigger out-of-pocket costs to see specialists.

Now that COVID-19 has slammed the health care industry, especially the small practices that are barely seeing patients, the trend is likely to accelerate.

“I don’t see anything that’s going to stop this wave of consolidations amongst docs,” said Glenn Melnick, a health care economist at the University of Southern California.

“If this thing goes on a long time,” he said of the coronavirus, “then it becomes a tsunami.”

California Attorney General Xavier Becerra has made battling health care consolidation a signature issue since he took office in 2017. With the additional pressure that COVID-19 is putting on vulnerable practices and facilities, Becerra is now pressing the state legislature to expand his authority to slow health care mergers.

“We find that in these times of crisis, economic and health crisis, that the smaller health care players and stakeholders are oftentimes most at risk of being swallowed up by the big fish,” Becerra told California Healthline.

His success would fundamentally change how the health care industry merges and grows in California.

When a health care system, private equity firm or hedge fund plans to merge with or acquire another practice or facility — whether that means buying a small practice or joining a multistate hospital chain — Becerra wants to know about it. He wants written notice, and the ability to deny any sale that doesn’t deliver better access, cost or quality health care to Californians.

Becerra already can regulate mergers among nonprofit health care facilities. Under SB-977, a collaboration between Becerra’s office and the legislature, he would get the ability to regulate the for-profit sector as well.

“Certainly it would put California where it’s accustomed to being,” Becerra said. “At the head of the pack.”

The bill has support from organized labor and consumer advocacy groups. Gov. Gavin Newsom has come out against health care consolidation in the past but hasn’t taken an official stance on the bill.

Yet Becerra isn’t convinced passage will be smooth.

“The biggest concern I have is the legislation will be killed by the industry,” he said. “We’ll end up seeing over-consolidation because decent practices that got on the edge could not swim with sharks.”

Indeed, health care industry players are already lining up against the bill. Alex Hawthorne, a lobbyist for the California Hospital Association, said that hospitals are stretched thin because of the pandemic, and that now isn’t the time for Becerra to be meddling in routine agreements between practices.

“It bestows absolute and arbitrary discretion on the office of the attorney general,” Hawthorne said at a budget hearing in May.

In 2010, about 25% of California physicians worked in a practice owned by a hospital. By 2016, more than 40% of doctors worked in hospital-owned practices, according to research published in the journal Health Affairs in 2018.

There’s evidence that consolidation can hurt consumers. A separate 2018 study found that the cost of medical procedures in highly consolidated Northern California was 20% to 30% higher than in Southern California.

Since 2018, California’s attorney general has had the authority to regulate mergers among nonprofit health care systems, which Becerra exercised the same year when considering a merger between two health care giants: Dignity Health and Catholic Health Initiatives. He said he would approve the deal only if the systems agreed to certain requirements, such as starting a homelessness program.

Later that year, Becerra joined a suit against Sutter Health for using its market power to drive up health care costs in Northern California.

The lawsuit alleged that Sutter, which has 24 hospitals and 34 surgery centers, had spent years buying up practices and facilities, giving insurers little choice but to include them in their networks and agree to higher rates for services.

In October 2019, Becerra secured a $575 million settlement against Sutter, which has yet to be finalized or paid out, that requires Sutter to change how it charges insurance companies and give patients more information about prices.

Sutter Health opposes SB-977, which was introduced in February by state Sen. Bill Monning (D-Carmel). The measure is intended to address some of the challenges Becerra encountered with the Sutter case, Becerra said.

“The best way to prevent problems from occurring in a merger is just to prevent the merger altogether,” said Jaime King, associate dean at UC Hastings College of the Law in San Francisco. “It’s really hard to unwind a merger after you’ve already done it.”

Under the measure, the attorney general must be notified before a system, hedge fund or private equity firm attempts to enter into a merger, acquisition or another kind of affiliation change with another practice or facility. The bill defines a health care system as one with two or more hospitals in multiple counties, or three or more hospitals within one county.

That would trigger a public review process allowing supporters and opponents to make their cases to a review board. The board would assess the transaction, using criteria to determine whether it would improve access, quality and price.

The bill also would make it illegal for systems to act anti-competitively and give the attorney general the power to bring a civil suit against monopolistic systems.

The Senate Health Committee approved the bill, which is expected to be heard in another committee this week.

“Maybe it does mean consolidation should occur, but only because we’ve done the oversight to make sure it’s because of quality and access,” Becerra said. “Not because a big fish wants to make bigger profit.”

The measure includes waivers for rural practices and a fast-track review process for transactions under $500,000.

The California Chamber of Commerce opposes the bill, as does the California Medical Association, which represents doctors. While the California Medical Association is concerned about the survival of small physician practices, it believes the bill is too broad and should focus more tightly on hospital consolidation, said spokesperson Anthony York.

“This approach will only further force smaller providers out of business,” especially as the health systems respond to the COVID-19 emergency, the group’s legislative advocate, Amy Durbin, wrote in a letter of opposition.

For many independent practices struggling for survival, the debate over Becerra’s powers is academic.

Dr. Sarah Azad, who owns a women’s health practice in Mountain View, California, said at least three independent practices in her area have started the process to merge or sell since March because of dramatically lower patient volume.

Her practice is fine for now, despite the fact that her patient volume was only about 30% of normal in March and 60% of normal in April. Azad received a loan from the federal Paycheck Protection Program for small businesses so she could pay her five doctors in May.

“If you catch me on a bad month, I feel like we’re one disaster away from bankruptcy,” Azad said.

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