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.

By Jay Hancock and Elizabeth Lucas

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 Baltimore criticized 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.

Tenet Healthcare, a national, for-profit chain whose stock trades on Wall Street, says it does not sue uninsured patients who are unemployed or who lack significant assets other than their house.

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 both circuit and district 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.

Jay Hancock: jhancock@kff.org, @JayHancock1

Elizabeth Lucas: elucas@kff.org, @eklucas

Not enough physicians know that Medicare will pay for nutritional counseling.

This article was first published on Monday, September 9, 2019 in Kaiser Health News.

By Phil Galewitz

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 the 20 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 estimated 1 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.

Fewer than 5% of Medicare beneficiaries use their 10 to 12 hours of diabetes self-management training benefit, which can cover individual and group sessions providing tips for eating healthily, being active, monitoring blood sugar, taking drugs and reducing risks.

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.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Centura Health Corp. abruptly terminated Barbara Morris, MD, a geriatrician who had planned to help a terminally ill patient end his life at his home.

This article was first published on Friday, August 30, 2019 in Kaiser Health News.

By JoNel Aleccia

DENVER — A Christian-run health system in Colorado has fired a veteran doctor who went to court to fight for the right of her patient to use the state's medical aid-in-dying law, citing religious doctrine that describes "assisted suicide" as "intrinsically evil."

Centura Health Corp. last week abruptly terminated Dr. Barbara Morris, 65, a geriatrician with 40 years of experience, who had planned to help her patient, Cornelius "Neil" Mahoney, 64, end his life at his home. Mahoney, who has terminal cancer, is eligible to use the state's law, overwhelmingly approved by Colorado voters in 2016.

The growing number of state aid-in-dying provisions are increasingly coming into conflict with the precepts of faith-based hospitals, which oppose the practice on religious grounds.

Morris' dismissal presents an early test of state laws. The Trump administration has moved to broaden the latitude of providers to refuse to participate in medical interventions they object to on religious grounds, though that has previously applied primarily to abortion and contraception.

As hospitals across the country have consolidated, five of the top 10 hospital systems by net patient revenue are associated with the Roman Catholic Church, according to Definitive Health. That includes hospitals that did not previously have any religious affiliation. Meanwhile, there are 10 U.S. jurisdictions where aid-in-dying has been approved and public support for the option is increasing.

The Aug. 26 firing came days after Morris joined with Mahoney in filing a state lawsuit that alleges that Centura's faith-based policy violates the law that allows doctors to prescribe lethal drugs to dying patients who want to end their own lives.

Officials at Centura, a system jointly run by Catholic and Seventh-day Adventist churches, told Morris on Monday that she had defied church doctrines that govern her employment.

"I was shellshocked," Morris said in an exclusive interview with Kaiser Health News. "Because of all the things I expected them to do, that was not in the playbook. Because it seemed so obvious that they can't do it."

But in legal documents filed Friday that ask to elevate the case to federal court and invoke the First Amendment in defense of their actions, Centura officials said Morris had violated terms of her physician's employment agreement and "encouraged an option that she knew was morally unacceptable to her employer."

For Mahoney, the firing deals yet another setback in his quest to use the law. Mahoney, who in July was given four to 14 months to live, said he watched his mother die a slow, painful death and hopes to avoid that for himself.

"Knowing that I could die at home is huge," said Mahoney, who has lost 30 pounds since April, even as his belly swelled painfully with fluid as a result of the cancer. "This gets dragged out too long."

The Trump administration in May approved a so-called conscience rule that strengthens the rights of hospitals and health workers to refuse to participate in patient care based on religious or moral grounds.

At the same time, more doctors and patients in the country are providing and receiving health care subject to religious restrictions. About 1 in 6 acute care beds nationally is in a hospital that is Catholic-owned or -affiliated, said Lois Uttley, a program director for the consumer advocacy group Community Catalyst.

In Colorado, one-third of the state's hospitals operate under Catholic guidelines.

In a letter hand-delivered to Morris, who has worked for the health care system since 2013, Centura president Vance McLarren said that she had violated the firm's governing rules, the Ethical and Religious Directives for Catholic Health Care Services.

"Rather than encouraging patient Cornelius Mahoney to receive care consistent with that doctrine or transferring care to other providers, you have encouraged a morally unacceptable option," the letter said.

The directives state that Catholic health care providers "may never condone or participate in euthanasia or assisted suicide in any way." Such acts are described as "intrinsically immoral" and "intrinsically evil" in the document.

"Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering," the document states.

Centura officials confirmed Thursday that Morris is no longer employed there, adding in a statement that the firm "expects all our caregivers to act in a manner consistent with our Mission and Core Values."

Company officials did not address claims that Centura violated state law but argued that its policy prohibiting doctors from prescribing drugs or otherwise participating in medical aid-in-dying is federally protected.

"We believe the freedom of religion doctrine at the heart of the First Amendment to the U.S. Constitution supports our policies as a Christian health-care ministry," Centura spokeswoman Wendy Forbes said in an email. "We will vigorously defend our Constitutional rights."

Legal experts said that Morris' firing may be rare or even unprecedented, but the argument based on the First Amendment has gained support recently in conservative circles.

"In recent years, the radical right has gotten traction with the argument that religious peoples' constitutional rights are violated if they have to follow the same law as everybody else," said Robert Rivas, a Florida lawyer who serves as general counsel for the Final Exit Network, a nonprofit group that promotes right-to-die causes.

"When you look closely at what they are saying," he said, "it turns out they really want to be empowered to force their religion on others."

Officials with the Archdiocese of Denver said they supported Centura's efforts to uphold church doctrine.

"Asking a Christian hospital to play any role in violating the dignity of human life is asking the Christian hospital to compromise its values and core mission," spokesman Mark Haas said in a statement. "This is not the hospital forcing its beliefs upon others, but rather having outside views forced upon it."

The issue is playing out against growing federal protections for religious views of health care, said Kathryn Tucker, executive director of the End of Life Liberty Project and co-counsel on the Centura lawsuit filed Aug. 21.

The Trump administration conscience rule, which was challenged by two dozen states and cities, including Colorado, has been delayed until Nov. 22.

"What's getting lost here is the patient, and the doctor may hold equally strong ethical and religious views as Centura," Tucker said. "Why should their views be overridden by the views of corporate religious medicine?"

Morris' termination was immediate, according to the letter. She was asked to hand over her badge and her company laptop computer. The action abruptly halted her care of 400 geriatric  patients and left Morris worried about their future.

"These are complex, ill patients," Morris said. "We have a pretty big thing in medicine about not abandoning patients, so that's a pretty big issue."

In the lawsuit, Morris joined with Mahoney, a Golden, Colo., nursery manager diagnosed in July with stage 4 metastatic cancer. The pair alleged that Centura's policy prohibiting doctors from prescribing aid-in-dying drugs is broader than state law allows.

Colorado's End of Life Options Act, approved by 65% of voters in 2016, allows hospitals and health systems to opt out of offering aid-in-dying drugs for use on their premises.

In addition, another Colorado law says health care facilities may not "limit or otherwise exercise control" over a physician's medical judgment.

The suit asks a judge to rule that the hospital system may not bar Morris from prescribing the lethal drugs — or penalize her if she does.

Centura officials expressed sadness over Mahoney's illness but said the institution promotes "the sacredness of every human life."

After he received his grim diagnosis, Mahoney asked an oncologist and a social worker at his cancer center to help him access aid-in-dying. Both said no.

"I feel like I got slapped in the face," Mahoney said.

Mahoney was advised to transfer his care to a secular provider, but he said he didn't want to undergo additional tests, costs and travel as he struggled with debilitating symptoms.

Morris said she understood that Centura was religiously affiliated when she was hired but didn't anticipate a problem.

"I didn't think it was going to affect my general family practice," she said. "Until these conversations about medical aid-in-dying, I hadn't felt any interference."

Once the law passed, however, a growing number of patients asked about the option.

"I've had patients as they face devastating illness or the end of life where they say, 'Will you do this for me?'" she said, adding later: "At a certain point, we have to stand up for what's right."

Morris is considering her next steps, including separate legal action against Centura over her termination. Mahoney, who is scheduled for his third round of chemotherapy soon, said he's not sure what to do in the wake of the firing.

Raised Catholic, he said, he rejected that theology long ago.

"I don't believe in church. I don't believe in religion," he said. "I just think they're getting way too much power."

Touring the Golden State as an unpaid advisor to Gov. Gavin Newsom, Thomas Insel looks to revamp mental healthcare.

This article was first published on Thursday, August 29, 2019 in Kaiser Health News.

By Rob Waters

In a career full of twists, turns and high-powered assignments, Thomas Insel may now be embarking on one of his most daunting tasks yet — helping California find its way out of a worrisome mental health care crisis.

This year, he assumed a new role to help Gov. Gavin Newsom revamp mental health care in the state. Newsom called Insel his "mental health czar," though his position is unpaid and Insel says it grants him "no authority." Even so, he is zigzagging across California this summer, visiting mental health facilities to try to understand what works and what doesn't.

Insel's meandering career path began early. A precocious student, he enrolled in a joint B.A.-M.D. program at Boston University at age 15 and then took a one-year hiatus to volunteer in clinics across Asia. He returned to finish his medical degree and later completed a three-year psychiatry residency at the University of California-San Francisco.

As a young scientist at the National Institute of Mental Health in the 1980s, Insel researched the effects of antidepressants, then shifted gears to study the neurobiology of emotional attachment in the prairie vole, a rodent known for monogamous behavior.

His groundbreaking research revealed that the vole's devotion to a single mate was attributable to higher levels of a protein in its brain. That work — along with earlier research on anxiety in monkeys — led to a job running the Yerkes National Primate Research Center in Atlanta starting in 1994. He returned to NIMH in 2002 as its director and headed the institute, the world's largest funder of mental health research, for the next 13 years.

In 2015, Insel left NIMH to lead mental health initiatives at Verily, Google's life sciences research subsidiary. He jumped ship after a year and a half to join a startup, Mindstrong Health, which hopes to prove that the way people use their smartphones can reveal the state of their mental health — and provide opportunities to intervene. Insel also serves as board chairman of the Steinberg Institute, a Sacramento-based nonprofit focused on California mental health policy.

In May, he took a temporary leave from Mindstrong to work intensively, at Newsom's behest, on a mental health plan for the state. He intends to return to the company early next year and continue advising the governor for "as long as I can be useful."

California Healthline joined Insel on Aug. 19 as he toured Oakland's Trust Clinic, a medical and mental health center serving the city's homeless population. We sat down with him for an interview afterward. His comments have been edited for space and clarity.

Q: How would you describe the state of mental health in California and in the U.S.?

California has all the issues every other state has — incarceration, homelessness, fragmentation. More than half of people with mental illness are not getting care. There is a very shallow workforce, particularly for kids. We don't have inpatient beds where we need them.

I've spent 40 years working in this field. We have seen vast improvement in those 40 years in infectious diseases, cardiovascular care, many areas of medicine, but not behavioral health. Suicides are up about 33% since the turn of the century. Overdose deaths are skyrocketing. People with serious mental illness die about 23 years early — and we're not closing that gap. We've got to come up with better solutions now.

Q: What insights are you gaining as you visit programs around the state?

People managing these programs are heroic in what they're able to do with limited resources and tremendous demands. We have 58 mental health systems because we have 58 counties, and we have a separate system for mild to moderate mental illness. It's very fragmented — including between mental health and substance use. One family might interact with four different providers to get behavioral health care. That's not the system one would design if you're starting with the patient.

Q: How should the system be designed?

The system now is crisis-driven. The biggest transformation will come when we can identify problems and intervene earlier. That's when we get the best outcomes in diabetes, heart disease, cancer. It's equally true in behavioral health. We have to manage crisis better, keep people out of the criminal justice system, provide more continuity of care. But we also have to move upstream and capture people much earlier in their journey. This will require building infrastructure we don't have right now: crisis residential beds, sub-acute beds, places for people to live.

Q: So how do we bring about the needed changes?

California has one advantage few states enjoy. The Mental Health Services Act (MHSA) will provide $2.4 billion this year, including for early intervention, prevention and innovation. We also have [other] funds. Every county is using those funds in the way it sees fit.

The time has come to ask: How can we reduce suicide, overdose deaths and re-hospitalization in California? One approach would be to set goals for these, i.e., reduce suicide by X% in Y years. Housing and incarceration have gotten worse over time. Should the state make a pledge to its citizens to do better in those areas?

Q: Who would ensure such a pledge is honored?

Counties are still ground zero for all this. They're our connection to schools and jails, and places where the mental health crisis is playing out. The question is, can the state do more to help them succeed? One thing I've heard from every county is that the burden for documentation means that 35% to 40% of the time is taken up with paperwork, not providing services. Can we set them loose to do what they want to do?

Q: Can technology play a role in improving mental health?

As much as one might hope there'd be an app for that — it's really complicated. In the months I've focused on creating a mental health plan for California, technology is barely in the conversation. Having said that, I do think in the future using digital tools to connect people to care will be transformative.

Q: The recent mass shootings in El Paso and Dayton, like numerous others before them, were perpetrated by angry, alienated young men. What does this say about our culture and the American psyche?

It's a complicated question. There is an element of untreated mental illness that leads to high risk of violence. That violence is usually self-directed in the form of suicide; occasionally, it's other-directed. We did better, oddly enough, when I started in the field than we're doing today in providing more comprehensive, continuous care. I think we are in a crisis, but it's a crisis of care. So whether the mass shootings are a reflection of that or not — maybe to some extent, but they're a small part of a much bigger issue. We are failing to provide care to people with brain disorders. We need to do better.

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