Nurse Heather Gatchet's shift in the emergency department at Salem Health's Salem Hospital in Oregon typically starts at 6 a.m. Before that, she packs her daughter's lunch, drinks tea, and — to stave off her panic — calls her mom on the way to work.
"My mom's like my cup of coffee," Gatchet said, her voice breaking, "to mentally psych myself up for what I'm walking into." Gatchet's mother reminds her she is good at what she does and she's loved. After she walks in and sees her colleagues in the break room, Gatchet said, her panic lifts: "This is my team, and it feels safe again."
More than 700 days have passed since the first case of COVID-19 was confirmed in Oregon. Like the rest of the country, Oregon had far more cases in early 2022's omicron surge than in any previous peak of the pandemic. New cases have begun to recede, but the sheer volume of infections continues to swamp hospitals nationwide. Salem Hospital, where Gatchet works, is adapting, yet again, to accommodate more patients than it is licensed to hold.
Dr. Peter Hakim works alongside Gatchet. Recently, his mother-in-law had a heart attack and was taken to a small, rural hospital. She needed specialty care that wasn't available there. "They could not find a bed for her anywhere in Washington or Oregon for 24 hours," Hakim said. "So she was sitting in this small six-bed emergency department and couldn't get transferred out."
His mother-in-law eventually got the care she needed. A lot of people, Hakim said, "are not as lucky."
The Salem Hospital emergency department has 100 beds. To handle the influx of people seeking treatment, hospital staffers have made space by putting dozens of beds in the halls.
By noon, those hall beds are occupied, and ambulances are pulling up to the bay behind the hospital — seven, eight, nine at a time.
The pressure builds through the afternoon as more patients arrive. Three years ago, treating people in the hallways would have been an extraordinary measure. Now Gatchet and Hakim prepare for it every day.
Some of what Hakim does as a physician, like cutting off a patient's clothing to examine a broken hip, is too sensitive for the hallway. He said he took one patient into the bathroom to complete an exam: "That is the one private space we could find at the time."
The hospital has been above 100% capacity for months, with patients doubled up — and even occasionally tripled up — in their rooms, according to hospital executives. Salem Health allowed a reporter to shadow Gatchet and other staff members on Jan. 27, which proved to be the day with the highest number of COVID patients yet — 122 people, nearly 1 in 4 patients in the hospital had the virus.
About 70% of those COVID patients were admitted with respiratory symptoms, while the rest were asymptomatic cases discovered during admissions screening, according to hospital executives.
But those 122 patients were just part of the strain from the pandemic. If the health system were a line of dominoes, emergency medicine would be at one end. But the domino that tipped first and knocked the other parts down is long-term care. Statewide, more than 70% of long-term care facilities had a staff member or resident test positive for COVID in January, with many reporting full-blown outbreaks.
Low-paid caregivers are burned out and quitting the long-term care sector in huge numbers — it's one of many industries competing for workers in a crunched labor market experiencing record resignations and retirements.
The COVID outbreaks and staffing shortages mean Salem Hospital can't discharge patients to nursing homes. Those facilities are closed to new admissions.
It's also harder to find support for patients who need assistance to return to their homes after an illness or disabling accident. The pandemic has made hospital beds, in-home caregivers, and even wheelchairs all more difficult to get.
Dr. Sarah Webber, a hospitalist, said that before the pandemic, coming up with a safe discharge plan for patients took her team a few days. "And now sometimes it is taking a week or two. And I do have some patients that have been here for several weeks," she said. Of the 20 hospital patients she was responsible for the prior week, eight were stable and ready to leave but didn't have a discharge plan.
Statewide, almost 600 patients are ready to leave the hospital but waiting on a discharge plan. One in 10 patients in an Oregon hospital bed could leave but has nowhere to go.
As in the delta wave, a majority of the COVID patients hospitalized at Salem Hospital are people who haven't been vaccinated.
Patients infected with the omicron variant are, on the whole, requiring less oxygen and less intensive care. "I'm seeing more patients live," said Jackie Williams, a respiratory therapist who works on every floor of the hospital. "It's like a little glimmer of hope."
Many of the less critical COVID patients are behind closed doors in the hospital's medical-surgical unit. Being hospitalized with COVID — even a milder variant — is a lonely experience.
In the hallway on Jan. 27, a nurse manager spoke with the wife of a COVID patient who had been transferred from the emergency room. The manager was explaining that the patient's wife needed to leave the unit because she was exposed to COVID while caring for her husband and could infect hospital staff members or patients. The wife quietly fought back tears as she handed over a bag with glasses and a clean change of clothes for her husband.
"Does he have a cell phone?" the nurse manager asked. "The nurses, they can help him do FaceTime so you can talk to him, OK?" She added: "I'm sorry."
An Oregon National Guard member deployed to the hospital to help the nurses pushed a cart full of supplies down the hall and called out a greeting. The guard members provide a little lift — and a show of solidarity — to staff members who are feeling ground down.
For Webber, it stings that many of her patients don't take her advice to get vaccinated after they recover. "People come to the hospital sick and they want me to help them, but they won't trust me over the basics of how to prevent it," she said.
At home, she has less patience for her children — and they seem to need her more. Her 6-year-old daughter recently asked why Webber couldn't just stay home with her.
"She asked me, 'Are the sick people more important than me?'" Webber said.
In recent days, hospitalizations in Oregon appear to have reached their peak and are plateauing. Salem Hospital staff members hope that as the omicron wave subsides, the pressure will ease up a bit.
Even as it does, it's still flu season, and health issues that have worsened through the pandemic in Oregon will resurface. "It might not be breathing problems, but it's alcoholism. It's suicide," said Williams, the respiratory therapist. "It's traumas, it's all these other things that are what the world is dealing with after coming out of two years of a pandemic. And those are critical illnesses too."
The rapid spread of omicron across the nation — and the finding that vaccines continue to provide strong protection against severe disease — brings COVID-19 one step closer, perhaps, to truly earning its place on the list of diseases that have been tamed by vaccines. These include polio, measles, mumps, rubella, and chickenpox, all of which most kids must generally be vaccinated against before they enter school or day care. Some states have announced COVID vaccine requirements for certain students.
But not everyone agrees that vaccine mandates for children are the way forward. Sen. Rand Paul, who has opposed vaccine mandates, called omicron "nature's vaccine." Seventeen mostly Republican-led states have proactively banned, in some form, COVID vaccine requirements for students. Resistance to adopt mandates has profound repercussions, especially as vaccination rates among kids ages 5 to 11 remain alarmingly low — under 15% in some states — even though children 5 and over have been eligible for shots since last fall.
History holds lessons for why low vaccination rates for children are so risky and why officials should strongly consider school mandates for the COVID vaccine.
In the United States, children generally must get a number of vaccines before they enter school. Such requirements help ensure an entire generation gets their shots against diseases that were feared for decades — sometimes centuries — before vaccines did their work. Such diseases proved even more terrifying in places that were immunologically "naïve," showing up in bodies that hadn't seen them before. That's the devastating place we were with COVID-19 in early 2020.
When explorers brought diseases like measles, which had long circulated on the European continent, to Native populations of the New World, they killed up to an estimated 80% to 95% of the Indigenous population in repeated outbreaks over the ensuing 100 to 150 years. When global travel become more available, the king and queen of Hawaii arrived in England in 1824 and both died there of measles. The virus came back to Hawaii in 1848 and started an epidemic that killed one-quarter of the Native population, by one estimate, then flared to create additional waves that killed more people in the following decades.
Even after vaccines were invented and diseases like measles and chickenpox were no longer common (and not medically dangerous for the average child), the United States continued to mandate school vaccination for different but important reasons.
We vaccinate against chickenpox and measles in part because those diseases can be more deadly for adults, for the immunocompromised, and for babies, whose immune systems are still developing. Like COVID.
We vaccinate against mumps, in itself usually a mild disease, because some who get it will suffer serious lasting effects, such as hearing loss or infertility in males who've passed puberty. You can draw parallels here with "long COVID," and we still don't know about the long-term effects of the coronavirus, which can inflame organs.
Also, kids with chickenpox must endure a prolonged, miserable isolation at home. And we vaccinate against the chickenpox virus — and measles — because an outbreak at a school can cause significant disruption if vaccination rates are low, triggering actions like contact tracing and other public health measures.
Just as with the coronavirus today.
We could get lucky and achieve more widespread immunity for COVID relatively quickly, after new waves become less and less overwhelming. But even if that happens, many unvaccinated people will die or get seriously ill and some kids will miss school when they didn't need to. New, potentially more dangerous strains have a better chance to emerge. Do we really want to roll the dice and not take full advantage of this very effective tool at our disposal?
Which path do we want to take to put the pandemic behind us: the quicker, more certain one of mandatory vaccination or a stuttering, drawn-out affair?
Unfortunately, the COVID vaccines landed at a time of deep national divides, when science had become politicized and mistrust of government was high. Even parents who get their children the school-required shotshave balked at COVID vaccines. States and school districts that have announced plans for school vaccination requirements already face backlash.
This is a far cry from the way the public reacted to the introduction of childhood vaccines in the 20th century. People reacted enthusiastically to the availability in 1955 of the vaccine against polio, a disease that could have disastrous health consequences, but — like COVID — was asymptomatic or mild in most people who were infected, particularly children. The hesitancy that existed then was not driven by intense partisanship or political division.
One explanation for that era's enthusiasm for a new shot was that Americans' memories were long, having lived through fearsome polio outbreaks and the attendant quarantines through much of the mid-20th century. By 1955, many Americans knew someone who had perished from polio or was left partly paralyzed. People have lived with COVID for a relatively short amount of time.
Resistance to the COVID vaccine will perhaps dissipate once the FDA moves the shot for children from emergency use authorization to full approval and as waves of COVID affect more Americans.
Here's how my thinking about another vaccine was affected a generation ago: My older child got chickenpox before the shot was available and spent hours in oatmeal baths covered with hundreds of itchy blisters. She couldn't return to preschool (nor I to work) for 10 days, until her blisters scabbed over; some scars took years to fade.
So when the chickenpox vaccine came to market in 1995, I raced to get my 2-year-old the shot. He still got chickenpox, but a mild case, just like most breakthrough COVID cases: One evening while he was playing, I noticed two telltale blisters on his upper arm that disappeared within 24 hours. He didn't miss a single play date.
Like many childhood vaccines, that shot protected him, our family, my work, our caregiver, his toddler classes, his grandmother, and all the vulnerable people we had come in contact with at the market or on the subway. If we want to bring this pandemic to a rapid denouement, vaccinating schoolchildren can have the same ripple effect and may well be the best way to go.
ST. LOUIS — Republican Missouri state Sen. Mike Moon believes that COVID-19 vaccinations, especially among children, should cease until the long-term effects are known. He points to the research of sources of COVID misinformation like America's Frontline Doctors and Dr. Robert Malone, a guest on Joe Rogan's podcast. He himself is not vaccinated.
So, on Feb. 1, he and other senators tanked the nomination of Donald Kauerauf to become the state's next health director. Kauerauf had held the office in an interim capacity since September and professed on the record that he was anti-abortion and anti-mandate for masks and vaccinations, all while being nominated by a Republican governor who is also anti-mandate. But it wasn't enough for Moon.
"Missourians don't want to be ruled with an iron fist," Moon said.
The heartland state's kerfuffle is one more example of political pushback to public health leadership. A KHN and Associated Press investigation last year found that at least 1 in 5 Americans lived in places that had lost their top local public health official amid a wave of threats to the profession and chronic stress that led to firings, resignations, and retirements since the pandemic began. Such blows endanger the public health system's ability to respond to other issues in the future, public health officials said.
In Florida, the nominee for that state's surgeon general declined five times to definitively acknowledge in a hearing that COVID vaccines work. And the state health department recently placed a local public health official on administrative leave for encouraging vaccinations among his staff.
A Tennessee legislator threatened the existence of the state medical board for warning that doctors could jeopardize their licenses if they spread COVID misinformation.
Serving at the pleasure of elected leaders is becoming "twisted and grotesque" amid extreme politicization, said Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health. Governmental public health leaders are being chosen based on their political ideology rather than their scientific and leadership abilities, he added.
"This is public health dying," he said. "A dark age of politics has begun that is choking science."
Over half of states have rolled back public health powers during the pandemic, which experts say permanently weakens states' abilities to protect their constituents' health.
"Both the fundamental legal authorities of public health, as well as the people who are practicing, are being threatened in ways we've never seen before," said Dr. Georges Benjamin, executive director of the American Public Health Association. He warned that even more legislative rollbacks would take place this year across the country, as well as court rulings limiting public health authorities.
This stripping of public health powers doesn't just mean that unpopular COVID restrictions will end, he said. These curbs often cripple public health's ability to fight other scourges.
In Missouri, state legislators passed a law last summer limiting public health powers. A judicial ruling in November further chipped away at local health officials' authority to issue COVID restrictions, saying they were "based on the unfettered opinion of an unelected official." Missouri Attorney General Eric Schmitt — who is also running for Senate — is suing schools to eliminate mask mandates and in December created an email tip box where parents can send concerns, photos, and videos that involve mask wearing by students.
Kelley Vollmar, executive director of the health department in Jefferson County, in eastern Missouri, said these actions have severely weakened her public health powers. The state legislation, for example, requires her to get orders confirmed by the county board of health. But the orders must be reconfirmed after 30 days, and Vollmar has to spend $2,000 advertising them in her local paper.
"You cannot rule by committee," Benjamin said. "That's like telling the chief of police that they can't make an arrest."
The November judicial ruling stripped Vollmar and other public health officials in the state of the ability to issue any orders involving infectious diseases. Those must now come from elected officials above them. That affects public health tools like contact tracing, isolation, and quarantine — not just for COVID, but also for the other 134 communicable diseases she's tasked with protecting the public from.
"The things they are stripping powers of are things normally happening in the background," she said.
Vollmar has seen a sharp increase in requests for vaccine exemptions for measles and other preventable infectious diseases — and fears what could come next.
It doesn't help that Missouri has underfunded public health for years — a 2020 KHN and AP investigation found public health spending per person was $50 a year in Missouri — one of the bottom 10 states in the nation.
That is part of a right-wing strategy, said Democratic state Sen. John Rizzo, minority floor leader. "They actively go and break government, and then run their next campaign about how government is broken," he said.
All the while, the vaccination rate against COVID in Missouri hovers around 55%, with outliers like Pulaski County in the Ozarks below 21%. But those who opposed Kauerauf took his statements that he wanted to increase vaccination levels as a sign that he may be pro-mandate, despite his protestations otherwise.
Kauerauf declined to comment for this article.
Republican Gov. Mike Parson was outraged that his nominee had been blocked. "I've been a conservative Republican my entire life and contrary to what some Senators believe, tarnishing a man's character by feeding misinformation, repeating lies, and disgracing 35 years of public health experience is not what it means to be conservative," he tweeted.
Finding a state health department leader to tackle all these issues now may be nearly impossible, said former Kansas City health department head Dr. Rex Archer, who left his Missouri-based post last summer after 23 years. He'd advise anyone who asked about the job not to buy a house in the state or move their family.
"What qualified candidate would want to risk coming here and then not get confirmed because the party in power won't even support their governor's nomination?" he said.
Moon's not worried. He believes the state will find an anti-abortion, anti-mandate candidate whose positions he can stomach. "We don't want someone coming in who has been part of a state that had strict processes and procedures for this virus, bringing them with them," he told KHN, citing Kauerauf's prior public health experience in Illinois.
And he said he received roughly 1,000 emails encouraging his move to block the nomination, as well as support from dozens of protesters, including some from the Concerned Women for America of Missouri, which opposed Kauerauf's appointment.
That's terrifying to Vollmar, who said that means Moon doesn't want a public health director — he wants a politician.
"Our greatest chance for a better public health system in Missouri lies in the hands of the silent majority of our population that support science-based decisions," she said. "I pray they find their voice before it is too late."
The federal government has penalized 764 hospitals — including more than three dozen it simultaneously rates as among the best in the country — for having the highest numbers of patient infections and potentially avoidable complications.
The penalties — a 1% reduction in Medicare payments over 12 months — are based on the experiences of Medicare patients discharged from the hospital between July 2018 and the end of 2019, before the pandemic began in earnest. The punishments, which the Affordable Care Act requires be assessed on the worst-performing 25% of general hospitals each year, are intended to make hospitals focus on reducing bedsores, hip fractures, blood clots, and the cohort of infections that before COVID-19 were the biggest scourges in hospitals. Those include surgical infections, urinary tract infections from catheters, and antibiotic-resistant germs like MRSA.
This year's list of penalized hospitals includes Cedars-Sinai Medical Center in Los Angeles; Northwestern Memorial Hospital in Chicago; a Cleveland Clinic hospital in Avon, Ohio; a Mayo Clinic hospital in Red Wing, Minnesota; and a Mayo hospital in Phoenix. Paradoxically, all those hospitals have five stars, the best rating, on Medicare's Care Compare website.
Eight years into the Hospital-Acquired Condition Reduction Program, 2,046 hospitals have been penalized at least once, a KHN analysis shows. But researchers have found little evidence that the penalties are getting hospitals to improve their efforts to avert bedsores, falls, infections, and other accidents.
"Unfortunately, pretty much in every regard, the program has been a failure," said Andrew Ryan, a professor of healthcare management at the University of Michigan's School of Public Health, who has published extensively on the program.
"It's very hard to capture patient safety with the surveillance methods we currently have," he said. One problem, he added, is "you're kind of asking hospitals to call out events that are going to have them lose money, so the incentives are really messed up for hospitals to fully disclose" patient injuries. Academic medical centers say the reason nearly half of them are penalized each year is that they are more diligent in finding and reporting infections.
Another issue raised by researchers and the hospital industry is that under the law, the Centers for Medicare & Medicaid Services each year must punish the quarter of general care hospitals with the highest rates of patient safety issues even if they have improved and even if their infection and complication rates are only infinitesimally different from those of some non-penalized hospitals.
In a statement, CMS noted it had limited ability to alter the program. "CMS is committed to ensuring safety and quality of care for hospital patients through a variety of initiatives," CMS said. "Much of how the Hospital-Acquired Condition (HAC) Reduction Program is structured, including penalty amounts, is determined by law."
In allotting the penalties, CMS evaluated 3,124 general acute hospitals. Exempted from the evaluation are around 2,000 hospitals. Many of those are critical access hospitals, which are the only hospitals serving a geographic — often rural — area. The law also excuses hospitals that focus on rehabilitation, long-term care, children, psychiatry, or veterans. And Maryland hospitals are excluded because the state has a different method for paying its hospitals for Medicare patients.
For the penalized hospitals, Medicare payments are reduced by 1% for each bill from October 2021 through September 2022. The total amount of the penalties is determined by how much each hospital bills Medicare.
A third of the hospitals penalized in the list released this year had not been punished in the previous year. Some, like UC Davis Medical Center in California, have gone in and out of the penalty box over the program's eight years. Davis has been penalized four years and not punished four years.
"UC Davis Medical Center is usually within a few points of the [Hospital-Acquired Condition Reduction Program] threshold, so it's not unusual to move in and out of the program year to year," UC Davis Health said in an email. It said Davis ranked 38th out of 101 academic medical centers that use a private quality measurement system.
The Cleveland Clinic said that its satellite hospital in Avon has received awards from private groups, such as an "A" grade for patient safety from the nonprofit Leapfrog Group. Both it and Cedars-Sinai touted their five-star ratings. In addition, Cedars said that overall assessment comes even though the hospital deals with large numbers of very sick patients. "This rating is particularly meaningful because of the complexity of the care that many of our patients require," Cedars said in a statement.
Other hospitals declined to comment or did not respond to emails.
The KHN analysis found that the government penalized 38 of the 404 hospitals that were both included in the hospital-acquired conditions evaluation and had received five stars for "overall quality," which CMS calculates using dozens of metrics. Those include not just infection and complication rates but also death rates, readmission frequencies, ratings that patients give the hospital after discharge, and hospitals' consistency in following basic protocols in a timely manner, such as giving patients medicine to break up blood clots in the 30 minutes after they display symptoms of potential heart attacks.
In addition, 138 of 814 hospitals with the next-highest rating of four stars were docked by the program, KHN found.
Lower-rated hospitals were penalized with a higher frequency: Although just 9% of five-star hospitals were punished, 67% of one-star hospitals were.
KHN's analysis found major discrepancies between the list of penalized hospitals and how Medicare's Care Compare rated them for virtually the same patient safety infection rates and conditions. On the Medicare site, two-thirds of the penalized hospitals are rated as "no different than average" or "better than average" for the public safety measures CMS uses in assigning star ratings. The major differences center on the time frames for those measures and the structure of the penalty program. The Medicare website, for instance, evaluated only one year of infection rates, rather than the 18 months' worth that the penalty program examined. And the public ratings are more forgiving than the penalties: Care Compare rates each hospital's patient safety metric as average unless it's significantly higher or lower than the scores of most hospitals, while the penalty program always punishes the lowest quartile.
Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, said the penalties would cause more stress to hospitals already struggling to handle the influx of COVID patients, staffing shortages, and the extra costs of personal protective equipment. "It is demoralizing to the staff when they see their hospital is deemed unsafe or less safe than other hospitals," she said.
Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, said it was time for Congress and CMS to reevaluate the penalty program. "When this program had started, the thought was that we would get to zero" avoidable complications, she said, "and that hasn't proven to be the case despite a really good effort on the part of some of these hospitals."
She said the hospital-acquired conditions penalty program, along with other quality-improvement programs created by the ACA, feels "very ready for a refresh."
Orthopedic surgeons have raked in billions through ties to medical device companies via consulting deals, royalties or ownership stakes, while patients' injuries mount.
This article was published on Tuesday, February 8, 2022 in Kaiser Health News.
A Texas consulting company that arranges spine surgery and other medical care for people injured in car crashes has come under scrutiny in a widening federal bribery investigation.
How orthopedic surgeons have raked in billions through ties to medical device companies via consulting deals, royalties or ownership stakes, while patients' injuries mount.
Meg Healthcare, run by Dallas personal injury attorney Manuel Green and his wife, Melissa Green, is the focus of a search warrant recently unsealed by a Massachusetts federal court in an alleged healthcare fraud prosecution there. The probe is unusual because it uses a little-known law meant to crack down on organized crime racketeering across state lines.
Investigators alleged in the 2019 affidavit that the Texas company accepted thousands of dollars in bribes from SpineFrontier, a Massachusetts medical device company. SpineFrontier; its CEO, Dr. Kingsley Chin; and its chief financial officer, Aditya Humad, were indicted in September on charges of paying kickbacks to surgeons. All have pleaded not guilty.
No charges have been filed against the Greens or their company, and federal officials declined to discuss the investigation, which is detailed in the now-unsealed 2019 search warrant.
The Greens could not be reached for comment.
Meg Healthcare sets up spine surgery and other medical treatment through "letters of protection," or LOPs, legal contracts in which patients agree to pay medical bills using proceeds from a lawsuit or other claims against the party responsible for their injuries. These contracts are common in personal injury cases when people either lack health insurance or choose not to use it to pay for medical treatments after an accident. The downside is that patients can be left to foot the bill if their cases settle for less than they owe.
On its website, Meg Healthcare says it "represents a group of doctors and hospitals who were tired of seeing injured people without access to medical care they needed after an accident. We hold firm to the belief that under the law, and as a matter of basic decency, the person or business that caused the injury should be held responsible."
According to investigators, Manuel Green steered injured patients with LOPs to a local neurosurgeon who used SpineFrontier implants in surgeries at two Dallas-area hospitals.
"In exchange for attorney Green's referral, SpineFrontier agreed to pay attorney Green forty percent (40%) of the revenue SpineFrontier received in connection with those surgical procedures as a bribe," according to the search warrant affidavit.
Chin and SpineFrontier were the subjects of a KHN investigation published in June that found that manufacturers of hardware for spinal implants, artificial knees, and hip joints had paid more than $3.1 billion to orthopedic and neurological surgeons from August 2013 through 2019.
Government officials have argued for years that payments from device makers to surgeons and other medical providers can corrupt medical decisions, endanger patients, and inflate healthcare costs. The SpineFrontier indictment alleges that the company paid millions of dollars in bogus consulting fees to spine surgeons in exchange for their using its products, often in surgeries paid for by Medicare or other government-funded health insurance plans.
The Texas investigation adds a new dimension to the case by focusing on medical care that is paid for privately, which is not covered under federal anti-kickback statutes. Instead, the search warrant alleges violations of a law called the Travel Act. Enacted by Congress in the early 1960s to combat the mob, the Travel Act makes it a federal offense to commit crimes like bribery, prostitution, and extortion across state lines, including through the mail or by phone or email. Convictions can bring up to five years in prison, more if violence is involved.
Jonathan Halpern, a New York white-collar criminal defense attorney, said that such a use of the Travel Act reflects "an aggressive expansion" of the U.S. government's power to prosecute healthcare fraud.
One of the first healthcare fraud prosecutions under the Travel Act took place in Texas and led to convictions on bribery and kickback charges of 14 people, including six doctors, associated with Forest Park Medical Center in Dallas. They drew a combined sentence of 74 years and were ordered to pay $82.9 million in restitution.
Chris Davis, a Dallas lawyer who specializes in government investigations, said the Travel Act grants federal prosecutors jurisdiction in cases "where you don't have state or federal money involved."
The Meg Healthcare search warrant cites payments of more than $93,000 in 10 checks allegedly sent by SpineFrontier to the Texas company between April 2017 and October 2018. Investigators allege that the money was paid as a bribe for referring patients for surgeries using SpineFrontier products.
Investigators also cited a February 2016 email in which Melissa Green told the device company that a patient's legal case had been settled and asked: "Please let me know when MEG can expect to receive payment per our agreement. Thank you!"
About two months later, the device maker cut the company a check for $3,953.60, according to the search warrant.
Nine of the 10 checks were signed either by Chin, a Fort Lauderdale spine surgeon and SpineFrontier's founder, or Humad, according to the search warrant affidavit. Chin and Humad are the two executives indicted in September. Their lawyers had no comment.
Federal investigators sought the search warrant for Melissa Green's email account at Meg Healthcare in August 2019, arguing that they had "probable cause" to investigate the company for Travel Act violations, court records show. A federal judge in Massachusetts unsealed the warrant and related documents late last year.
Meg Healthcare invites lawyers whose clients have a "significant medical need" to apply to the company, according to its website. If approved, Meg Healthcare schedules an appointment with one of its doctors. "From there, our doctors will handle every aspect of the treatment sought, including surgery (if necessary)," the website says.
In a 2019 court filing in Dallas County, unrelated to the search warrant issued in the Massachusetts case, Manuel Green said he was the "founder and owner" of the company. He said it "assists physicians and medical facilities with reducing their exposure to risk when providing treatments to patients under [a] letter of protection."
He went on to say the company's "business model and the consulting services it provides are unique within the healthcare industry in the state of Texas." The company's website lists medical providers in 11 Texas cities.
According to investigators in the Massachusetts case, Green referred patients with LOPs to Dr. Jacob Rosenstein, an Arlington, Texas, neurosurgeon who used implants that SpineFrontier sold to two hospitals, Pine Creek Medical Center in Dallas and Saint Camillus Medical Center in Hurst, Texas. Pine Creek has since declared bankruptcy.
Neither Rosenstein nor representatives of the hospitals could be reached for comment.
Although proponents say that LOPs may be the only option for uninsured or underinsured crash victims to get medical care, a recent KHN investigation found that doctors and hospitals that accept them often charge much higher rates than Medicare or private insurance would pay for similar care and that the process can saddle patients with medical debt or expose them to safety risks.
Disputes over the size of medical bills and even whether the care was necessary are common in personal injury lawsuits in Texas. In one 2016 Dallas County case, for instance, a spine surgeon billed more than $100,000 for his services, while the hospital charged more than $435,000. By contrast, an expert hired by the defense set a reasonable fee at less than $4,000 for the surgeon and about $25,000 for the hospital, court records show. The case has since been settled.
Christine Dickison, a Texas nurse and medical coding consultant, said she routinely sees "hugely inflated" bills in car-crash lawsuits — and in some cases doubts whether the care was necessary.
"I see people who are undergoing surgery when there are literally no objective findings that support it," Dickison said. "That is very disturbing to me."
Faced with a stream of difficult choices about health and safety during a global pandemic, we may experience a unique kind of burnout that could deeply affect our brains and our mental health.
This article was published on Monday, February 7, 2022 in Kaiser Health News.
Most all of us have felt the exhaustion of pandemic-era decision-making.
Should I travel to see an elderly relative? Can I see my friends and, if so, is inside OK? Mask or no mask? Test or no test? What day? Which brand? Is it safe to send my child to day care?
Questions that once felt trivial have come to bear the moral weight of a life-or-death choice. So it might help to know (as you're tossing and turning over whether to cancel your non-refundable vacation) that your struggle has a name: decision fatigue.
In 2004, psychologist Barry Schwartz wrote an influential book, "The Paradox of Choice: Why More Is Less." The basic premise is this: Whether picking your favorite ice cream or a new pair of sneakers or a family physician, choice can be a wonderful thing. But too many choices can leave us feeling paralyzed and less satisfied with our decisions in the long run.
And that's just for the little things.
Faced with a stream of difficult choices about health and safety during a global pandemic, Schwartz suggests, we may experience a unique kind of burnout that could deeply affect our brains and our mental health.
Schwartz, an emeritus professor of psychology at Swarthmore College and a visiting professor at the Haas School of Business at the University of California-Berkeley, has been studying the interactions among psychology, morality, and economics for 50 years. He spoke with KHN's Jenny Gold about the decision fatigue that so many Americans are feeling two years into the pandemic, and how we can cope. The conversation has been edited for length and clarity.
Q: What is decision fatigue?
We all know that choice is good. That's part of what it means to be an American. So, if choice is good, then more must be better. It turns out, that's not true.
Imagine that when you go to the supermarket, not only do you have to choose among 200 kinds of cereal, but you have to choose among 150 kinds of crackers, 300 kinds of soup, 47 kinds of toothpaste, etc. If you really went on your shopping trip with the aim of getting the best of everything, you'd either die of starvation before you finished or die of fatigue. You can't live your life that way.
When you overwhelm people with options, instead of liberating them, you paralyze them. They can't pull the trigger. Or, if they do pull the trigger, they are less satisfied, because it's so easy to imagine that some alternative that they didn't choose would have been better than the one they did.
Q: How has the pandemic affected our ability to make decisions?
In the immediate aftermath of the pandemic, all the choices that we faced vanished. Restaurants weren't open, so you didn't have to decide what to order. Supermarkets weren't open, or they were too dangerous, so you didn't have to decide what to buy. All of a sudden your options were restricted.
But, as things eased up, you sort of go back to some version of your previous life, except [with] a whole new set of problems that none of us thought about before.
And the kinds of decisions you're talking about are extremely high-stakes decisions. Should I see my parents for the holidays and put them at risk? Should I let my kid go to school? Should I have gatherings with friends outside and shiver, or am I willing to risk sitting inside? These are not decisions we've had practice with. And having made this decision on Tuesday, you're faced with it again on Thursday. And, for all you know, everything has changed between Tuesday and Thursday. I think this has created a world that is just impossible for us to negotiate. I don't know that it's possible to go to bed with a settled mind.
Q: Can you explain what's going on in our brains?
When we make choices, we are exercising a muscle. And just as in the gym, when you do reps with weights, your muscles get tired. When this choice-making muscle gets tired, we basically can't do it anymore.
Q: We've heard a lot about more people feeling depressed and anxious during the pandemic. Do you think that decision fatigue is exacerbating mental health issues?
I don't think you need decision fatigue to explain the explosion of mental health problems. But it puts an additional burden on people.
Imagine that you decided that, starting tomorrow, you are going to be thoughtful about every decision you make. OK, you wake up in the morning: Should I get out of bed? Or should I stay in bed for another 15 minutes? Should I brush my teeth, or skip brushing my teeth? Should I get dressed now, or should I get dressed after I've had my coffee?
What the pandemic did for a lot of people is to take routine decisions and make them non-routine. And that puts a kind of pressure on us that accumulates over the course of the day, and then here comes tomorrow, and you're faced with them all again. I don't see how it could possibly not contribute to stress and anxiety and depression.
Q: As the pandemic wears on, are we getting better at making these decisions? Or does the compounded exhaustion make us worse at gauging the options?
There are two possibilities. One is that we are strengthening our decision-making muscles, which means that we can tolerate more decisions in the course of a day than we used to. Another possibility is that we just adapt to the state of stress and anxiety, and we're making all kinds of bad decisions.
In principle, it ought to be the case that when you're confronted with a dramatically new situation, you learn how to make better decisions than you were able to make when it all started. And I don't doubt that's true of some people. But I also doubt that it's true in general, that people are making better decisions than they were when it started.
Q: So what can people do to avoid burnout?
First, simplify your life and follow some rules. And the rules don't have to be perfect. [For example:] "I am not going to eat indoors in a restaurant, period." You will miss out on opportunities that might have been quite pleasant, but you've taken one decision off the table. And you can do that with respect to a lot of things the way that, when we do our grocery shopping, we buy Cheerios every week. You know, I'm going to think about a lot of the things I buy at the grocery, but I'm not going to think about breakfast.
The second thing you can do is to stop asking yourself, "What's the best thing I can do?" Instead, ask yourself, "What's a good enough thing I can do?" What option will lead to good enough results most of the time? I think that takes an enormous amount of pressure off. There's no guarantee that you won't make mistakes. We live in an uncertain world. But it's a lot easier to find good enough than it is to find best.
Already strained by the COVID-19 pandemic, hospitals around the country are desperate to staff their facilities as the highly transmissible omicron variant spreads.
This article was published on Monday, February 7, 2022 in Kaiser Health News.
A recent lawsuit filed by one Wisconsin health system that temporarily prevented seven workers from starting new jobs at a different health network raised eyebrows, including those of Brock Slabach, chief operations officer of the National Rural Health Association.
"To me, that signifies the desperation that hospital leaders are facing in trying to staff their hospitals," said Slabach.
His concern is for the smaller facilities that lack the resources to compete.
Already strained by the COVID-19 pandemic, hospitals around the country are desperate to staff their facilities as the highly transmissible omicron variant spreads. Governors in states such as Massachusetts and Wisconsin deployed the National Guard to help hospitals combat the surge. Six hospitals in Cleveland took out a full-page ad in the Sunday Plain Dealer with a singular plea to the community, "Help." CoxHealth is among the medical systems in Missouri to ask its office staff to help out on the front lines.
With no end to the crisis in sight, hospitals have taken to enticing workers from other facilities to fulfill needs. In South Dakota, Monument Health offered signing bonuses up to $40,000 for experienced nurses who would make a two-year commitment to the health system. Job listings for nurses in Maine and Virginia include $20,000 signing bonuses. Montana is offering healthcare workers up to $12,500 in moving expenses to relocate to the state.
The labor market squeeze is affecting more than just healthcare. People are being lured into teaching jobs and the military with $20,000 signing bonuses, while construction and trucking companies are looking everywhere for workers, even within their competitors' ranks.
But in the life-or-death field of medical care, these sorts of bounties have turned an already stressful situation into one that Slabach called "almost combustible." Smaller facilities — particularly rural ones that have struggled for years to stay afloat — are finding it difficult, if not impossible, to compete for healthcare workers in this labor market. If a hospital is unable to maintain safe staffing levels, it could be forced to curtail services or possibly close, a devastating blow for both the patients and economies of those communities. Nineteen rural hospitals closed in 2020 alone.
In Pilot Knob, Missouri, Iron County Medical Center CEO Joshua Gilmore said staffing costs for his 15-bed rural hospital have jumped 15% to 20% during the pandemic after he gave raises across the board to nurses and nursing assistants. He's also offering $10,000 signing bonuses to fill three nursing positions.
Those are big expenses for such a small facility, particularly during a pandemic when spending on supplies like masks and other personal protective equipment has also increased. The hospital has received just under $5 million in federal COVID relief, without which it likely would have closed, Gilmore said.
Gilmore said he has lost nurses to travel nursing jobs that can pay $10,000 per week. Typical pay for a nurse at Gilmore's facility is about $70,000 per year, he said. The hospital's staffing costs could have risen even higher if he had hired more travel nurses. Not only is their pay rate too expensive, he said, but his hospital lacks an intensive care unit — the area most commonly staffed by temporary nurses.
Two hundred miles to the west in Springfield, Missouri, CoxHealth has invested in training and retaining healthcare workers for years, according to Andy Hedgpeth, its vice president of human resources. Those efforts included increasing the class size at the affiliated nursing school from 250 to 400 students per year. Even so, the health system spent $25.5 million last year to give raises to 6,500 employees in an effort to retain workers.
"What we are seeing right now is the magnification of a critical shortage across the nation," Hedgpeth said. "The way out of that is through workforce development and showing individuals they can have stable careers in their community."
When hospitals do spend the money to hire travel nurses, it often ruffles the feathers of staff nurses, many of whom are already fighting for better working conditions. Hospitals are also losing workers to the very agencies they depend on for help.
In La Crosse, Wisconsin, the travel nursing agency Dedicated Nursing Associates placed a billboard near a Gundersen Health System facility advertising the agency's pay: $91 an hour for registered nurses, $69 for licensed practical nurses, and $41 for certified nursing assistants. Neither Gundersen nor Dedicated Nursing Associates responded to requests for comment.
Shane Johnson took to travel nursing after he was laid off from MU Healthcare in Columbia, Missouri, as part of pandemic cutbacks in May 2020. He said it's hard to see himself going back to being on staff at a hospital given the better pay and flexibility that the temporary assignments afford him. A six-week contract in Chicago allowed him to earn as much in two days as he would have in two weeks at his previous job. A 15-week contract in Louisville, Kentucky, allowed him to be closer to family. His current work with the staffing platform CareRev allows him to choose his assignments on a shift-by-shift basis while still getting health insurance and retirement benefits.
"The question all these nurses are asking is: If they can pay these crisis wages right now, why couldn't they pay us more to do the work we were doing?" Johnson said.
The travel nursing industry has caught the eye of lawmakers. Some states are considering legislation that would cap travel nurses' pay. Federally, more than 200 members of Congress asked the White House Coronavirus Response Team coordinator to investigate possible "anticompetitive activity."
Even in a hiring environment this competitive, the Wisconsin lawsuit filed on Jan. 20 is a new frontier in the staffing battles. ThedaCare, a regional health system in Wisconsin's Fox Valley, filed a temporary injunction attempting to prevent three of its nurses and four of its technicians — all at-will employees — from leaving and joining competitor Ascension Wisconsin until ThedaCare could find replacement workers. A judge temporarily blocked those healthcare workers from starting their new jobs before deciding ThedaCare couldn't force the employees to stay.
The spat is just a small piece of "a much bigger issue," according to Tim Size, executive director of Rural Wisconsin Health Cooperative. Without intervention, he said, the staffing shortages currently attributed to the pandemic could become the new normal.
Case in point, Size said, is a 2021 report by the Wisconsin Council on Medical Education and Workforce that projects the state could be short almost 16,000 nurses by 2035. Even if the reality is only half as bad as the projection, Size said, a shortage of 8,000 nurses in Wisconsin dwarfs the shortages now experienced in the pandemic.
"We have to make a much more substantive investment in our schools of nursing," Size said.
According to Slabach, one missed opportunity was the National Healthcare Workforce Commission created in 2010 by the Affordable Care Act but never funded by Congress. The commission would have been tasked with measuring the scope of the healthcare workforce challenges and proposing solutions, but it has never convened.
"We need to mobilize all of the resources that we have to figure out how we're going to solve this problem, and it starts with a systemic approach," Slabach said. "We can't just pay our way out of this through bonuses and bounties."
In the shorter term, Gilmore said, small hospitals like his could use more federal support. The $5 million that Iron County Medical Center received was critical, Gilmore said, but has already been spent. Now his facility is dealing with the omicron surge and is still reeling from the delta wave over the summer.
"I'm calling my congressman and letting him know that we need help," Gilmore said. "We can't do this on our own."
SACRAMENTO, Calif. — Gov. Gavin Newsom's administration has negotiated a secret deal to give Kaiser Permanente a special Medicaid contract that would allow the healthcare behemoth to expand its reach in California and largely continue selecting the enrollees it wants, which other health plans say leaves them with a disproportionate share of the program's sickest and costliest patients.
The deal, hammered out behind closed doors between Kaiser Permanente and senior officials in Newsom's office, could complicate a long-planned and expensive transformation of Medi-Cal, the state's Medicaid program, which covers roughly 14 million low-income Californians.
It has infuriated executives of other managed-care insurance plans in Medi-Cal, who say they stand to lose hundreds of thousands of patients and millions of dollars a year. The deal allows KP to limit enrollment primarily to its previous enrollees, except in the case of foster kids and people who are eligible for both Medicare and Medi-Cal.
"It has caused a massive amount of frenzy," said Jarrod McNaughton, CEO of the Inland Empire Health Plan, which covers about 1.5 million Medi-Cal enrollees in Riverside and San Bernardino counties. "All of us are doing our best to implement the most transformational Medi-Cal initiative in state history, and to put all this together without a public process is very disconcerting."
Linnea Koopmans, CEO of the Local Health Plans of California, echoed McNaughton's concerns.
Insurance plans got wind of the backroom talks when broad outlines of the deal were leaked days before the state briefed their executives Thursday.
Dr. Bechara Choucair, Kaiser Permanente's chief health officer, argued in a prepared written response on behalf of KP that because it operates both as a health insurer and a healthcare provider, KP should be treated differently than other commercial health plans that participate in Medi-Cal. Doing business directly with the state will eliminate complexity and improve the quality of care for the Medi-Cal patients it serves, he said.
"We are not seeking to turn a profit off Medi-Cal enrollment," Choucair said. "Kaiser Permanente participates in Medi-Cal because it is part of our mission to improve the health of the communities we serve. We participate in Medi-Cal despite incurring losses every year."
His statement cited nearly $1.8 billion in losses in the program in 2020 and said KP had donated $402 million to help care for uninsured people that year.
Kaiser Permanente, the state's largest managed-care organization, is one of Newsom's most generous supporters and close political allies.
The new, five-year contract, confirmed to KHN by administration officials and expected to be announced publicly Friday, will take effect in 2024 pending approval from the legislature — and will make KP the only insurer with a statewide Medi-Cal contract. It allows KP to solidify its position before California's other commercial Medi-Cal plans participate in a statewide bidding process — and after those plans have spent many months and considerable resources developing their bidding strategies.
Other health plans fear the contract could also muddle a massive and expensive initiative called CalAIM that aims to provide social services to the state's most vulnerable patients, including home-delivered meals, housing aid for homeless people, and mold removal from homes. Under its new contract, KP must provide some of those services. But some executives at other health plans say KP will not have to enroll a large number of sick patients who need such services because of how it limits enrollment.
Critics of the deal noted Newsom's close relationship with KP, which has given nearly $100 million in charitable funding and grant money to boost Newsom's efforts against homelessness, COVID response, and wildfire relief since 2019, according to state records and KP news releases. The healthcare giant was also one of two hospital systems awarded a no-bid contract from the state to run a field hospital in Los Angeles during the early days of the COVID pandemic, and it got a special agreement from the Newsom administration to help vaccinate Californians last year.
Jim DeBoo, Newsom's executive secretary, used to lobby for KP before joining the administration. Toby Douglas, a former director of the state Department of Healthcare Services, which runs Medi-Cal, is now Kaiser Permanente's vice president for national Medicaid.
Still, many critics agree that Kaiser Permanente is a linchpin of the state's healthcare system, with its strong focus on preventive care and high marks for quality of care. Many of the public insurance plans upset by the deal subcontract with KP for patient care and acknowledge that their overall quality scores will likely decline when KP goes its own way.
Michelle Baass, director of the state Department of Healthcare Services, said Medi-Cal had risked losing KP's "high quality" and "clinical expertise" altogether had it been required to accept all enrollees, as the other health plans must. But she said KP will have to comply with all other conditions that other plans must meet, including tightened requirements on access, quality, consumer satisfaction, and health equity.
The state will also have greater oversight over patient care, she said.
"This proposal is a way to help ensure Kaiser treats more low-income patients, and that more low-income patients have access to Kaiser's high-quality services," Baass said.
Though Kaiser Permanente has 9 million enrollees, close to a quarter of all Californians, only about 900,000 of them are Medi-Cal members.
Under the current system, 12 of the 24 other managed care insurance plans that participate in Medi-Cal subcontract with KP to care for a subset of their patients, keeping a small slice of the Medi-Cal dollars earmarked for those patients. Under the new contract, KP can take those patients away and keep all of the money.
In its subcontracts, and in counties where it enrolls patients directly, KP accepts only people who are recent Kaiser Permanente members and, in some cases, their family members. It is the only health plan that can limit its Medi-Cal enrollment in this way.
The new contract allows KP to continue this practice, but it also requires Kaiser Permanente to take on more foster children and complex, expensive patients who are eligible for both Medi-Cal and Medicare. It allows KP to expand its geographic reach in Medi-Cal to do so.
Baass said the state expects KP's Medi-Cal enrollment to increase 25% over the life of the contract.
KP defended the practice of limiting enrollment primarily to its previous members, arguing that it provides "continuity of care when members transition into and out of Medi-Cal."
The state has long pushed for a larger KP footprint in Medi-Cal, citing its high quality ratings, its strong integrated network, and its huge role on the broader healthcare landscape.
"Kaiser Permanente historically has not played a very big role in Medi-Cal, and the state has long recognized that we would benefit from having them more engaged because they get better health outcomes and focus on prevention," said Daniel Zingale, a former Newsom administration official and health insurance regulator who now advises a lobbying firm that has Kaiser Permanente as a client.
But by accepting primarily people who have been KP members in the recent past, the health system has been able to limit its share of high-need, expensive patients, say rival health plan executives and former state health officials.
The executives fear the deal could saddle them with even more of these patients in the future, including homeless people and those with mental illnesses — and make it harder to provide adequate care for them. Many of those patients will join Medi-Cal for the first time under the CalAIM initiative, and KP will not be required to accept many of them.
"Awarding a no-bid Medi-Cal contract to a statewide commercial plan with a track record of 'cherry picking' members and offering only limited behavioral health and community support benefits not only conflicts with the intent and goals of CalAIM but undermines publicly organized healthcare," according to an internal document prepared by the Inland Empire Health Plan.
The plan said it stands to lose the roughly 144,000 Medi-Cal members it delegates to KP and about $10 million in annual revenue. L.A. Care, the nation's largest Medicaid health plan, with 2.4 million enrollees in Los Angeles County, will lose its 244,000 KP members, based on data shared by the plan.
The state had been scheduled on Wednesday to release final details and instructions for the commercial plans that are submitting bids for new contracts starting in 2024. But it delayed the release a week to make the KP deal public beforehand.
Baass said the state agreed to exempt KP from the bidding process because the standardized contract expected to result from it would have required the insurer to accept all enrollees, which Kaiser Permanente does not have the capacity to do.
"It's not surprising to me that the state will go to extraordinary means to make sure that Kaiser is in the mix, given it has been in the vanguard of our healthcare delivery system," Zingale said.
Having a direct statewide Medi-Cal contract will greatly reduce the administrative workload for KP, which will now deal with only one agency on reporting and oversight, rather than the 12 public plans it currently subcontracts with.
And the new contract will give it an even closer relationship with Newsom and state health officials.
In 2020, KP gave $25 million to one of Newsom's key initiatives, a state homelessness fund to move people off the streets and into hotel rooms, according to a KHN analysis of charitable payments filed with the California Fair Political Practices Commission. The same year, it donated $9.75 million to a state COVID relief fund.
In summer 2020, when local and state public health departments struggled to contain COVID spread, the healthcare giant pledged $63 million in grant funding to help contract-tracing efforts.
KP's influence extends beyond its massive charitable giving. Its CEO, Greg Adams, landed an appointment on the governor's economic recovery task force early in the pandemic, and Newsom has showcased KP hospitals at vaccine media events throughout the state.
"In California and across the U.S., the campaign contributions and the organizing, the lobbying, all of that stuff is important," said Andrew Kelly, an assistant professor of health policy at California State University-East Bay. "But there's a different type of power that comes from your ability to have this privileged position within public programs."
Because comprehensive data isn't available, the scope and impact of current shortages can't be documented with precision. But anecdotal reports suggest the situation is severe.
This article was published on Thursday, February 3, 2022 in Kaiser Health News.
Frail older adults are finding it harder than ever to get paid help amid acute staff shortages at home health agencies.
Several trends are fueling the shortages: Hospitals and other employers are hiring away home health workers with better pay and benefits. Many aides have fallen ill or been exposed to COVID-19 during the recent surge of omicron cases and must quarantine for a time. And staffers are burned out after working during the pandemic in difficult, anxiety-provoking circumstances.
The implications for older adults are dire. Some seniors who are ready for discharge are waiting in hospitals or rehabilitation centers for several days before home care services can be arranged. Some are returning home with less help than would be optimal. Some are experiencing cutbacks in services. And some simply can't find care.
Janine Hunt-Jackson, 68, of Lockport, New York, falls into this last category. She has post-polio syndrome, which causes severe fatigue, muscle weakness, and, often, cognitive difficulties. Through New York's Medicaid program, she's authorized to receive 35 hours of care each week. But when an aide left in June, Hunt-Jackson contacted agencies, asked friends for referrals, and posted job notices on social media, with little response.
"A couple of people showed up and then disappeared. One man was more than willing to work, but he didn't have transportation. I couldn't find anybody reliable," she said. Desperate, Hunt-Jackson arranged for her 24-year-old grandson, who has autism and oppositional defiant disorder, to move into her double-wide trailer and serve as her caregiver.
"It's scary: I'm not ready to be in a nursing home, but without home care there's no other options," she said.
Because comprehensive data isn't available, the scope and impact of current shortages can't be documented with precision. But anecdotal reports suggest the situation is severe.
"Everyone is experiencing shortages, particularly around nursing and home health aides, and reporting that they're unable to admit patients," said William Dombi, president of the National Association for Home Care & Hospice. Some agencies are rejecting as many as 40% of new referrals, according to reports he's received.
"We're seeing increasing demand on adult protective services as a result of people with dementia not being able to get services," said Ken Albert, president of Androscoggin Home Healthcare and Hospice in Maine and chair of the national home care association's board. "The stress on families trying to navigate care for their loved ones is just incredible."
In mid-January, the Pennsylvania Homecare Association surveyed its members: Medicare-certified home health agencies, which provide assistance from aides and skilled nursing and therapy services, and state-licensed home care agencies, which provide nonmedical services such as bathing, toileting, cooking, and housekeeping, often to people with disabilities covered by Medicaid. Ninety-three percent of Medicare-certified home health and hospice agencies and 98% of licensed agencies said they had refused referrals during the past year, according to Teri Henning, the association's chief executive officer.
"Our members say they've never seen anything like this in terms of the number of openings and the difficulty hiring, recruiting, and retaining staff," she told me.
Lori Pavic is a regional manager in Pennsylvania for CareGivers America, an agency that provides nonmedical services, mostly to Medicaid enrollees who are disabled. "Our waiting list is over 200 folks at this time and grows daily," she wrote in an email. "We could hire 500 [direct care workers] tomorrow and still need more."
Another Pennsylvania agency that provides nonmedical services, Angels on Call, is giving priority for care to people who are seriously compromised and live alone. People who can turn to family or friends are often getting fewer services, said C.J. Weaber, regional director of business development for Honor Health Network, which owns Angels on Call.
"Most clients don't have backup," she said.
This is especially true of older adults with serious chronic illnesses and paltry financial resources who are socially isolated — a group that's "disproportionately affected" by the difficulties in accessing home healthcare, said Jason Falvey, an assistant professor of physical therapy and rehabilitation science at the University of Maryland School of Medicine.
Many agencies are focusing on patients being discharged from hospitals and rehab facilities. These patients, many of whom are recovering from COVID, have acute needs, and agencies are paid more for serving this population under complicated Medicare reimbursement formulas.
"People who have long-term needs and a high chronic disease burden, [agencies] just aren't taking those referrals," Falvey said.
Instead, families are filling gaps in home care as best they can.
Anne Tumlinson, founder of ATI Advisory, a consulting firm that specializes in long-term care, was shocked when a home health nurse failed to show up for two weeks in December after her father, Jim, had a peripherally inserted central catheter put in for blood cell transfusions. This type of catheter, known as a PICC line, requires careful attention to prevent infections and blood clots and needs to be flushed with saline several times a day.
"No show from nurse on Friday, no call from agency," Tumlinson wrote on LinkedIn. "Today, when I call, this 5 star home health agency informed me that a nurse would be out SOMETIME THIS WEEK. Meanwhile, my 81 year old mother and I watched youtube videos this weekend to learn how to flush the picc line and adjust the oxygen levels."
Tumlinson's father was admitted to the hospital a few days before Christmas with a dangerously high level of fluid in his lungs. He has myelodysplastic syndrome, a serious blood disorder, and Parkinson's disease. No one from the home health agency had shown up by the time he was admitted.
Because her parents live in a somewhat rural area about 30 minutes outside Gainesville, Florida, it wasn't easy to find help when her father was discharged. Only two home health agencies serve the area, including the one that had failed to provide assistance.
"The burden on my mother is huge: She's vigilantly monitoring him every second of the day, flushing the PICC line, and checking his wounds," Tumlinson said. "She's doing everything."
Despite growing needs for home care services, the vast majority of pandemic-related federal financial aid for healthcare has gone to hospitals and nursing homes, which are also having severe staffing problems. Yet all the parts of the health system that care for older adults are interconnected, with home care playing an essential role.
Abraham Brody, associate professor of nursing and medicine at New York University, explained these complex interconnections: When frail older patients can't get adequate care at home, they can deteriorate and end up in the hospital. The hospital may have to keep older patients for several extra days if home care can't be arranged upon discharge, putting people at risk of deteriorating physically or getting infections and making new admissions more difficult.
When paid home care or help from family or friends isn't available, vulnerable older patients may be forced to go to nursing homes, even if they don't want to. But many nursing homes don't have enough staffers and can't take new patients, so people are simply going without care.
Patients with terminal illnesses seeking hospice care are being caught up in these difficulties as well. Brody is running a research study with 25 hospices, and "every single one is having staffing challenges," he said. Without enough nurses and aides to meet the demand for care, hospices are not admitting some patients or providing fewer visits, he noted.
Before the pandemic, hospice agencies could usually guarantee a certain number of hours of help after evaluating a patient. "Now, they really are not able to guarantee anything on discharge," said Jennifer DiBiase, palliative care social work manager at Mount Sinai Health System in New York City. "We really have to rely on the family for almost all hands-on care."
We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the healthcare system. Visit khn.org/columnists to submit your requests or tips.
Therapists are concerned about a price transparency provision that requires most licensed medical practitioners to give patients detailed upfront cost estimates.
This article was published on Thursday, February 3, 2022 in Kaiser Health News.
Groups representing a range of mental health therapists say a new law that protects people from surprise medical bills puts providers in an ethical bind and could discourage some patients from care.
The therapists take no issue with the main aim of the legislation, which is to prevent patients from being blindsided by bills, usually for treatment received from out-of-network medical providers who work at in-network facilities. Instead, they are concerned about another part of the law — a price transparency provision — that requires most licensed medical practitioners to give patients detailed upfront cost estimates, including a diagnosis, and information about the length and costs involved in a typical course of treatment. That's unfitting for mental healthcare, they say, because diagnoses can take time and sometimes change over the course of treatment.
Finally, if they blow the estimate by at least $400, the law says uninsured or self-pay patients can challenge the bills in arbitration.
Arguing that the rule is burdensome and unnecessary, mental health providers wrote a Jan. 25 letter to the Department of Health and Human Services, seeking an exemption from the "good faith" estimates for routine mental and behavioral health services. The letter was signed by 11 groups, including the American Psychological Association, the National Association of Social Workers, the American Psychiatric Association, and the Psychotherapy Action Network.
Some also worry that the law will allow insurance companies to play a larger role in dictating what even non-network mental health therapists can charge, although policy experts say it isn't clear how that could happen. Although exact figures are not available, it's estimated that one-third to one-half of psychologists are not in-network with insurers, the psychologists' association said. And those numbers do not include other practitioners, such as psychiatrists and licensed clinical social workers, who are also out of network.
"We got thrown into this bill, but the intention [of the law] was not mental health but high-cost medical care," said Jared Skillings, chief of professional practice with the American Psychological Association. "We're deeply concerned that this [law] inadvertently would allow private insurance companies to set regional rates across the country that, for independent practitioners, would be a race to the bottom."
Therapy costs vary widely around the U.S. and by specialty, but generally range from $65 an hour to $250 or more, according to the website GoodTherapy.
The good faith estimates must be given this year to uninsured or self-pay patients for medical or mental healthcare services. They were included in the No Surprises Act as part of a broader effort to give patients a good idea of cost, both per visit and for a course of treatment, in advance.
Therapists say their professional codes of ethics already require disclosure to patients of per-visit costs. Requiring diagnostic billing codes in the estimate before even seeing a patient — as they interpret the rule — is unethical, they argue, and tallying up what might be weeks or even months of treatment costs could keep some patients from undergoing care.
"If people see a large dollar amount, they might be intimidated or scared into not getting help at all," said Linda Michaels, a private practice therapist in Chicago and co-chair of the Psychotherapy Action Network.
The counterargument, though, is that one of the law's aims was to provide patients with pricing information — for mental health services or medical care — that is less opaque and more similar to what they're used to when shopping for other types of goods or services.
Benedic Ippolito, an economist at the American Enterprise Institute, said he is sympathetic to medical providers' concerns about the extra administrative burden. But "giving consumers a better sense of financial obligation they are exposed to and imposing some cost pressure on providers are both reasonable goals," he said.
Even among providers, there is no universal agreement on how burdensome the estimates will be.
"It's not an unreasonable thing, frankly, for psychiatrists, not just plastic surgeons or podiatrists, to say, 'If you want me to do this and you're not covered by insurance or whatever, it will cost you X amount for the whole episode of care and this is what you get in return,'" said Dr. Robert Trestman, chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine. Although he serves on an American Psychiatric Association committee, he was voicing his own opinion.
The Centers for Medicare & Medicaid Services said mental health providers are not exempt from the rules about good faith estimates, in a written statement to KHN. It added, however, that the agency is working on "technical assistance geared toward mental health providers and facilities." Federal agencies often issue additional clarification of rules, sometimes in the form of FAQs.
The No Surprises Act took effect on Jan. 1. Its thrust was to bar medical providers from sending what are called surprise or "balance" bills to insured patients for out-of-network care provided in emergencies or for nonemergency situations at in-network facilities. Common before the law passed, such bills often amounted to hundreds or thousands of dollars, representing the difference between the amount insurers paid toward out-of-network care and the often much higher amounts charged.
Now, insured patients in most cases will pay only what they would have been billed for in-network care. Any additional amount must be worked out between their insurer and the provider. Groups representing emergency doctors, anesthesiologists, air ambulance providers, and hospitals have filed lawsuits over a Biden administration rule that outlines the factors independent arbitrators should consider when deciding how much an insurer must pay the medical provider toward disputed bills.
Most mental health services, however, aren't directly touched by this part of the directive because treatment is not typically performed in emergency situations or in-network facilities.
Instead, the complaint from mental health providers focuses on the good faith estimates.
Additional rules are expected soon that will spell out how upfront estimates will be handled for people with health coverage. In their letter to HHS, the behavioral health groups say they fear the estimates will then be used by insurers to limit treatment for insured patients, or influence pay negotiations with therapists.
Several policy experts say they do not think the law will affect mental health reimbursement in most cases.
"Mental health professionals will have the exact same ability to bill out-of-network, to have patients agree to whatever market price is for their services," said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, who has long studied balance billing issues. "Nothing about the No Surprises Act restricts that."
Some of the therapy groups' concerns may stem from misreading the law or rules implementing it, say policy experts, but they still reflect the confusion providers share surrounding the rollout of the law.
As for how to handle pre-treatment diagnoses that are needed to deliver good faith estimates, CMS said in its email to KHN that providers could estimate costs for an initial screening, then follow up with an additional estimate after a diagnosis.
"No one is going to be forced to make a diagnosis of a patient they have not met," Adler said.