KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Betting on 'Golden Age' of Colonoscopies, Private Equity Invests in Gastro Docs

KFF Health News, May 27, 2022

With market dominance comes the business opportunity to set and maintain high prices.

This story was published on Friday, May 27, 2022 in Kaiser Health News.

By Emily Pisacreta and Emmarie Huetteman

Mariel needed a new gastroenterologist.

Having just moved back to San Antonio, the 30-something searched for a doctor to manage her Crohn's disease, an inflammatory bowel condition that is successfully managed with medications and lifelong monitoring — including regular colonoscopies.

Mariel booked an appointment and learned she would be on the hook for a $1,100 colonoscopy — about three times what she had paid for the same test in a different state. Almost three-quarters of the bill would be a "facility fee" for the in-office procedure at a colonoscopy clinic. (KHN agreed not to disclose Mariel's last name because she is concerned speaking out might affect her doctor's willingness to manage her medical condition.)

Preventive colonoscopies are covered without patient cost sharing under the Affordable Care Act, but colonoscopies for patients with existing conditions, like Mariel, are not. A 2019 study found patients with inflammatory bowel diseases, including Crohn's disease, incur about $23,000 in healthcare costs a year. Medication treatments alone can cost tens of thousands of dollars annually.

But shopping around proved frustrating. Although San Antonio has plenty of gastroenterology offices, more than two dozen of them are controlled by the same private equity-backed group.

In 2018, one of the nation's largest independent gastroenterology practices, Texas Digestive Disease Consultants, announced a deal with the Chicago-based private equity firm Waud Capital to expand by offering management services to other physicians. At the time, the Dallas-based practice had 110 locations, mostly in Texas — including San Antonio. Today its management group, the GI Alliance, operates in a dozen states with more than 400 locations — and is growing fast.

With market dominance comes the business opportunity to set and maintain high prices. "It's pretty much the only game in town," Mariel said.

Private equity, known for making a profit on quick-turnaround investments in struggling businesses across many industries, has taken an increasingly active interest in healthcare in the past decade. It has invested in gastroenterology practices in recent years to tap into the revenue potential in meeting growing demand.

"We are in the Golden Age of older rectums," one investment manager wrote in 2017.

Tired of having to manage the increasingly complicated business of running a practice and, often, lured by the sweet deals investors offer, more and more doctors have partnered with or even sold their practices to private equity funds. So investment managers now control the financial decisions for many medical offices caring for patients with digestive ailments. With profit the primary driver, patients may find they pay much more for the same — or less — care.

The Centers for Disease Control and Prevention recently lowered the age at which healthy Americans are urged to begin routine screenings for colon cancer — ensuring that most will undergo regular colonoscopies beginning at age 45. And the population is aging, meaning more people will be needing the procedure.

For those 65 and older, Medicare picks up the tab. But even when a benign polyp is found during a simple screening, patients sometimes end up with an unexpected bill. And less-than-scrupulous providers often find ways to bill for some services, such as out-of-network anesthesia monitoring.

Studies show that private equity investment in healthcare results in more surprise bills and overall higher costs for patients. Surprise billing is the practice of charging insured patients for out-of-network care unknowingly received, including in emergencies and at otherwise in-network facilities.

Before a federal ban on surprise billing took effect this year, it was common for patients to get slapped with an expensive bill after being treated by an emergency room doctor employed by a private equity-owned staffing service — a problem that policy experts say was not a glitch but rather a business model for private equity companies.

Nearly 10% of the nation's 14,000 gastroenterologists were partners in or employed by a private-equity backed organization as of last fall, according to a report by Physician Growth Partners, which represents independent physician groups in transactions with private equity.

In 2021, the number of private equity acquisitions of gastroenterology practices grew by 28% over the previous year, according to Spherix Global Insights and Fraser Healthcare.

Complex government regulations, technological innovations, and insurance industry practices have driven many gastroenterologists to sell shares in their practices, said Praveen Suthrum, who runs a consulting company for physician practices. Many physicians argue reimbursement rates are too low to keep up with complex negotiations with insurers and the other rising costs of operating an independent practice.

Private equity typically purchases a stake in a healthcare practice, then adjusts its operations to make it more profitable. It may switch to cheaper suppliers, shorten appointment windows, bill aggressively, or lay off staff, to name a few strategies — the kind of changes that save money at the expense of patient care.

In December, NBC News reported on how one private equity-owned group of dermatology practices overbooked patients, lost test results, and leaned on cheaper labor from physician assistants and nurse practitioners who may miss critical diagnoses.

A study out last year from the National Bureau of Economic Research showed that when private equity owned a nursing home, patients were more likely to die in their first months there and much more likely to be prescribed antipsychotic drugs — which are known to increase mortality among the elderly. Taxpayer spending per procedure or service in a private equity-owned facility goes up about 11%.

Private equity has shown a lot of interest in healthcare practices that perform high-volume procedures, especially those with growth potential.

"Lots of people are needing injections in the eye for macular edema, and lots of people need colonoscopies, and lots of people need skin biopsies," said Dr. Jane Zhu, a health services researcher at Oregon Health and Science University in Portland who has studied the role of private equity in healthcare. "And these are things that will only grow in volume over time as the population ages."

Zhu said usually the investors start by acquiring a well-performing practice, or group of practices, in one geographic area — called a "platform practice."

"It's well established. It has some brand recognition," Zhu said. "It has good market reach. There may be multiple sites. It has lots of patients that are already affiliated with that practice, and they buy that up, and there are opportunities for consolidation."

Mergers create larger groups with more power to negotiate rates with insurance companies and charge what they'd like. The possibility of capitalizing on the good name of a respected practice alone may make it a valuable investment.

Zhu said these medical practices are considered a short- to medium-term investment, with an average period of three to eight years before the investors sell.

Suthrum said private equity firms are good at making their case to doctors, assuring them they'll let the doctors do the medicine while the businesspeople do the business.

Doctors think, "If I'm going to survive, then I will either have to sell myself to the hospital or, what is the alternative?" Suthrum said in an interview. "The alternative is private equity."

This article was adapted from a recent episode of "An Arm and a Leg," a podcast about the cost of healthcare, produced in partnership with KHN.

Emmarie Huetteman: ehuetteman@kff.org, @emmarieDC

'An Arm and a Leg': Private Equity Is Everywhere in Healthcare. Really.

KFF Health News, May 27, 2022

In this episode of the podcast, we find out why these doctors are selling their practices to private equity.

This podcast was released on Friday, May 27, 2022 by Kaiser Health News.

By Dan Weissmann

Private equity companies are the house-flippers of the investment world, and they’ve found their way into many areas of our lives. Now, they’re at gastroenterologists’ offices, too, hoping to change the way these doctors do business and make a quick buck selling the practice down the road.

In this episode of the podcast, we find out why these doctors are selling their practices to private equity to begin with, and what it could mean for the quality and cost of your healthcare.

Here's a transcript.

'Almost Like Malpractice': To Shed Bias, Doctors Get Schooled to Look Beyond Obesity

KFF Health News, May 24, 2022

Despite obesity's prevalence, it carries a unique stigma.

This article was published on Tuesday, May 24, 2022, in Kaiser Health News.

By Lauren Sausser

When Melissa Boughton complained to her OB-GYN about dull pelvic pain, the doctor responded by asking about her diet and exercise habits.

The question seemed irrelevant, considering the type of pain she was having, Boughton thought at the time. But it wasn't unusual coming from this doctor. "Every time I was in there, she'd talk about diet and exercise," said Boughton, who is 34 and lives in Durham, North Carolina.

On this occasion, three years ago, the OB-GYN told Boughton that losing weight would likely resolve the pelvic pain. The physician brought up diet and exercise at least twice more during the appointment. The doctor said she'd order an ultrasound to put Boughton's mind at ease.

The ultrasound revealed the source of her pain: a 7-centimeter tumor filled with fluid on Boughton's left ovary.

"I hate that doctor for the way she treated me — like my pain was no big deal," Boughton said. "She seemed to make a decision about me based off of a very cursory look."

Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories. Obesity, which characterizes patients whose body mass index is 30 or higher, is pervasive in the South and Midwest, according to the Centers for Disease Control and Prevention. The state with the highest rate is Mississippi, where 4 in 10 adults qualify as obese.

Obesity is a common, treatable condition linked to a long list of health risks, including Type 2 diabetes, heart disease, and some cancers. Despite obesity's prevalence, it carries a unique stigma.

Doctors often approach the practice of medicine with an anti-fat bias and struggle to communicate with patients whose weight exceeds what's considered the normal range. Some obesity experts blame a lack of focus on the subject in medical schools. Others blame a lack of empathy.

To counter that, the Association of American Medical Colleges plans to roll out in June new diversity, equity, and inclusion standards aimed at teaching doctors, among other things, about respectful treatment of people diagnosed as overweight or obese.

That's not happening for many patients, said Dr. Scott Butsch, director of obesity medicine at the Cleveland Clinic's Bariatric and Metabolic Institute. "This is almost like malpractice. You have these physicians or clinicians — whoever they are — relating everything to the patient's obesity without investigation," Butsch said. "The stereotypes and misperceptions around this disease just bleed into clinical practice."

The problem, Butsch argued, is that too little attention is paid to obesity in medical school. When he trained and taught at Harvard Medical School for several years, Butsch said, students received no more than nine hours of obesity education spread over three days in four years.

In 2013, the American Medical Association voted to recognize obesity as a disease. But, Butsch said, doctors often approach it with a one-size-fits-all approach. "Eat less, move more" doesn't work for everyone, he said.

Parents and medical providers need to take special care when talking to children who have been diagnosed with obesity about their weight, psychologists have warned. The way parents and providers talk to kids about their weight can have lifelong consequences and in some cases trigger unhealthy eating habits. For children who are obese, obesity experts agree, weight loss isn't always the goal.

"There are many different forms of obesity, but we're treating them like we're giving the same chemotherapy to all kinds of cancer," Butsch said.

All but four of the country's 128 M.D.-granting medical schools reported covering content related to obesity and bariatric medicine in the 2020-21 academic year, according to curriculum data provided to KHN by the Association of American Medical Colleges, which does not represent osteopathic schools.

Even so, research suggests that many physicians haven't been sufficiently trained to address weight issues with patients and that obesity education in medical schools across the world is "grossly neglected." A survey completed by leaders at 40 U.S. medical schools found that only 10% felt their students were "very prepared" to manage patients with obesity.

Meanwhile, "half of the medical schools surveyed reported that expanding obesity education was a low priority or not a priority," wrote the authors of a 2020 journal article that describes the survey's results.

Butsch wants Congress to pass a resolution insisting that medical schools incorporate substantive training on nutrition, diet, and obesity. He acknowledged, though, that the medical school curriculum is already packed with subject matter deemed necessary to cover.

Dr. David Cole, president of the Medical University of South Carolina, said plenty of topics should be covered more comprehensively in medical school but aren't. "There's this massive tome — it's about this big," Cole said, raising his hand about a foot off the top of a conference table in Charleston. "The topic is: Things I never learned in medical school."

The bigger issue, he said, is that medicine has historically been taught to emphasize memorization and has failed to emphasize culturally competent care. "That was valid 100 years ago, if you were supposed to be the fount of all knowledge," Cole said. "That's just not valid anymore."

The Association of American Medical Colleges is trying to tackle the problem in two ways.

First, it developed a professional readiness exam for aspiring medical school students, called PREview, designed to assess an applicant's cultural competence, social skills, and listening skills, as well as their ability to think through situations they may encounter in medical school and clinical settings. "We call them softer skills, but they're really the harder ones to learn," said Lisa Howley, an educational psychologist and senior director of strategic initiatives at the association. More than a dozen medical schools now recommend or require that applicants submit their PREview test scores with their Medical College Admission Test scores.

Second, the medical college association will roll out new competency standards for existing medical students, residents, and doctors related to diversity, equity, and inclusion in June. Those standards will address racism, implicit bias, and gender equality and will aim to teach doctors how to talk with people who are overweight.

"The bias toward those individuals is way too high," Howley said. "We have a lot more work to do in this space."

After the source of Melissa Boughton's pelvic pain was discovered, the OB-GYN who had recommended diet and exercise to ease her symptoms told Boughton the tumor was no big deal. "She acted like it was the most normal thing in the world," Boughton said.

Boughton sought a second opinion from a doctor who marketed her practice as a "Healthy at Every Size" office. That doctor referred Boughton to a surgical oncologist, who removed the tumor, her left ovary, and part of a fallopian tube. The tumor was large, but it wasn't cancerous. And although the surgery to remove it was considered successful, Boughton has since had trouble conceiving and is undergoing fertility treatment as she tries to have a baby.

"It's an emotional roller coaster," she said. "I feel very young at 34 to be going through this."

Boughton — who describes herself as someone who doesn't "fit into the BMI box" — said the experience taught her to choose her doctors differently.

"You can ask me if I diet and exercise like once," she said. Any more than that, and she starts shopping for a different doctor.

Lauren Sausser: lsausser@kff.org, @laurenmsausser

After Medical Bills Broke the Bank, This Family Headed to Mexico for Care

KFF Health News, April 27, 2022

Although the CDC doesn't endorse traveling to another country for medical care, millions of Americans each year do so.

This story was published on Wednesday, April 27, 2022 in Kaiser Health News.

By Paula Andalo

The Fierro family of Yuma, Arizona, had a string of bad medical luck that started in December 2020.

That's when Jesús Fierro Sr. was admitted to the hospital with a serious COVID-19 infection. He spent 18 days at Yuma Regional Medical Center, where he lost 60 pounds. He came home weak and dependent on an oxygen tank.

Then, in June 2021, his wife, Claudia, fainted while waiting for a table at the local Olive Garden. She felt dizzy one minute and was in an ambulance on her way to the same medical center the next. She was told her magnesium levels were low and was sent home within 24 hours.

The family has health insurance through Jesús Sr.'s job. But it didn't protect the Fierros from owing thousands of dollars. So, when their son Jesús Fierro Jr. dislocated his shoulder, the Fierros — who hadn't yet paid the bills for their own care — opted out of U.S. healthcare and headed south to the U.S.-Mexico border.

And no other bills came for at least one member of the family.

The Patients: Jesús Fierro Sr., 48; Claudia Fierro, 51; and Jesús Fierro Jr., 17. The family has Blue Cross Blue Shield of Texas health insurance through Jesús Sr.'s employment with NOV Inc., formerly National Oilwell Varco, a multinational oil company.

Medical Services: For Jesús Sr., 18 days of inpatient care for a severe COVID infection. For Claudia, less than 24 hours of emergency care after fainting. For Jesús Jr., a walk-in appointment for a dislocated shoulder.

Total Bills: Jesús Sr. was charged $3,894.86. The total bill was $107,905.80 for COVID treatment. Claudia was charged $3,252.74, including $202.36 for treatment from an out-of-network physician. The total bill was $13,429.50 for less than a day of treatment. Jesús Jr. was charged about $5 (70 pesos) for an outpatient visit that the family paid in cash.

Service Providers: Yuma Regional Medical Center, a 406-bed, nonprofit hospital in Yuma, Arizona. It's in the Fierros' insurance network. And a private doctor's office in Mexicali, Mexico, which is not.

What Gives: The Fierros were trapped in a situation that more and more Americans find themselves in: They are what some experts term "functionally uninsured." They have insurance — in this case, through Jesús Sr.'s job, which pays $72,000 a year. But their health plan is expensive, and they don't have the liquid savings to pay their "share" of the bill. The Fierros' plan says their out-of-pocket maximum is $8,500 a year for the family. And in a country where even a short stay in an emergency room is billed at a staggering sum, that means minor encounters with the medical system can take virtually all of the family's disposable savings, year after year. And that's why the Fierros opted out.

According to the terms of the insurance plan, which has a $2,000 family deductible and 20% coinsurance, Jesús Sr. owed $3,894.86 of a total bill of nearly $110,000 for his COVID care in late 2020.

The Fierros are paying off that bill — $140 a month — and still owe more than $2,500. In 2020, most insurers agreed to waive cost-sharing payments for COVID-19 treatment after the passage of federal COVID relief packages that provided emergency funding to hospitals. But waiving treatment costs was optional under the law. And although Blue Cross Blue Shield of Texas has a posted policy saying it would waive cost sharing through the end of 2020, the insurer didn't do that for Jesús Sr.'s bill. Carrie Kraft, a spokesperson for the insurer, wouldn't discuss why his COVID bill was not waived.

(More than two years into the pandemic and with vaccines now widely available to reduce the risk of hospitalization and death, most insurers again charge patients their cost sharing.)

On Jan. 1, 2021, the Fierros' deductible and out-of-pocket maximum reset. So when Claudia fainted — a fairly common occurrence and rarely indicative of a serious problem — she was sent by ambulance to the emergency room, leaving the Fierros with another bill of more than $3,000. That kind of bill is a huge stress on the average American family; fewer than half of U.S. adults have enough savings to cover a surprise $1,000 expense. In recent polling by KFF, "unexpected medical bills" ranked second among family budget worries, behind gas prices and other transportation costs.

The new bill for a fainting spell destabilized the Fierros' household budget. "We thought about taking a second loan on our house," said Jesús Sr., a Los Angeles native. When he called the hospital to ask for financial assistance, he said, people he spoke with strongly discouraged him from applying. "They told me that I could apply but that it would only lower Claudia's bill by $100," he said.

So when Jesús Jr. dislocated his shoulder boxing with his brother, the family headed south.

Jesús Sr. asked his son, "Can you bear the pain for an hour?" The teen replied, "Yes."

Father and son took the hourlong trip to Mexicali, Mexico, to Dr. Alfredo Acosta's office.

The Fierros don't consider themselves "health tourists." Jesús Sr. crosses the border into Mexicali every day for his work, and Mexicali is Claudia's hometown. They've been traveling to the neighborhood known as La Chinesca ("Chinatown") for years to see Acosta, a general practitioner, who treats the asthma of their youngest son, Fernando, 15. Treatment for Jesús Jr.'s dislocated shoulder was the first time they had sought emergency care from the physician. The price was right, and the treatment effective.

A visit to a U.S. emergency room likely would have involved a facility fee, expensive X-rays, and perhaps an orthopedic specialist's evaluation — which would have generated thousands of dollars in bills. Acosta adjusted Jesús Jr.'s shoulder so that the bones aligned in the socket and prescribed him ibuprofen for soreness. The family paid cash on the spot.

Although the Centers for Disease Control and Prevention doesn't endorse traveling to another country for medical care, the Fierros are among millions of Americans each year who do so. Many of them are fleeing expensive care in the U.S., even with health insurance.

Acosta, who is from the Mexican state of Sinaloa and is a graduate of the Autonomous University of Sinaloa, moved to Mexicali 20 years ago. He witnessed firsthand the growth of the medical tourism industry.

He sees about 14 patients a day (no appointment necessary), and 30% to 40% of those are from the U.S. He charges $8 for typical visits.

In Mexicali, a mile from La Chinesca, where the family doctors have their modest offices, are medical facilities that rival those in the United States. The facilities have international certification and are considered expensive, but they are still cheaper than hospitals in the U.S.

Resolution: Both Blue Cross Blue Shield of Texas and Yuma Regional Medical Center declined to discuss the Fierros' bills with KHN, even though Jesús Sr. and Claudia gave written permission for them to do so.

In a statement, Yuma Regional Medical Center spokesperson Machele Headington said, "Applying for financial support starts with an application — a service we extended, and still extend, to these patients."

In an email, Kraft, the Blue Cross Blue Shield of Texas spokesperson, said: "We understand the frustration our members experience when they receive a bill containing COVID-19 charges that they do not understand, or feel may be inappropriate."

The Fierros are planning to apply to the hospital for financial support for their outstanding debts. But Claudia said never again. "I told Jesús, 'If I faint again, please drive me home,'" rather than calling an ambulance, she said.

"We pay $1,000 premium monthly for our employment-based insurance," added Jesús. "We should not have to live with this stress."

The Takeaway: Be aware that your deductible "meter" starts over every year and that virtually any emergency care can generate a bill in the thousands of dollars and may leave you owing most of your deductible and out-of-pocket maximum.

Also be aware that even if you seem not to qualify for financial assistance based on a hospital's policy, you can apply and explain your circumstances. Because of the high cost of care in the U.S., even many middle-income people qualify. And many hospitals give their finance departments leeway to adjust bills. Some patients discover that if they offer to pay cash on the spot, the bill can be reduced dramatically.

All nonprofit hospitals have a legal obligation to help patients: They pay no tax in exchange for providing "community benefit." Make a case for yourself, and ask for a supervisor if you get an initial "no."

For elective procedures, patients can follow the Fierros' example, becoming savvy healthcare shoppers. Recently, Claudia needed an endoscopy to evaluate an ulcer. The family has been calling different facilities and discovered a $500 difference in the cost of an endoscopy. They will soon drive to a medical center in Central Valley, California, two hours from home, for the procedure.

The Fierros didn't even consider going back to their local hospital. "I don't want to say 'hello' and receive a $3,000 bill," joked Jesús Sr.

Stephanie O'Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Paula Andalo: paulaA@kff.org, @paula_andalo

Shopping for Space, Health Systems Make Over Malls

KFF Health News, April 26, 2022

Nationwide, 32 enclosed malls house healthcare services in at least part of their footprint.

By Blake Farmer, Nashville Public Radio

This article was published on Tuesday, April 26, 2022 in Kaiser Health News.

The hulking Hickory Hollow Mall — a full 1.1 million square feet of retail space in southeastern Nashville — was once the largest shopping center in Tennessee. But like many malls, it's been in a downward death spiral for more than a decade.

Now the mammoth complex surrounded by acres of parking is on track to join the ranks of malls making a transition into a booming economic sector: medicine. Vanderbilt University Medical Center has had such success reviving a different mall that its health system, Vanderbilt Health, plans to add medical clinics at the former Hickory Hollow Mall, rebranded a decade ago as the Global Mall at the Crossings.

"The possibilities for service offerings in a facility of this scale are endless," Dr. Jeff Balser, the medical center's CEO, announced in March. What big-city health systems need most is something shopping malls have plenty of: space and parking. They offer convenience for patients and practitioners, as well as costing less than expanding an existing hospital campus.

Nationwide, 32 enclosed malls house healthcare services in at least part of their footprint, according to a database kept by Ellen Dunham-Jones, a Georgia Tech urban design professor. One of the first was Jackson Medical Mall in Mississippi, founded by Dr. Aaron Shirley in 1996. Nearly a third of those medical transformations have been announced since the start of the COVID-19 pandemic.

The more recent additions include the Capital Hill Mall in Helena, Montana, where Benefis Health System is building a 60,000-square-foot primary care and specialty clinic on part of the 13-acre site that was razed in 2019. In Alexandria, Virginia, Inova Health System is part of a billion-dollar mixed-use development on the Landmark Mall site, which includes plans for a full-service hospital and trauma center.

The lockdowns brought by COVID — both required and voluntary — pushed many bricks-and-mortar retailers already on the brink out of business. But medicine's reuse of retail space is more than pandemic opportunism, according to a November article in the Harvard Business Review. The three authors suggest the rise of telemedicine and continued push toward outpatient procedures will make malls increasingly attractive locations for healthcare.

The proposition makes sense for commercial real estate investors, too, especially as mall owners struggle. A few went bankrupt during the pandemic. Every mall owner is now looking for mixed-use opportunities, said Ginger Davis of Trademark Properties in Charleston, South Carolina.

In 2017, her company started redeveloping the Citadel Mall, whose anchor tenant is now the Medical University of South Carolina. The clinics and surgery centers are housed in the old J.C. Penney department store.

"Right now they're doing surgery where people used to buy sheets and towels," Davis said.

In many cases, the transition to medicine is intended to complement what remains of the retail. At Citadel Mall, a spouse with a partner having outpatient surgery must stay on-site. But browsing Target, Davis said, still counts as on-site.

"We feel like this model can work in communities across the country that are struggling with similar malls that are underperforming," she said.

Since 2009, Vanderbilt Health has added 22 specialty clinics to nearly a half-million square feet of One Hundred Oaks, a mall still owned by investors. The mall retains big-box retailers on the ground floor, but the mall interior is now virtually all medical.

In some of these deals, such as those for Alexandria's Landmark and Nashville's Hickory Hollow malls, the local government has bought the mall property that the hospital system leases, so those portions no longer generate property taxes.

Some failing malls like Hickory Hollow in Nashville are in diverse neighborhoods that need increased access to health services. The surrounding ZIP codes had Nashville's highest rates of COVID infections early in the pandemic and they have some of the lowest rates of primary care visits, according to survey data from the nonprofit NashvilleHealth.

Mall locations remain desirable. Many are even more convenient to dense populations and interstates than when they were built nearly 50 years ago, before surrounding suburbs filled in.

When retiree Jennifer Johnson moved to Nashville to be closer to her grandchild, her family warned her not to see a doctor at Vanderbilt's main campus, which is under perpetual construction. She quickly understood why.

"It's a zoo," she said. "First you get to drive through the maze of the parking garage, which is under construction. Then you try to find out which elevator you're going to get to, get to what floor you're going to get to."

At One Hundred Oaks, she said, "you can go straight up the escalator and straight down the hall — easy peasy."

Despite the size and age of many malls, they are fairly easy to navigate compared with many hospitals. In Charleston, the Citadel Mall uses football-style yardage marked on the floor to help patients find the right clinic (a detail that its owner insisted on and dubbed the "secret sauce").

By contrast, many hospital campuses confound patients. Vanderbilt's main site in the West End area of Nashville has been expanded two dozen times since the first building was constructed in 1925.

"Most of these hospitals are in areas where there's just no room to grow. And if you do, it's so expensive," said Andrew McDonald, a former hospital administrator who leads healthcare consulting for accounting and consulting firm LBMC. "These buildings are old. They're antiquated. They're very expensive to maintain."

Malls make for a nice fit, at least for big health systems, McDonald said. They can essentially move everything short of the emergency room and intensive care unit — including surgery and imaging centers — and keep them clustered. While doctor offices are often scattered around a hospital district, in a mall setting, if someone needs an MRI, it's right beyond the food court under the same sprawling roof.

"It just creates a whole lot more efficient flow for the patient going through the healthcare system with whatever infirmity they may have," McDonald said.

Vanderbilt's renovation of the former Hickory Hollow Mall will also create an employment pipeline for medical technicians from Nashville State Community College, which already has a location in what was previously a Dillard's department store.

The mall has been mostly empty for years, which makes no sense to nearby resident Ricky Grigsby. The area around it is otherwise booming.

"Somebody needs to do something with it," he said. "It could be jobs for somebody."

Grigsby just retired from Vanderbilt after a career spent managing surgical instruments for busy operating rooms on the main campus. Now he's a patient along with everyone else — looking for a more convenient place to receive care.

Bundling care in suburban shopping mall sites also makes sense because of their surrounding demographics, Dunham-Jones said. These areas are no longer filled primarily with young families, who first flocked to the planned neighborhoods and shopping centers built in the 1970s.

"The adults are still in the suburbs, but the kids have long since grown," Dunham-Jones said. And now those aging parents who remain are "pretty heavy-duty healthcare consumers."

This story is from a partnership that includes Nashville Public Radio and KHN.

Blake Farmer, Nashville Public Radio: bfarmer@wpln.org, @flakebarmer

Despite Losing Federal Money, California Is Still Testing Uninsured Residents for COVID — For Now

KFF Health News, April 25, 2022

Absent free options, people without health insurance could pay as much as several hundred dollars out-of-pocket depending on where they get tested.

This article was published on Monday, April 25, 2022 in Kaiser Health News.

By Rachel Bluth

SACRAMENTO, Calif. — California is still offering free COVID testing to uninsured residents even though the federal government ran out of money to pay for it.

While Congress debates whether to put more money into free testing, California is leaning on programs it already had in place: special state-based coverage for uninsured Californians, school testing, and free tests offered by clinics, counties, and other groups. Absent free options, people without health insurance could pay as much as several hundred dollars out-of-pocket depending on where they get tested.

At the same time, demand for community testing — from residents with and without insurance — has dropped precipitously.

On a recent Thursday, only three people could be found getting tested at seven testing sites in Sacramento County. Staffers at these locations — from the formerly bustling mass-testing site at the state fairgrounds to a tiny kiosk in a church parking lot — said hardly anyone shows up anymore even though testing is still important for monitoring and reducing the spread of COVID-19. They mostly see regulars who come in for routine testing required by their employer or school.

Dr. Olivia Kasirye, the public health officer for Sacramento County, said the county sends specimens to a state lab at no cost to the county, which has helped keep free testing services up and running. California is quietly ending its contract with a central lab, but the state says it will shift testing to a network of commercial labs. State officials told KHN there will be no changes for patients.

"I think we can maintain services" for now, but the future is uncertain, Kasirye said.

Since the beginning of the pandemic, the federal government had reimbursed providers for testing, treating, and vaccinating uninsured people for COVID-19. But the Health Resources and Services Administration stopped accepting reimbursement claims for tests and treatments March 22, and for vaccinations April 5, saying the money had run out. The government had been reimbursing providers $36 to $143 per test.

Since then, states and counties have been watching their case rates and coffers to see whether they can keep testing uninsured residents.

In Alabama, Dr. Scott Harris, the state health officer, said offering free testing to people five days a week through county health departments is "probably not something we're going to be able to sustain much longer," especially in pockets of the state with large uninsured populations.

"We're going to have zero services for those people," Harris said. "And no ability to incentivize providers to see them."

Congress returns from recess in late April but may not renew the program. Lawmakers previously considered extending it but chose not to include money for it in a $10 billion COVID funding deal that's been pending since early April.

The COVID-19 Uninsured Group

Healthcare advocates say California has been able to continue free testing for the uninsured, including for residents without legal documentation, because of how it used a separate pot of federal funding. Although 15 other states also leveraged pandemic support, advocates believe California expanded benefits the most.

In August 2020, California created an insurance program with pandemic relief money to cover COVID-related treatments, testing, and vaccines for uninsured people or those whose insurance plans don't cover those services. The COVID-19 Uninsured Group essentially acts as Medicaid for COVID, but with no income requirements. That's different from traditional Medi-Cal, California's Medicaid program, which is for low-income people.

Coverage will end when the federal public health emergency does. On April 13, the U.S. Department of Health and Human Services renewed the emergency declaration for 90 days, extending it to mid-July.

The state program is a clever way to use federal dollars, said David Kane, a senior attorney at the Western Center on Law & Poverty. But he noted there are drawbacks. People must be enrolled before they can obtain services, and they can't enroll themselves. Only certain healthcare providers, mostly hospitals and clinics, can sign people up.

"The program was never designed to exist in isolation," Kane said, "but now it does."

About 291,000 people were enrolled in the program as of April 4, according to Anthony Cava, a spokesperson for the state Department of Healthcare Services, which administers Medi-Cal. An estimated 3.2 million Californians, or around 9.5% of people younger than 65, are uninsured.

Kane suggested that people find a qualified provider from a database maintained by the Department of Healthcare Services or by calling the Medi-Nurse line and get enrolled as soon as possible, especially if they are used to walking up to a testing site and paying nothing.

The challenge is getting people to sign up before they get sick or need a test, Kane said, and keeping the program going with the added patient load.

Screening Students

Another major source of free testing in California is public schools.

California distributed more than 14.3 million at-home tests to schools before students left for spring break. The schools in turn handed out the rapid tests to families so they can screen students before sending them back to campus. The state had a similar program for the winter holidays.

The winter testing was "incredibly effective," according to Primary Health, the company running the program for the state. About 77% of K-12 families voluntarily reported their results back to a sampling of schools, according to the company.

In addition, the state is paying Primary Health to operate more than 7,000 free testing sites — most of which are in schools — by using leftover federal COVID relief money disbursed to states at the beginning of the pandemic.

How long that funding will last isn't clear.

"It seems like the federal government is stepping back and saying this portion of healthcare is going back to healthcare as we know it," said Abigail Stoddard, Primary Health's general manager of government and public programs.

Stoddard's conversations with schools outside California are changing. Instead of conducting surveillance testing to determine whether the virus is circulating on campus, as California is doing, many are moving toward testing only kids with symptoms, she said.

For example, Primary Health operates in Minnesota, where schools are applying for grants to fund testing and will decide whether tests will be for sick students, healthy ones, or just staffers.

Local Free Testing

Free testing is still available in California through some hospitals, community clinics, local health departments, and private companies working with the state, although how long those options will remain is unclear.

In Sacramento County, the loss of federal funding for testing uninsured people has gone mostly unnoticed so far. "Our hope is that we have enough services and resources in the community that the additional coverage going away will not have a huge impact," Kasirye said.

The county health department still offers free community testing to uninsured people every day at churches or community centers.

But they may get harder to find. The testing company Curative used to offer free lab-run PCR and rapid antigen tests around the state, but now that the federal funding has run out, it offers only PCR tests to the uninsured for free. The company has also reduced the number of its sites, from 283 on April 14 to 135 on April 19.

In some states, Curative has either stopped testing uninsured people — or is charging them $99 to $135 per test.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Rachel Bluth: rbluth@kff.org, @RachelHBluth

Physicians Are Uneasy as Colorado Collects Providers' Diversity Data

KFF Health News, April 25, 2022

Officials are trying to figure out how they might use demographic data to guide patients to practitioners with similar identities while avoiding unintended consequences.

This article was published on Monday, April 25, 2022 in Kaiser Health News.

By Markian Hawryluk

Shaunti Meyer, medical director at the STRIDE Community Health Center in Aurora, Colorado, discloses her sexual orientation to patients when it feels appropriate. LGBTQ+ patients often deal with stigma in health settings. "They feel more connected because I'm part of the community," Meyer says. (Rachel Woolf for KHN)

Shaunti Meyer, a certified nurse-midwife and medical director at STRIDE Community Health Center in Colorado, doesn't usually disclose her sexual orientation to patients. But at times it feels appropriate.

After telling a transgender patient that she is a lesbian, Meyer learned the woman had recently taken four other trans women, all estranged from their birth families, under her wing. They were living together as a family, and, one by one, each came to see Meyer at the Aurora clinic where she practices. Some were at the beginning of their journeys as transgender women, she said, and they felt comfortable with her as a provider, believing she understood their needs and could communicate well with them.

"They feel more connected because I'm part of the community," Meyer said.

Research shows that when patients see health providers who share their cultural background, speak the same language, or mirror their experiences, their healthcare outcomes improve. Now, Colorado is trying to help patients find such providers. As part of this effort, the state is asking insurers offering certain health plans to collect demographic information, such as race, ethnicity, disability status, sexual orientation, and gender identity, from both health professionals and enrollees — a move that some healthcare workers say could threaten their safety.

A new state law takes effect later this year that requires insurers to offer the "Colorado Option," a plan on the state-run Affordable Care Act marketplace with benefits that have been standardized by the state. Colorado is requiring those plans to build out culturally responsive provider networks, with a diverse set of health practitioners who can meet the needs of a diverse population.

Some other states — including California — and Washington, D.C., require plans sold on their health insurance marketplaces to collect demographic data from patients, although not providers, and patients are generally asked only about their race and ethnicity, not their sexual orientation or gender identity.

"Nobody knows how many particular racial or ethnic identities they might have among their providers, what the percentages are, and how they correspond with the communities that they serve," said Kyle Brown, Colorado's deputy commissioner for affordability programs. "Traditionally, data like this isn't collected."

The state and insurers will be able to see how similar the plans' patient and provider populations are and then work on ways to narrow the gap, if needed. For example, a plan might find that 30% of its enrollees are Black but that only 20% of its providers are.

Colorado had considered including providers' demographic data in directories so patients could use it to choose their doctors. But after physician groups raised privacy concerns, the state opted to make reporting of the demographic data by providers voluntary and confidential. That means insurers must ask, but the providers can decline to answer. And the data collected will be reported to the state only in aggregate.

State officials and consumer advocates hope that the demographic data could eventually help inform patients. But, for now, the physician groups and other stakeholders fear that making the data public could subject some providers, particularly LGBTQ+ people, to harm.

"There are a lot of really conservative parts of Colorado," said Steven Haden, a mental health therapist and CEO of Envision:You, a Denver-based nonprofit focusing on LGBTQ+ behavioral health services. "In lots of communities outside of our metropolitan areas, it's not safe to be out."

State officials say the Colorado Option will be the first health plan in the nation built specifically to advance health equity, a term used to describe everyone having the same opportunity to be healthy. The framework includes better coverage for services that address health disparities. It requires anti-bias training for providers, their front-office staffers, and health plan customer service representatives. Plans must increase the number of community health centers — which treat more patients from underserved communities than other clinics — in their networks, as well as certified nurse-midwives, to help reduce maternal mortality.

Health plans' directories will have to list the languages spoken by providers and their front-office staffers, say whether offices are accessible for those with physical disabilities, and note whether a provider has evening or weekend hours.

But officials are trying to figure out how they might use demographic data to guide patients to practitioners with similar identities while avoiding unintended consequences, particularly around sexual orientation or gender identity.

Dr. Mark Johnson, president of the Colorado Medical Society, said more doctors than ever feel comfortable disclosing their sexual orientation or gender identity, but incidents of disgruntled patients who lash out by referencing a physician's personal characteristics do still occur.

"Even though we're a purple state, there's still a lot of bias here and there," he said. "There could be some real problems that come out of this, so I am hoping they will be very, very sensitive to what they're doing."

LGBTQ+ patients often deal with stigma in health settings, which can result in negative experiences that range from feeling uncomfortable to being outright mistreated.

"There are lots of marginalized and disenfranchised people that when they don't have a good experience, they disengage from care. They don't go back to that provider," Haden said. "So needs remain unmet."

As a result, Haden said, LGBTQ+ people have rates of depression, anxiety, overdose, and suicide that are two to four times the rate of straight, cisgender people.

Many people in the LGBTQ+ community share information about which doctors and clinics are welcoming and competent and which to avoid. Finding medical professionals who are themselves LGBTQ+ is a way of increasing the likelihood that a patient will feel comfortable. But many experts stress that being trained in LGBTQ+ healthcare is more important for a provider than being part of that community.

"The best doctor to go to is someone who's done the work to understand what it means to be a safe, affirmative practice," said Jessica Fish, director of the Sexual Orientation, Gender Identity and Health Research Group at the University of Maryland.

Many health plans allow enrollees to search for providers who have such training but don't identify which ones are part of the LGBTQ+ community themselves. Deciding to self-identify to patients or colleagues can be difficult and often depends on a provider's circumstances.

"There are multiple variables that contribute to one's comfort level and decision whether or not disclosure is safe for them," said Nick Grant, a clinical psychologist and president of GLMA: Health Professionals Advancing LGBTQ Equality, formerly the Gay and Lesbian Medical Association. "In different areas of the country, it depends on what the climate is. National politics have influenced those conversations."

Grant said the debate over transgender laws in conservative states like Florida and Texas has a chilling effect on doctors across the country, making them less willing to come out. In contrast, the moves toward culturally responsive networks being made by Colorado, he said, help signal that the state is much more protective of LGBTQ rights.

"I've never seen anything similar in the other states," he said.

The new data collection requirement will apply only to Colorado Option plans, which become available in 2023 and are likely to enroll just a portion of the more than 200,000 people who purchase plans through the state's health insurance marketplace. But state officials hope that health plans will use some of the same network-building strategies for their other plans.

Colorado's approach has caught the eyes of other states. And as part of a new federal health equity initiative, the Centers for Medicare & Medicaid Services recently announced it would collect more demographic data — covering race, ethnicity, language, sexual orientation, gender identity, disability, income, geography, and other factors — across all CMS programs, which cover 150 million people.

"We have learned from bits and pieces of what other states have been doing and what the national leading experts have been talking about in terms of health equity and cultural competence, and we have synthesized that into something that we think is really leading the nation," said Brown, the Colorado affordability programs official. "People are going to look at Colorado as an example."

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk

Battle Lines Are Drawn Over California Deal with KP

KFF Health News, April 18, 2022

The deal would allow KP to operate Medi-Cal plans in at least 32 counties without having to bid for the contracts.

This article was published on Monday, April 18, 2022 in Kaiser Health News.

By Bernard J. Wolfson

[Editor's note: KHN is not affiliated with Kaiser Permanente.]

California counties, health insurance plans, community clinics, and a major national healthcare labor union are lining up against a controversial deal to grant HMO giant Kaiser Permanente a no-bid statewide Medicaid contract as the bill heads for its first legislative hearing Tuesday.

The deal, hammered out earlier this year in closed-door talks between Kaiser Permanente and Gov. Gavin Newsom's office and first reported by KHN, would allow KP to operate Medi-Cal plans in at least 32 counties without having to bid for the contracts. Medi-Cal's other eight commercial health plans must compete for their contracts.

Medi-Cal is California's version of Medicaid, the federal-state program that provides health coverage to low-income people.

Opponents of the KP proposal say they were blindsided by it after having spent months planning for big changes happening in Medi-Cal, which serves more than 14 million Californians. They say the deal would largely allow KP to continue picking the enrollees it wants, and they fear that would give it a healthier and less expensive patient population than other health plans.

Currently, the state allows KP to limit its Medi-Cal membership by accepting only those who have been its members in the recent past, primarily in employer-based or Affordable Care Act plans, and their immediate family members.

"A closed system that excludes vulnerable populations is inequitable," the heads of 10 county boards said in a letter to Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee, which will consider the proposal. They questioned whether Kaiser Permanente would be assigned patients with "more complex physical, behavioral, and socio-economic needs versus giving the existing safety net system and local plans, who do not exclude populations, a disproportionate share of complex and costly patients."

Kaiser Permanente said in an emailed statement that, under the terms of the deal, it would take more Medi-Cal patients with high needs and would collaborate with counties and other health plans on patient care.

Michelle Baass, director of the Department of Healthcare Services, which runs Medi-Cal, told KHN in early February that the deal would "ensure that more low-income patients have access to Kaiser's high quality services" and "lead to better healthcare for more Medi-Cal enrollees."

The deal must win state legislative and federal approval. Opposition to the bill that would codify it, AB 2724, is being spearheaded by Local Health Plans of California, which represents the 16 local, publicly governed Medi-Cal plans that cover most of the 12 million Medi-Cal beneficiaries in managed care. The proposal would make many of them direct competitors of Kaiser Permanente, and they could lose hundreds of thousands of enrollees and millions of dollars in Medi-Cal revenue.

Among them are some of the state's largest Medi-Cal health plans, including L.A. Care, by far the biggest, with 2.4 million members; and the Inland Empire Health Plan, with about 1.5 million members in San Bernardino and Riverside counties.

In addition, the boards of supervisors of 16 counties had registered their opposition as of April 15, as had the California State Association of Counties, at least two community clinic groups, and the National Union of Healthcare Workers, which represents thousands of KP clinicians.

The other commercial Medi-Cal plans are lying low as they bid for the state's Medi-Cal business. The two largest, Health Net and Anthem Blue Cross, declined to comment.

The public health plans and many of the counties said the proposal was sprung on them after they spent months preparing for major Medi-Cal shifts — for example, a more demanding contract with the state, scheduled to take effect in 2024, and an ambitious $6 billion project to provide enrollees with nontraditional services, such as food assistance, home modifications, and help with housing.

Some medical providers are also critical of the proposal.

Leslie Conner, CEO of Santa Cruz Community Health, which operates three clinics in Santa Cruz County, said her group is building a $19 million primary care clinic based on estimates — available at the time the plan was drawn up — of the number of uninsured residents and Medi-Cal members who don't have a doctor.

"It's just not helpful to have to recalculate when Kaiser comes in taking more primary care lives," Conner said. "We didn't get a chance to talk through that with the state or with Kaiser."

Conner said that KP, which currently doesn't have Medi-Cal members in Santa Cruz County, has generously collaborated with Santa Cruz Community Health in the past and that she expects that to continue.

"I'm more disturbed by the state doing this negotiation with a private company," she said. "That's just wrong."

Kaiser Permanente said in its emailed statement that the Department of Healthcare Services approached it with the proposal and that it agreed to collaborate "because we recognize, fundamentally, the benefits to the enrollees." The proposal, it said, "meets the fundamental objectives the state has for Medi-Cal: to improve quality, reduce complexity and improve patient outcomes."

KP, which covers 9.4 million Californians, the vast majority in its commercial plans, has 912,000 Medi-Cal enrollees. Most of them are through subcontracts with other Medi-Cal health plans in 17 counties, and the rest are in the five counties where KP already contracts directly with the state.

Kaiser Permanente calls its current enrollment-limiting arrangement continuity of care, but critics say it leaves other health plans at a disadvantage — and they worry about it becoming enshrined in state law. In addition to leaving them with a disproportionate share of sicker, costlier patients, they say, it could saddle them with lower quality ratings from the state.

But KP said its mix of sick and healthy Medi-Cal patients is "comparable to other Medi-Cal managed care plans." It added that the proposal calls on it to increase the number of its Medi-Cal enrollees, including those from "more vulnerable populations."

Under the proposal, KP has committed to increasing its Medi-Cal membership 25% over the five years of the contract. It would accomplish this partly by taking previous KP enrollees in counties where it currently doesn't have Medi-Cal members, according to an 11-page document released in March by the Department of Healthcare Services. KP would also take, for the first time, a limited number of the enrollees who don't choose a plan when they sign up for Medi-Cal. And it would enroll children in foster care and the typically complex, expensive patients who are eligible for both Medi-Cal and Medicare.

As of April 15, many details were not yet in the bill language, which will be fleshed out and debated over the next several months.

For instance, the bill makes no mention of the 25% enrollment growth target. And although the Department of Healthcare Services document says KP's direct contract would cover 32 counties, the bill leaves that number open.

"The state clearly has to disclose a lot more information and detail about how this will work," said Edwin Park, a California-based research professor with Georgetown University's Center for Children and Families.

Felicia Matlosz, a spokesperson for the bill's author, Assembly member Joaquin Arambula (D-Fresno), said his office is "working to reconcile the language" with the state's proposal.

Arguably, the health plans that would be most affected by this proposal are those that are the sole Medi-Cal plan in their counties, known as county organized health systems, or COHS.

They were created by the boards of their counties and operate in partnership with the counties, their safety-net health facilities, and private-sector medical providers. In the 40 years since they were established in California, they have been the only state-contracted Medi-Cal plan in their counties.

"It's the end of the model," said Stephanie Sonnenshine, CEO of the Central California Alliance for Health, a county organized health system for Santa Cruz, Monterey, and Merced counties. "It's a significant policy change that hasn't been vetted as a policy change."

KHN correspondent Rachel Bluth contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

Pfizer says booster in children 5-11 raises antibodies against omicron

KFF Health News, April 14, 2022

The company says it plans to submit its data to the FDA for authorization.

Persistent Problem: High C-Section Rates Plague the South

KFF Health News, April 14, 2022

High C-section rates have persisted — and in some states, such as Alabama and Kentucky, even grown slightly — despite continual calls to reduce them.

This article was published on Thursday, April 14, 2022 in Kaiser Health News.

By Lauren Sausser

All along, Julia Maeda knew she wanted to have her baby naturally. For her, that meant in a hospital, vaginally, without an epidural for pain relief.

This was her first pregnancy. And although she is a nurse, she was working with cancer patients at the time, not with laboring mothers or babies. "I really didn't know what I was getting into," said Maeda, now 32. "I didn't do much preparation."

Her home state of Mississippi has the highest cesarean section rate in the U.S. — nearly 4 in 10 women who give birth there deliver their babies via C-section. Almost two weeks past her due date in 2019, Maeda became one of them after her doctor came to her bedside while she was in labor.

"'You're not in distress, and your baby is not in distress — but we don't want you to get that way, so we need to think about a C-section,'" she recalled her doctor saying. "I was totally defeated. I just gave in."

C-sections are sometimes necessary and even lifesaving, but public health experts have long contended that too many performed in the U.S. aren't. They argue it is major surgery accompanied by significant risk and a high price tag.

Overall, 31.8% of all births in the U.S. were C-sections in 2020, just a slight tick up from 31.7% the year before, according to the latest data from the Centers for Disease Control and Prevention. But that's close to the peak in 2009, when it was 32.9%. And the rates are far higher in many states, especially across the South.

These high C-section rates have persisted — and in some states, such as Alabama and Kentucky, even grown slightly — despite continual calls to reduce them. And although the pandemic presented new challenges for pregnant women, research suggests that the U.S. C-section rate was unaffected by COVID. Instead, obstetricians and other health experts say the high rate is an intractable problem.

Some states, such as California and New Jersey, have reduced their rates through a variety of strategies, including sharing C-section data with doctors and hospitals. But change has proved difficult elsewhere, especially in the South and in Texas, where women are generally less healthy heading into their pregnancies and maternal and infant health problems are among the highest in the U.S.

"We have to restructure how we think about C-sections," said Dr. Veronica Gillispie-Bell, an OB-GYN who is medical director of the Louisiana Perinatal Quality Collaborative, a group of 43 birthing hospitals focused on lowering Louisiana's C-section rate. "It's a lifesaving technique, but it's also not without risks."

She said C-sections, like any operation, create scar tissue, including in the uterus, which may complicate future pregnancies or abdominal surgeries. C-sections also typically lead to an extended hospital stay and recovery period and increase the chance of infection. Babies face risks, too. In rare cases, they can be nicked or cut during an incision.

Although C-sections are sometimes necessary, public health leaders say these surgeries have been overused in many places. Black women, particularly, are more likely to give birth by C-section than any other racial group in the country. Often, hospitals and even regions have wide, unexplained variations in rates.

"If you were delivering in Miami-Dade County, you had a 75% greater chance of having a cesarean than in northern Florida," said Dr. William Sappenfield, an OB-GYN and epidemiologist at the University of South Florida who has studied the state's high C-section rate.

Some physicians say their rates are driven by mothers who request the procedure, not by doctors. But Dr. Rebekah Gee, an OB-GYN and former secretary of the Louisiana Department of Health, said she saw C-section rates go dramatically up at 4 and 5 p.m. — around the time when doctors tend to want to go home.

She led several initiatives to improve birth outcomes in Louisiana, including leveling Medicaid payment rates to hospitals for vaginal deliveries and C-sections. In most places, C-sections are significantly more expensive than vaginal deliveries, making high C-section rates not only a concern for expectant mothers but also for taxpayers.

Medicaid pays for 60% of all births in Louisiana, according to KFF, and about half of all births in most Southern states, compared with 42% nationally. That's one reason some states — including Louisiana, Tennessee, and Minnesota — have tried to tackle high C-section rates by changing how much Medicaid pays for them. But payment reform alone isn't enough, Gee said.

"There was a guy in central Louisiana who was doing more C-sections and early elective deliveries than anyone in the U.S.," she said. "When you have a culture like that, it's hard to shift from it."

Linda Schwimmer, president and CEO of the New Jersey Healthcare Quality Institute, said many hospitals and doctors don't even know their C-section rates. Sharing this data with doctors and hospitals — and making it public — made some providers uncomfortable, she said, but it ultimately worked. New Jersey's C-section rate among first-time, low-risk mothers dropped from 33.1% in 2013 to 26.7% six years later once the state began sharing this data, among other initiatives.

The New Jersey Healthcare Quality Institute, and other groups like it around the country, focuses on reducing a subset of C-sections called "nulliparous, term, singleton, vertex" C-sections, or surgeries on first-time, full-term moms giving birth to a single infant who is positioned head-down in the uterus.

NTSV C-sections are important to track because women who have a C-section during their first pregnancy face a 90% chance of having another in subsequent pregnancies. Across the U.S., the rate for these C-sections was 25.9% in 2020 and 25.6% in 2019.

Dr. Elliott Main, a maternal-fetal specialist at Stanford University and the medical director of the California Maternal Quality Care Collaborative, co-authored a paper, published in JAMA last year, that outlines interventions the collaborative took that lowered California's NTSV C-Section rate from 26.0% in 2014 to 22.8% in 2019. Nationally, the rate was unchanged during that period.

Allowing women to labor for longer stretches of time before resorting to surgery is important, he said.

The cervix must be 10 centimeters dilated before a woman gives birth. The threshold for "active labor" used to be when the cervix was dilated at least 4 centimeters. In more recent years, though, the onset of active labor has been changed to 5 to 6 centimeters.

"People show up at the hospital too early," said Toni Hill, president of the Mississippi Midwives Alliance. "If you show up to the hospital at 2 to 3 centimeters, you can be at 2 to 3 centimeters for weeks. I don't even consider that labor."

Too often, she said, women at an early stage of labor end up being induced and deliver via C-section.

"It's almost like, at this point, C-sections are being handed out like lollipops," said LA'Patricia Washington, a doula based in Jackson, Mississippi. Doulas are trained, nonmedical workers who help parents before, during, and after delivery.

Washington works with a nonprofit group, the Jackson Safer Childbirth Experience, that pays for doulas to help expectant mothers in the region. Some state Medicaid programs, such as New Jersey's, reimburse for services by doulas because research shows they can reduce C-section rates. California has been trying to roll out the same benefit for its Medicaid members.

In 2020, when Julia Maeda became pregnant again, she paid out-of-pocket for a doula to attend the birth. The experience of having her son via C-section the previous year had been "emotionally and psychologically traumatic," Maeda said.

She told her OB-GYN that she wanted a VBAC, short for "vaginal birth after cesarean." But, she said, "he just shook his head and said, 'That's not a good idea.'"

She had VBAC anyway. Maeda credits her doula with making it happen.

"Maybe just her presence relayed to the nursing staff that this was something I was serious about," Maeda said. "They want you to have your baby during business hours. And biology doesn't work that way."