In California Nursing Homes, Omicron Is Bad, but So Is the Isolation

KFF Health News, January 31, 2022

COVID infections are again spiking at nursing homes around the country.

This article was published on Monday, January 31, 2022 in Kaiser Health News.

By Linda Marsa  

Dina Halperin had been cooped up alone for three weeks in her nursing home room after her two unvaccinated roommates were moved out at the onset of the omicron surge. "I'm frustrated," she said, "and so many of the nursing staff are burned out or just plain tired."

The situation wasn't terrifying, as it was in September 2020, when disease swept through the Victorian Post Acute facility in San Francisco and Halperin, a 63-year-old former English as a Second Language teacher, became severely ill with COVID. She spent 10 days in the hospital and required supplemental oxygen. Since the pandemic began, 14 residents of the nursing home have died of COVID, according to state figures.

Over time, Victorian Post Acute has gotten better at dealing with the virus, especially its milder omicron form, which accounted for 31 cases as of Jan. 27 but not a single illness serious enough to cause hospitalization, said Dan Kramer, a spokesperson for Victorian Post Acute. But the ongoing safety protocols at this and other nursing homes — including visitor restrictions and frequent testing of staff and residents — can be soul-killing. For the 1.4 million residents of the nation's roughly 15,000 nursing homes, the rules have led to renewed isolation and separation.

"I'm feeling very restless," Halperin said. She has Cushing's syndrome, an autoimmune disease that caused tumors and a spinal fracture that left her mostly wheelchair-bound and unable to live independently. Although she has residual COVID symptoms, including headaches and balance problems, Halperin, who has lived in the nursing home for nine years, is usually quite sociable. She volunteers in the dining room, helps other residents with their activities, and shops and runs errands during her frequent forays outside the building.

But COVID infections are again spiking at nursing homes around the country. In California, 792 new nursing home cases were reported on Jan. 19, compared with fewer than 11 cases on Dec. 19, 2021. However, the death rates are not nearly as bad as they were during pre-vaccine COVID surges. From Dec. 23, 2021, to Jan. 23, 2022, 217 nursing home residents died of COVID in California. By contrast, in just the week from Christmas 2020 to New Year's Day 2021, 555 people died at nursing homes in the state.

Those numbers, and others cited in this article, don't filter out patients who entered hospitals for treatment of other conditions but tested positive for COVID upon admission — a common occurrence during the omicron wave.

To keep nursing home residents out of overwhelmed hospitals, California public health officials have mandated masking and imposed strict vaccination and testing requirements for visitors and staffers at the homes, said Dr. Zachary Rubin, a medical epidemiologist with the Los Angeles County Department of Public Health. "Our approach is to prevent cases from coming into the facility, stop transmission once it gets into the facility, and to prevent serious outcomes," he said.

Rubin acknowledged that some of these policies may seem like they're doing more harm than good — but only temporarily, he hopes.

The omicron surge has created staffing shortages as nurses and aides call in sick, and the strict testing requirements have the effect of limiting visits by friends and relatives who provide crucial care and contact for some residents, bathing and grooming them, overseeing their diets and medications, and making sure they're not being neglected.

Nationally, a federal mandate requires all workers in federally funded facilities to be fully vaccinated by Feb. 28. The deadline was extended to March 15 for 24 states that challenged the requirement in court. Last month, California issued a similar order, which also requires nursing home staffers to receive booster shots by Feb. 1.

However, while vaccination rates for staff members and residents are high in California (96% for staffers and 89% for residents), only 52% of nursing home workers and 68% of their residents in California have received boosters, according to Jan. 23 figures from the Centers for Disease Control and Prevention. At Victorian Post Acute, 95% of staff and 92% of residents had been vaccinated with boosters as of Jan. 27, Kramer said.

Across the state, many unvaccinated staff members claim religious exemptions. Others say they can't get vaccinated at their workplaces and don't have time to get shots on their own, said Deborah Pacyna, a spokesperson for the California Association of Health Facilities, which represents the nursing home industry in Sacramento.

"We're going to have to deal with that as the deadline approaches. If they're not boosted, does that mean they can't work?" she asked. "That would be an extraordinary development."

The state hasn't indicated how it will enforce mandates, especially for boosters, said Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform.

Most nursing home visitors, as of Jan. 7, must be fully vaccinated — including boosters, if eligible — under California Department of Public Health requirements. Guests also must present a negative COVID test taken within one or two days, depending on the type of test. The federal government is sending four rapid tests to families that request them, and the state of California has distributed 300,000 tests to nursing homes.

That's "better than nothing," said Pacyna, but it may not be enough for families that visit several times a week. Some experts think any policy that tends to restrict visitors sets the wrong priority.

"Limiting visitation is bad psychologically," said Charlene Harrington, a professor emeritus in social and behavioral sciences at the University of California-San Francisco who has done extensive research on nursing homes. Numerous studies have shown that social isolation and loneliness can lead to depression, worsening dementia and cognitive decline, anxiety, a loss of the will to live — and increased risk of mortality from other causes.

Besides, Harrington said, most nursing home outbreaks are caused by infected staffers, who often work multiple jobs because of the low pay.

Maitely Weismann visits her 79-year-old mother, who has dementia and uses a wheelchair, at a Los Angeles residential facility several times a week. Her mother deteriorated considerably during the initial lockdown, and Weismann is doing her best to slow her mother's decline, she said.

"It's much harder to do this during the pandemic because there are so many barriers to entry," said Weismann, co-founder of the advocacy group Essential Caregivers Coalition. "Family caregivers can't actually tell if a loved one is doing OK through a screen, or a window, or a phone call."

Responding to the critical healthcare staff shortages, the CDC issued emergency guidelines in December — California followed suit in January — that allow workers who have been exposed to or test positive for COVID to return to work if they are asymptomatic.

It's a short-term, last-resort measure, Rubin said. "It's just not possible to adequately take care of people and do the daily activities of living if you don't have a nurse or caregivers. You just can't operate the place."

On one recent day alone — Jan. 24 — more than 10,300 workers were out sick — which is roughly a tenth of the combined staff in California nursing homes. To deal with the crunch, said Pacyna, "we're asking people to work extra hours, knowing that the peak is near and this isn't going to last forever."

In the meantime, families continue to worry about their loved ones. "When residents are isolated, they become completely dependent on the caregivers in the facility," Weismann said. "But when staff stops coming to work, the system falls apart."

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

States Were Sharing COVID Test Kits. Then Omicron Hit.

KFF Health News, January 31, 2022

Some states are holding on to expired tests for use as a last resort.

This article was published on Monday, January 31, 2022, in Kaiser Health News.

By Katheryn Houghton 

In a few short months, states have gone from donating surplus rapid COVID-19 tests to states with shortages to hoarding them as demand driven by the spike in cases strains supplies.

Last January, North Dakota had amassed 2.7 million Abbott Laboratories BinaxNOW rapid COVID tests from the federal government — roughly 3½ tests for each person in the state of 775,000 people.

The state had so many COVID tests that it donated a total of 1 million of them to Montana and Pennsylvania as part of a sharing program among states that formed when the delta variant was the dominant strain and COVID outbreaks rippled across the nation in waves. But now that omicron has turned the entire nation into a coronavirus hot spot and driven up demand for tests everywhere, that system has been upended.

Some states are holding on to expired tests for use as a last resort. In early January, North Dakota was one of them, with a stockpile of 600,000 expired rapid tests.

"I want to make sure that our state is covered," said Nicole Brunelle, North Dakota's chief nursing officer. "The entire nation is fighting for these tests."

Jasmine Reed, a spokesperson for the Centers for Disease Control and Prevention, said the state exchange program has stopped operating, and while federal health officials are working to get it going again, the timing is unclear. "Once COVID-19 and its variants began to ramp up and more testing was needed, states no longer had a surplus to provide extra tests," Reed said.

By early January, some states, including Montana and Indiana, had depleted their inventory of rapid COVID tests for distribution. Along with North Dakota, Florida and Maryland have held on to expired tests in hopes the federal government would extend the tests' shelf life.

The inevitable result: States have gone from cooperation to competition.

"Emergency management and federal assistance across the country is built on the idea that we won't have a need everywhere at once," said Ken Sturrock, a Colorado-based regional emergency coordinator for the U.S. Department of Health and Human Services.

The state test exchange program was created amid concerns that tests would expire unused. Federal health agencies built an online platform that states could use to relay what they had or needed.

Some states have gone outside the program to exchange tests. For example, Mississippi donated more than 79,000 tests to Pennsylvania in November, said Jim Craig, senior deputy for the Mississippi State Department of Health.

For the states that participated, the exchange program was effective in identifying and shipping tests to places in need across the country through much of 2021. Colorado, for instance, received tests from five states from May through August of last year, bringing in about 340,000 kits that were close to expiring.

Some donations went farther. When nationwide demand for testing diminished early last year, the Arkansas Department of Health couldn't find a state to take 300,000 tests close to expiring. Danyelle McNeill, a department spokesperson, said Arkansas donated the tests to India, where the delta variant was first identified, in late winter 2021.

Brunelle, North Dakota's chief nursing officer, said the state expanded access to its supply of tests to schools, businesses, health providers, and others, offering free kits and training to those who would use them. Even then, Brunelle said, the state had more tests than it could distribute before they expired.

In January 2021, North Dakota sent 250,000 tests to Montana. Demand in Montana was low at the time, but Jon Ebelt, a spokesperson for the state Department of Public Health and Human Services, said the state "did not want to turn down free tests" after supplies had been tight earlier in the pandemic.

That summer, Montana sent 51,000 of those tests to Colorado.

But by January 2022, Montana's supplies had been depleted. Health officials notified school districts that the pool of BinaxNOW test kits had run dry. The state worked through suppliers to order 650,000 tests and planned to start distributing them on Jan. 30. Montana Gov. Greg Gianforte, a Republican, blamed the Biden administration, saying it had repeatedly failed to increase testing supplies.

The Biden administration has created a website where households can sign up to receive four free tests, and officials have said tests are expected to ship within seven to 12 days of orders being placed. But that initial rollout raised access issues for some of the most vulnerable.

In fall 2021, North Dakota sent 750,000 rapid tests to the Children's Hospital of Philadelphia. Dr. David Rubin, the hospital's director of population health innovation, said the hospital distributed those supplies to a school-based testing program in southeastern Pennsylvania.

Rubin said that without the federal platform, the hospital is trying to get more tests for the program through federal agencies but that the line for them is long.

"We're starting to imagine a world with less testing right now because it's the reality," Rubin said.

In some cases, the FDA has extended the shelf life for certain tests, most recently this month when it put a 15-month life span on Abbott's at-home tests.

Amid the shortage, states have also sought permission to use outdated stock still on their shelves. Andy Owen, a spokesperson for the Maryland Department of Health, said that on Jan. 18, the FDA gave the state an additional three months to use 97,000 expired rapid tests that must be administered by a provider. That's after Florida got another three-month extension to use roughly 1 million test kits that had expired at the end of December.

The Centers for Medicare & Medicaid Services released guidelines in 2020 that allowed states to use expired tests "until non-expired supplies become available."

New Mexico Department of Health spokesperson Katy Diffendorfer said the state told a school that it could use older tests after the school's supply dwindled to outdated kits. "They desperately needed to be able to test," Diffendorfer said, adding that the state would send non-expired tests as soon as possible.

In North Dakota, which once had an abundance of tests, Brunelle said the state was starting to see access issues this winter, especially in rural places. The state has been careful about sending tests out, even within the state. North Dakota stalled its program to distribute tests to businesses, which Brunelle hopes is temporary.

"Right now, we need to keep our priority with our healthcare system, our first responders, our vulnerable populations," she said.

Katheryn Houghton: khoughton@kff.org, @K_Hought

Listen: Generous Deals, and a Few Unwanted Surprises, at Covered California

KFF Health News, January 28, 2022

Because of a significant increase in federal tax credits, many people qualify for generous coverage without paying a penny in monthly premiums.

This audio presentation was released on Friday, January 28, 2022 by Kaiser Health News.

KHN Southern California correspondent Bernard J. Wolfson was on "Línea Abierta," a Radio Bilingüe weekday news program, answering questions for a Spanish-speaking audience about his recent column on health plan enrollment through California's Affordable Care Act marketplace, Covered California.

Wolfson's column discusses the extraordinary deals available through Covered California. Because of a significant increase in federal tax credits, many people qualify for generous coverage without paying a penny in monthly premiums. Others, with higher incomes, qualify for tax credits large enough to reduce their premiums to easily affordable levels.

But, as Wolfson notes, some enrollees are facing sticker shock: People who received unemployment benefits for at least one week last year paid only $1 a month for comprehensive coverage in 2021, as a result of a federal rule that looks unlikely to be renewed for 2022.

Covered California's annual enrollment period ends Jan. 31, but people who undergo certain life-altering changes — losing a job, getting divorced, having or adopting a child, for example — can enroll anytime.

Medicare Patients Win the Right to Appeal Gap in Nursing Home Coverage

KFF Health News, January 28, 2022

A federal appeals court's decision applies only to people with traditional Medicare whose status was changed from inpatient to observation.

This article was published on Friday, January 28, 2022 in Kaiser Health News.

By Susan Jaffe

A three-judge federal appeals court panel in Connecticut has likely ended an 11-year fight against a frustrating and confusing rule that left hundreds of thousands of Medicare beneficiaries without coverage for nursing home care, and no way to challenge a denial.

The Jan. 25 ruling, which came in response to a 2011 class-action lawsuit eventually joined by 14 beneficiaries against the Department of Health and Human Services, will guarantee patients the right to appeal to Medicare for nursing home coverage if they were admitted to a hospital as an inpatient but were switched to observation care, an outpatient service.

The court's decision applies only to people with traditional Medicare whose status was changed from inpatient to observation. A hospital services review team can make this change during or after a patient's stay.

Observation care is a classification designed for patients who are not well enough to go home but still need the kind of care they can get only in a hospital. But it can have serious repercussions.

Without a three-day inpatient stay, beneficiaries are ineligible for Medicare's nursing home benefit. So if they need follow-up care in a nursing home after leaving the hospital, they can face charges of about $290 a day, the average national cost of nursing home care, according to a 2021 survey. Also, since observation care is categorized as outpatient treatment — even if the patient is on a hospital ward — they can get stuck with significant copays under Medicare rules.

"You can appeal almost every issue affecting your Medicare coverage except this one, and that is unfair," said Alice Bers, litigation director at the Center for Medicare Advocacy, which represented the patients in their lawsuit along with Justice in Aging, another advocacy group, and the California law firm of Wilson Sonsini Goodrich and Rosati.

Until Congress passed a law that took effect in 2017, hospitals weren't required to tell patients whether they were receiving observation care and had not been admitted. Under that law, hospitals must provide written notice, but it does not trigger any right to appeal.

The Department of Justice, representing HHS and the Medicare program, tried numerous times to get the case dismissed, arguing that the decision to admit patients or classify them as "observation patients" was based on a doctor's or hospital's medical expertise. Patients had nothing to appeal because the government can't change a decision it didn't make, so no Medicare rule had been violated.

Doctors rejected that notion and have long complained that the Medicare rule undermined their clinical judgment and produced "absurd results" that can hurt patients. The American Medical Association and state medical societies filed legal papers in support of the patients challenging the rule, as did several other organizations, including AARP, the National Disability Rights Network, and the American Healthcare Association, which represents nursing homes across the country.

But U.S. District Judge Michael Shea ruled against HHS in 2020, and estimated that hundreds of thousands of Medicare patients would be able to seek refunds for nursing home care and other costs that admitted patients don't pay. The trial took place in 2019.

The government continued to back the rule, however, and asked a federal appeals court panel to reverse Shea's decision — despite comments from then-chief of Medicare Seema Verma, who questioned these policies in a 2019 tweet, saying that "government doesn't always make sense."

On Jan. 25, the appeals court judges upheld Shea's decision, agreeing that when hospitals switched a patient's status they were following Medicare's 2013 "two-midnight rule." It requires hospitals to admit patients who are expected to stay through two midnights. The ruling applies to people in traditional Medicare.

"The decision to reclassify a hospital patient from an inpatient to one receiving observation services may have significant and detrimental impacts on plaintiffs' financial, psychological, and physical well-being," the judges wrote. "That there is currently no recourse available to challenge that decision also weighs heavily in favor of a finding that plaintiffs have not been afforded the process required by the Constitution."

A DOJ spokesperson declined to comment on whether government lawyers would appeal the new ruling.

Three groups of Medicare patients who were switched from inpatient to observation status after Jan.1, 2009, will be able to file appeals for nursing home coverage and reimbursement for out-of-pocket costs. People currently in the hospital will be able to request an expedited appeal, and others who have recently incurred costs can file a standard appeal by following instructions in their Medicare Summary Notice. A plan for appealing older claims has not yet been arranged, said Bers. The latest details are available on the Center for Medicare Advocacy's website. (The three-day inpatient hospital stay requirement is temporarily suspended due to the COVID-19 pandemic.)

Observation status also causes trouble for people like Andrew Roney, 70, of Teaneck, New Jersey, who was caught unawares when he was switched from inpatient to observation status. He had Medicare's Part A hospitalization coverage, which is free for most people 65 and older. But he didn't sign up for Part B, which carries a monthly premium and covers outpatient services, including observation care, doctor visits, lab tests, and X-rays. He spent three days in a nearby hospital for an intestinal infection in 2016.

Roney, a freelance editor and substitute teacher, didn't think he needed Part B and assumed Part A would cover his hospital stay. Instead, he was surprised to get a $5,000 bill because he was classified as an observation patient and was not admitted. Despite his best efforts, there was nothing he could do about it except to pay up.

"It came as a shock to the system," said Roney, who testified in the 2019 trial. "I don't want anybody else to go through that." Although he had given up hope of getting his money back, he intends to file an appeal now that he can. "It's a nice chunk of change."

Susan Jaffe: Jaffe.KHN@gmail.com, @SusanJaffe

In Super-Vaxxed Vermont, COVID Strikes — But Packs Far Less Punch

KFF Health News, January 28, 2022

In a state with the motto "Freedom and Unity," freedom has largely yielded to unity, and the state's pandemic response has been met with eager compliance.

This article was published on Friday, January 28, 2022 in Kaiser Health News.

By Sarah Varney   

Even Eden, a snow-covered paradise in northern Vermont, is poisoned by omicron.

The nearly vertical ascent of new coronavirus cases in recent weeks, before peaking in mid-January, affected nearly every mountain hamlet, every shuttered factory town, every frozen bucolic college campus in this state despite its near-perfect vaccination record.

Of all the states, Vermont appeared best prepared for the omicron battle: It is the nation's most vaccinated state against COVID, with nearly 80% of residents fully vaccinated — and 95% of residents age 65 and up, the age group considered most vulnerable to serious risk of COVID.

Yet, even this super-vaxxed state has not proved impenetrable. The state in mid-January hit record highs for residents hospitalized with COVID-19; elective surgeries in some Vermont hospitals are on hold; and schools and day care centers are in a tailspin from the numbers of staff and teacher absences and students quarantined at home. Hospitals are leaning on Federal Emergency Management Agency paramedics and EMTs.

And, in a troubling sign of what lies ahead for the remaining winter months: about 1 in 10 COVID tests in Vermont are positive, a startling rise from the summer months when the delta variant on the loose elsewhere in the country barely registered here.

"It shows how transmissible omicron is," said Dr. Trey Dobson, chief medical officer at Southwestern Vermont Medical Center, a nonprofit hospital in Bennington. "Even if someone is vaccinated, you're going to breathe it in, it's going to replicate, and if you test, you're going to be positive."

But experts are quick to note that Vermont also serves as a window into what's possible as the U.S. learns to live with COVID. Although nearly universal vaccination could not keep the highly mutated omicron variant from sweeping through the state, Vermont's collective measures do appear to be protecting residents from the worst of the contagion's damage. Vermont's COVID-related hospitalization rates, while higher than last winter's peak, still rank last in the nation. And overall death rates also rank comparatively low.

Children in Vermont are testing positive for COVID, and pediatric hospitalizations have increased. But an accompanying decrease in other seasonal pediatric illnesses, like influenza and respiratory syncytial virus, and the vaccinated status of the majority of the state's eligible children has eased the strain on hospitals that many other states are facing.

"I have to remind people that cases don't mean disease, and I think we're seeing that in Vermont," said Dr. Rebecca Bell, a pediatric critical care specialist at the University of Vermont Health Network in Burlington, the only pediatric intensive care hospital in the state. "We have a lot of cases, but we're not seeing a lot of severe disease and hospitalization."

She added, "I have not admitted a vaccinated child to the hospital with COVID."

Vermont in many ways embodies the future the Biden administration and public health officials aim to usher in: high vaccination rates across all races and ethnicities; adherence to evolving public health guidelines; and a stick-to-itiveness and social cohesion when the virus is swarming. There is no "good enough" in Vermont, a state of just 645,000 residents. While vaccination efforts among adults and children have stalled elsewhere, Vermont is pressing hard to better its near-perfect score.

"We have a high percentage of kids vaccinated, but we could do better," said Dobson.

He continues to urge unvaccinated patients to attend his weekly vaccination clinic. The "first-timers" showing up seem to have held off due to schedules or indifference rather than major reservations about the vaccines. "They are nonchalant about it," he said. "I ask, 'Why now?' And they say, 'My job required it.'"

Replicating Vermont's success may prove difficult.

"There is a New England small-town dynamic," said Dr. Tim Lahey, director of clinical ethics at the University of Vermont Medical Center in Burlington. "It's easy to imagine how your behavior impacts your neighbor and an expectation that we take care of each other."

While other rural states in the Midwest and South have struggled to boost vaccination rates, New England, in general, is outpacing the pack. Behind Vermont, Rhode Island, Maine, and Connecticut have the highest percentage of fully vaccinated residents in the country.

"It's something beyond just the size," said Dr. Ben Lee, an associate professor at the Robert Larner, M.D. College of Medicine at the University of Vermont. "There is a sense of communal responsibility here that is a bit unique."

In a state with the motto "Freedom and Unity," freedom has largely yielded to unity, and the state's pandemic response has been met with eager compliance. "The general attitude here has been enthusiasm to be safer," said Lahey.

Lahey credits the state's Republican governor, Phil Scott, who has been "unambivalent about pro-vax messaging." Combined with a "tendency to trust the vaccine, you get a different outcome than in places where political leaders are exploiting that minority voice and whipping people up in anger."

Vermont's medical leaders are advising state leaders to shift from a COVID war footing — surveillance testing, contact tracing, quarantines, and lockdowns — to rapprochement: testing for COVID only if the outcome will change how doctors treat a patient; ceasing school-based surveillance testing and contact tracing; and recommending that students with symptoms simply recuperate at home.

Once the omicron wave passes and less virus is circulating, Dobson said, a highly vaccinated state like Vermont "could really drop nearly all mitigation measures and society would function well." Vermonters will become accustomed to taking appropriate measures to protect themselves, he said, not unlike wearing seat belts and driving cautiously to mitigate the risk of a car accident. "And yet," he added, "it's never zero risk."

Spared the acrimony and bitterness that has alienated neighbor from neighbor in other states, Vermont may have something else in short supply elsewhere: stamina.

"All of us are just exhausted," said Lahey, the ethics director. But "we're exhausted with friends."

Sarah Varney: svarney@kff.org, @SarahVarney4

Resistance to a Boston Hospital's Expansion Centers on Rising Prices

KFF Health News, January 27, 2022

Mass General Brigham's plans to build three ambulatory care centers in three suburbs west of Boston is stirring controversy.

This article was published on Thursday, January 27, 2022 in Kaiser Health News.

By Harris Meyer

A boisterous political battle over a proposed expansion by the largest and most expensive hospital system in Massachusetts is spotlighting questions about whether similar expansions by big health systems around the country drive up healthcare costs.

Mass General Brigham, which owns 11 hospitals in the state, has proposed a $2.3 billion expansion including a new 482-bed tower at its flagship Massachusetts General Hospital in Boston and a 78-bed addition to Brigham and Women's Faulkner Hospital. The most controversial element, however, is a plan to build three comprehensive ambulatory care centers, offering physician services, surgery, and diagnostic imaging, in three suburbs west of Boston.

On Jan. 25, the state's 11-member Health Policy Commission unanimously concluded that these expansions would drive up spending for commercially insured residents by as much as $90 million a year and boost health insurance premiums.

The commission also ordered Mass General Brigham to develop an 18-month "performance improvement plan" to slow its cost growth. The action, believed to be the first time in the country a hospital has been ordered to develop a plan to control costs, reflects concern about giant hospitals' role in rising healthcare costs.

Other states, including California, Delaware, Oregon, Rhode Island, and Washington, have created or are considering commissions on healthcare costs with the authority to analyze the market impact of mergers and expansions. That's happening because the traditional "determination of need" process for approving health facility expansions, which nearly three dozen states still have in place, has not been effective in the current era of health system giants, said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy.

The Mass General Brigham health system, which generates $15.7 billion in annual operating revenue, announced that the massive expansion would better serve its existing patients, including 227,000 who live outside Boston. Its leaders said the new facilities would not raise health spending in the state, where policymakers are alarmed that cost growth in 2019 hit 4.3%, exceeding the state's target of 3.1%.

The hospitals' cost-analysis report, submitted to the state last month, concluded that the system's existing patients would pay lower prices at the new suburban sites than at its downtown locations. John Fernandez, president of Mass General Brigham Integrated Care, projected that prices at the new centers would be 25% less, and he said patients will not have to pay extra hospital "facility fees" at the new outpatient sites.

"We're all going to have a tsunami of patients over the next 20 years given the aging population, and everyone has to step up to meet that demand," he said in explaining the expansion.

But a well-funded coalition of competing hospitals, labor unions, and chambers of commerce argues that Mass General Brigham's invasion of the Boston suburbs would spike total spending by drawing in patients from lower-priced physicians and hospitals. They cite the health system's own planning projection, unearthed by the attorney general's office in a November report, that the expansion would boost annual profits by $385 million.

"How could you be fooled?" said Dr. Eric Dickson, CEO of UMass Memorial Healthcare, a safety-net health system serving the towns west of Boston that is part of the coalition of expansion opponents. "If you let the state's most expensive system grow wildly, it will drive up the cost of care."

The controversy signals a shift in the concerns about the cause of rapidly escalating healthcare costs. Up to now, state and federal policymakers examining how hospital system growth affects costs have largely focused on hospital mergers and purchases of physician practices. Studies have found that these deals significantly boost prices to consumers, employers, and insurers. State and federal regulators have stepped up antitrust scrutiny of mergers and acquisitions.

Deep-pocketed hospital systems increasingly are turning to solo expansion to gain a bigger share of the market. These expansions fall outside the legal authority of antitrust enforcers.

Health systems are building satellite ambulatory care centers to attract more well-insured patients and steer them to their own hospitals and other facilities, said Glenn Melnick, a health economist at the University of Southern California.

"The outcome is the same as a merger — capturing patients and keeping them," he said. "That's not necessarily good for consumers in terms of access to care or cost efficiency."

Critics of Mass General Brigham's plans also warn that the expansion would financially destabilize providers that heavily serve lower-income and minority residents because some of their more affluent patients would move to the new facilities. Those patients' commercial insurance plans pay nearly three times what the state's Medicaid program pays.

"It's a very, very good business move for MGB," said Dickson, whose system serves a large percentage of Medicaid patients. "But they know quite well this will impact our ability to care for vulnerable populations."

The Health Policy Commission agreed with those opposing the expansion and said it would advise the state Public Health Council — which will decide on the three expansion applications by April — that the proposals are not consistent with the state's goals for cost containment.

"Our strong assessment is this would substantially increase spending," said Stuart Altman, a health policy professor at Brandeis University who chairs the commission. In addition, "there is a clear indication it would reduce revenues to those institutions we count on to provide services to lower-income and historically marginalized communities."

In a written statement, Mass General Brigham ripped the commission's findings as flawed. It also disagreed with the commission's decision to require a cost-improvement plan but said it would work with the agency to address the challenge.

Under Massachusetts' determination of need process, Mass General Brigham must show the Public Health Council that its expansion proposals would contribute to the state's goals for cost containment, improved public health outcomes, and delivery system transformation.

The council has never blocked a project on cost grounds in its nearly 50-year history, said Dr. Paul Hattis, a former member of the Health Policy Commission. He argues that Massachusetts needs more explicit statutory power to decide whether health system expansions are good for the public, because he doesn't think the council understands its own regulation.

A bill passed by the Massachusetts House of Representatives last fall would give the commission, which was created in 2012, greater authority to investigate the cost and market impact of such expansions. Its legislative fate is uncertain.

Upping the stakes in the Massachusetts expansion fight: Massachusetts General Hospital charges by far the highest prices in the state, and Brigham and Women's Hospital isn't far behind.

Patients with a Mass General Brigham primary care physician had the highest total per-member spending in 2019, nearly $700 per month, according to the Health Policy Commission. That was 45% higher than spending for patients served by doctors at Reliant, which is owned by UnitedHealth Group's Optum unit. Average payments for major outpatient surgery at Massachusetts General and Brigham and Women's were nearly twice as high as at the state's lowest-paid high-volume hospital.

After Miscarriages, Workers Have Few Guarantees for Time Off or Job-Based Help

KFF Health News, January 26, 2022

There are no national laws that protect people when they need time off from work to deal with the loss.

This article was published on Wednesday, January 26, 2022 in Kaiser Health News.

By Bryce Covert January 26, 2022

For three years, Rachel Makkar said, she thrived in her job as a broker and asset manager at J&B Building Co. in Colorado. She excelled at her work — she said her performance reviews noted that — and she thought it was "the best place I've ever worked."

That changed in August. After trying for "a really long time" to conceive a second child, she suffered an early miscarriage at home one weekend. She couldn't go to work that Monday. "I was really traumatized," she said. "That entire first week was like a heightened level of emotion that I hadn't really been through before." She also had a doctor's appointment to ensure she wasn't experiencing an ectopic pregnancy, which would have required immediate surgery.

She had emailed her bosses, informing them of the miscarriage and her need to take Monday off, which she had enough paid leave to cover. Because of the pandemic, she had been working from home several days a week and opted to do that again Tuesday because she was still bleeding and her face was "so puffy from crying," she said. She returned to the office, as scheduled, on Wednesday, she said, and then, given that her managers were out of the office, worked from home the rest of the week.

The following week, 10 days after her miscarriage, one of the company owners called her and fired her, allegedly for working from home repeatedly, even though others at the firm had similar hybrid schedules, according to Makkar. She was "shocked."

When Makkar reminded him that she had worked from home because of her miscarriage, she said he responded, "When my wife had a miscarriage in the beginning of our marriage, she only took a half a day off work."

Getting fired right after her miscarriage "was really, really awful," she said through tears. "You're already so devastated, and it's just another blow."

Makker filed a complaint based on her allegations against J&B with the Colorado Civil Rights Division, accusing the company of gender and pregnancy discrimination for her firing, in violation of Colorado state laws. "This shouldn't have to happen to other women," she said.

A lawyer for J&B said its policy is not to comment on ongoing litigation and declined to provide any responses the company may have filed with the state. "We're just confident that once the facts are reviewed the company will be vindicated," he said.

Miscarriage, which occurs in about a quarter of all pregnancies, is the most common form of loss of a pregnancy. And yet there are no national laws that protect people when they need time off from work to deal with the loss.

The physical needs of someone who experiences a miscarriage vary greatly. Within the first week or two, symptoms may resemble a heavy menstrual period with cramping and some pain. The later in the pregnancy that a miscarriage occurs, the more likely there will be significant bleeding, "to the point where it leads to anemia in some cases," said Dr. Wael Salem, a reproductive endocrinologist and fertility specialist with CCRM San Francisco. Some people have such heavy contractions that they need pain management, he added. Miscarriages in the second trimester or later may require procedures needing hospital admission. The aftereffects are often unpredictable and can last for weeks or months.

"Miscarriage is not a one-and-done thing at all," Salem said. "It drags on physically, mentally, and emotionally."

The emotional aspect "can be a very traumatic experience," noted Maria Brann, a professor of communications studies at Indiana University who has studied miscarriage for a decade. Some people blame themselves even though the vast majority of early miscarriages are due to chromosomal abnormalities beyond people's control. Compounding the grief is the lack of established rituals that accompany other losses, as well as a stigma some people attach to miscarriage.

In the wake of such trauma, "it's very difficult to focus," Brann said. "An individual is probably not going to be as productive."

"It is really important that we encourage women to take care of themselves," Brann said. Otherwise, the grief won't be processed and it can "cause even greater mental anguish later on."

More people are speaking out about the experience of miscarriage, including high-profile women like Michelle Obama, Meghan Markle, and actress Gabrielle Union.

But many workers find it difficult to get time off from work. The federal Pregnancy Discrimination Act prohibits employers from treating workers who are pregnant, give birth, or have related medical conditions — including miscarriage — worse than comparable co-workers. Courts, however, have interpreted that law differently, even after a 2015 Supreme Court decision decided in favor of a plaintiff who claimed pregnancy discrimination. Judges have dismissed two-thirds of cases in the aftermath, according to a review by A Better Balance, a national legal nonprofit promoting workplace rights.

Thirty states and five localities — including Colorado — have enacted laws that require employers to offer workers accommodations related to pregnancy, which can include time off to recover from a miscarriage. But outside those states, workers are protected only by the pregnancy act or the Americans with Disabilities Act, if a miscarriage is severe enough to substantially limit a "life activity."

Currently, 13 states, 20 cities, and four counties, also including Colorado, have enacted laws requiring some employers to provide paid sick leave to workers for medical needs, such as for the physical and mental health impacts of miscarriage. They don't require employees to say why they need the time off, other than perhaps producing a doctor's note.

"It's not putting the onus on the worker to have to reveal something that might be very personal and very sensitive," said Sarah Brafman, a senior policy counsel at A Better Balance.

Nine states and the District of Columbia have paid family leave programs, which can be used for more serious complications resulting from miscarriage. Elsewhere workers can take unpaid leave through the Family and Medical Leave Act if they qualify.

To fill the gaps, Sen. Tammy Duckworth (D-Ill.) and Rep. Ayanna Pressley (D-Mass.) introduced legislation that would ensure three days of paid leave for miscarriage and other fertility challenges. Democrats have also put forward federal legislation to guarantee paid sick leave, and they've included paid family leave in President Joe Biden's social spending plan, although that provision is meeting stiff opposition from some lawmakers and the bill is languishing in Congress.

Makkar is living with the repercussions of her miscarriage. "It's all so traumatizing still," she said. She's trying to find a new job, but the search is complicated. She's "terrified of getting myself in this situation again," she said, because she wants to have more children. "I don't want to be somewhere that that's not going to be supported."

What the Federal 'No Surprises Act' Means in California

KFF Health News, January 26, 2022

The federal law that took effect Jan. 1 protects more than 100 million people enrolled in self-funded health plans across the nation.

This article was published on Wednesday, January 26, 2022 in Kaiser Health News.

By Bernard J. Wolfson

Betty Chow, a Los Angeles resident, had a cervical disc replaced in August 2020 at a surgery center that was part of her Anthem Blue Cross PPO network.

Thirteen months later, she was blindsided by a bill for nearly $2,000 from the anesthesiologist who was on her surgical team but was not contracted with her PPO, or preferred provider organization.

Chow, a 35-year-old veterinarian, says she discussed the bill with her boyfriend, a registered nurse. He told her about a California law that took effect in 2017 and prohibits such "surprise bills" from out-of-network medical providers who work at in-network facilities.

Unfortunately, that law does not protect Chow or nearly 6 million other Californians who get health coverage through employers that pay employee medical bills out of their own treasuries. These "self-funded" plans are regulated by the U.S. Department of Labor — and thus are beyond the reach of state law.

But a federal law that took effect Jan. 1 bridges that gap for the more than 100 million people enrolled in such health plans across the United States, including those nearly 6 million Californians. And it covers millions more in the 32 states that have no laws against surprise bills or have laws offering only partial protection.

The new federal law, the No Surprises Act, also protects nearly 1 million Californians not covered by a 2009 California Supreme Court ruling that prohibits emergency room doctors and other providers of emergency services from billing HMO patients for out-of-network charges not paid by their insurers — a practice known as balance billing.

"Millions more Californians will now be protected against these bills that are not just unfair but put families' economic security at risk," says Anthony Wright, executive director of Health Access California, a consumer advocacy group.

It's high time. Surprise bills have inflicted financial pain on millions of Americans for far too long.

When patients are seen by out-of-network providers they didn't choose, it is often a double whammy: They pay more out-of-pocket — even if their health plan covers some out-of-network care — and they may later receive balance bills from providers that can total thousands of dollars.

Research shows that surprise bills are common among the nearly 200 million U.S. residents enrolled in private health plans.

A 2020 study found that 20% of privately insured patients who had elective surgery at a hospital that was in their insurance network received surprise bills from providers who were not. Bills from anesthesiologists averaged $1,219. Bills from surgical assistants averaged more than twice that amount.

"When patients pay their insurance premiums, they presume — and I believe fairly presume — that they will be covered financially," says Katie Berge, director of federal government affairs at the Leukemia & Lymphoma Society.

The No Surprises Act covers all privately insured people in employer-sponsored and individual/family health plans. Medicare and Medicaid already protect their enrollees against nasty billing surprises.

The new federal law, which is largely in sync with California's, bans balance billing for nonemergency care by out-of-network providers at in-network facilities and for most emergency room care at any facility. Insurers must cover those services at in-network rates, and providers may not bill patients for any amounts beyond that. Providers and health plans must negotiate how much the plan will pay, leaving patients out of the fray.

The federal law also protects against outlandish bills from out-of-network air ambulance services. A California law that took effect in January 2020 does the same thing. But it doesn't cover the millions of people in federally regulated health plans and has been vulnerable to a possible legal challenge because it may conflict with the 1978 deregulation of airlines, which included air ambulances.

In cases where its provisions are stronger, the federal law will trump state laws.

What about enforcement? The federal government will defer to states in cases that involve state-regulated plans, and in those that involve federally regulated ones if the target of the complaint is a provider, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. But the federal government will step in if states refuse or cannot enforce the law, he says.

Federal health officials are sending letters about enforcement to the governors of every state.

California, with its strong laws against surprise billing, certainly has the means and experience for enforcement, though it has not seen a huge number of cases. In the past four years, the Department of Managed Healthcare has resolved 1,006 consumer complaints about balance billing, and 467 of them yielded total reimbursements of nearly $1 million to enrollees, says Rachel Arrezola, a department spokesperson.

Of course, not all bills that surprise patients are regulated by state or federal law. Sometimes people owe more than they thought on their deductible, or their cost sharing was higher than they realized, or their procedure wasn't covered by their health plan, or the facility they chose wasn't in their network.

So, bone up on your insurance policy. Know what and who it covers, which facilities are in the network, how much your out-of-pocket costs are, and how much of your deductible remains to be paid.

That will help you determine whether a bill is illegitimate. And there still will be illegitimate bills — because people make mistakes. And some medical professionals act in bad faith.

When you get a bill, don't pay it right away. Ask questions. Compare it with the explanation of benefits you receive from your insurer — and if that hasn't arrived yet, wait for it. If there's a discrepancy between what your provider and your health plan say, call them both, and try to iron it out.

If that doesn't work, don't get discouraged. You can file a grievance with your health plan. And if that doesn't resolve your problem, contact the Department of Managed Healthcare to open an appeal, either on its website (www.healthhelp.ca.gov) or by calling 1-888-466-2219. The department also has a fact sheet that may answer some of your questions about California's surprise billing law.

The federal government has launched a website (www.cms.gov/nosurprises) that may answer many of your questions about the No Surprises Act and will enable you to lodge a complaint or dispute a bill. You can also contact a federal "no surprises" help desk at 1-800-985-3059.

If you are simply befuddled by medical bills or lack the confidence to contest one on your own, the Health Consumer Alliance is a great resource. Find an office near you by going to www.healthconsumer.org or calling 1-888-804-3536.

Chow, a native of Hong Kong who has been a patient in the single-payer system there and in the United Kingdom, says she is baffled by the U.S. system, "where you pay for medical insurance, but then you have to pay more."

Although California's law does not protect her from the anesthesiologist's $2,000 bill and the new federal law is not retroactive, she nonetheless appears to be headed toward a happy ending.

After three collection attempts by the anesthesiologist and several phone calls by Chow, Anthem agreed to knock the bill down to $83 and to update the anesthesiologist's billing office. That still hasn't happened, but Chow is hopeful.

"I don't really understand what I'm responsible for," she says, "except $83 is a lot less than $2,000."

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

With a Vaccine Mandate Looming, Nursing Homes Face More Staffing Problems

KFF Health News, January 25, 2022

Healthcare sites in states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Eric Berger

ST. CHARLES, Mo. — Jamie Smith, a staffing agency nurse who loves end-of-life care, said she has been warmly welcomed by staffers and residents at Frontier Health & Rehabilitation in this conservative St. Louis suburb.  

That's even though she has not been vaccinated against COVID-19.

But leaders of the nursing home, where 22 residents died from COVID before vaccines were available, likely won't be able to employ unvaccinated people like Smith for much longer. The U.S. Supreme Court on Jan. 13 upheld a federal mandate requiring healthcare workers at facilities that receive Medicaid or Medicare funding to be fully vaccinated. If all staffers — excluding those with approved religious or medical exemptions — aren't fully vaccinated, the facility will lose that money.

Healthcare sites in Missouri and other states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated, according to the Centers for Medicare & Medicaid Services, while facilities in states that didn't sue to block the mandate have a Feb. 28 deadline.

That poses a challenge for Frontier and its residents because the nursing home already doesn't have enough staffers. And it is in the state with the lowest rate of fully vaccinated nursing home healthcare workers, 67% as of Jan. 9, according to CMS data. Frontier's reported staff vaccination rate was just 30% at the start of the year.

That compares with a national rate of 81%, according to the federal data.

Although the mandate ensures that unvaccinated staff members are not caring for some of the people most vulnerable to the virus, not enough workers are willing to take the low-paying, challenging jobs. If they quit to avoid getting shots or are fired because they won't get them, nursing home residents might not be any safer — because of lack of care.

"Obviously we need good staff members to take care of residents, but the residents need to be safe as well," said Marjorie Moore, who supports the mandate and is executive director of Voyce, a St. Louis nonprofit that advocates for nursing home residents and their families.

"A person who lives in their own home has the chance to say, 'I don't want somebody in my home who isn't vaccinated,'" she added. "In a nursing home, they don't have the opportunity to say, 'I don't want somebody who is unvaccinated coming up and feeding me.'"

The problem of inadequate staffing at nursing homes predates the pandemic, and it's gotten worse.

In March 2020, 3.3 million people were employed at U.S. nursing homes and residential care facilities, according to the Bureau of Labor Statistics. In December 2021, that number had dropped to 2.9 million, a loss of 400,000 workers.

Nursing home operators can't find enough staffers because they often don't pay much. The mean hourly wage for nursing assistants in Missouri was $13.33 in 2020, according to the statistics bureau. And the homes require employees to take on a slew of responsibilities, including feeding residents, changing adult diapers, and caring for residents who have dementia and may become combative.

Nursing assistants "can typically find a job with better pay that is less physically and emotionally demanding," said Brian McGarry, a University of Rochester professor who studies long-term care. "Somebody's life and dignity is in your hands, and it's a huge responsibility, and you are not getting paid commensurate with that responsibility."

Those downsides of the job often lead to significant turnover. In 2017-18, the turnover rate among nursing home employees in Missouri was 138%, the fourth-highest in the country, according to a study in the journal Health Affairs. Frontier had a rate of more than 300%, according to Huizi Yu, one of the study's authors.

The nursing home's management declined to comment.

Smith, the nurse who works for a healthcare staffing agency, said she has not been vaccinated against COVID because she had a rare cancer in 2017 and is "very particular about what I put in my body."

She said, "I'm not sure if I would be able to get it just to keep a job."

But, she noted in a text message, "I still practice safely."

And, indeed, no Frontier residents have died from COVID since the outbreak at the start of the pandemic, according to the federal data. But the center reported having seven new confirmed cases among its residents and 10 new cases among its staff as of Jan. 9. At the beginning of the year, 89% of residents were fully vaccinated against COVID.

Low vaccination levels among staffers place residents at greater risk, according to a recent analysis in The New England Journal of Medicine. Facilities in high-COVID counties with an average staff vaccination rate of approximately 30% had nearly three times as many COVID deaths among residents as facilities where about 82% of employees were vaccinated, the analysis found.

"An unvaccinated or low-vaccinated staff, I think, pretty clearly puts residents at risk — even if they are vaccinated," said McGarry, one of the analysis's authors.

The vaccination rate has increased from fewer than half of Missouri nursing home staff members when President Joe Biden announced the mandate for nursing homes Aug. 18 to about two-thirds of staffers now, according to the federal data.

Like Frontier, Northview Village does not have enough staffers, and most people who work there have not been vaccinated. The facility — a nursing home in a predominantly Black, low-income north St. Louis neighborhood — held a vaccination drive in December to increase its roughly 20% staff vaccination rate, but the numbers did not rise, according to the federal data. And only half of residents were fully vaccinated.

The Northview management declined to comment.

Kimberly Watkins, a technician who works to keep Northview residents active, was reluctant to get any of the shots, in part because she heard the conspiracy theory that they contained a tracking chip. But she said she decided to go ahead and get vaccinated because she has asthma and high blood pressure. Co-workers told her their doctors said that they didn't need the vaccine or that they may be allergic to it.

Now with the mandate taking effect, Moore, of the nonprofit Voyce, thinks most local nursing home staffers will comply.

She highlighted Mary, Queen and Mother Center, a Catholic nonprofit nursing home in St. Louis County, that announced its own mandate in August. Before its Sept. 30 deadline, the nursing home saw its staff vaccination rate increase from 67% to 92%, with the remainder being those with a medical or religious exemption, according to the organization. The facility retained almost all its staff.

Not everyone is worried about nursing home staffers being vaccinated, in part reflecting the community around them. Just 55% of Missourians are fully vaccinated.

"I'm not into forcing stuff on people," said Antuan Diltz, a St. Louis firefighter whose mother is a 64-year-old retired nurse with dementia and diabetes living at Frontier. She received the vaccine; Diltz had not.

But others, like Bill Talton, who have family at Frontier hope more staffers will get the shots. Talton, a 77-year-old retired computer programmer, said he is happy with the care his younger brother, who has dementia, has received, although he sometimes couldn't visit him during COVID-related lockdowns.

"It's kind of late in the game," said Talton, who is fully vaccinated and received a booster. "They'll get it done — I hope."

KHN data editor Holly K. Hacker contributed to this report.

Pharmacies Are Turning Away Immunocompromised Patients Seeking 4th COVID Shot

KFF Health News, January 25, 2022

Many pharmacists are unaware that the CDC's vaccine guidance has changed.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Liz Szabo    

Patients with weakened immune systems — who are at high risk from COVID-19 — say pharmacies are turning them away when they seek additional vaccine doses recommended by federal health officials.

Alyson Smith became eligible this month for a fourth vaccine dose because her medications leave her immunocompromised.

Although the Centers for Disease Control and Prevention encourages most adults to receive a total of three mRNA vaccines — two "primary" vaccinations and a booster — the agency now advises people with weak immune systems to receive three primary shots plus a booster, for a total of four doses.

Many people are confused about the difference between a primary vaccine series and a booster. A primary vaccine series helps people build antibodies to a new pathogen, while a booster combats waning immunity.

As Smith learned, many pharmacists are unaware that the CDC's vaccine guidance has changed.

Smith booked her vaccine appointment online. But when she showed up at a Chicago-area Walgreens for the appointment Jan. 19, an employee told her the pharmacy chain wasn't administering fourth doses to anyone.

Smith said she's frustrated that vulnerable people are being forced to make multiple visits to crowded pharmacies and supermarkets, where many customers are unmasked.

"I feel for the pharmacists, because they're overwhelmed like everyone else," said Smith, 52. "But two years into the pandemic, there is a corporate responsibility to take action when the guidance comes down."

In a written statement, Walgreens said it has administered thousands of fourth doses to immunocompromised people. "As vaccination guidelines continue to evolve, we make every effort to continuously update our pharmacy teams."

The confusion stems from recent updates in vaccine advice for immunocompromised people, as well as a change in the interval between the end of a primary vaccine series and a booster.

  • In August, the CDC began allowing immunocompromised people to receive a third dose of mRNA vaccine as part of their primary vaccination.
     
  • In October, the CDC quietly updated its website to allow people with suppressed immune systems to receive a fourth shot as a booster.
     
  • In January, the agency shortened the time that anyone must wait for a booster from six months to five.

People who received the one-dose Johnson & Johnson vaccine are eligible for a single booster, for a total of two shots, according to the CDC.

Given how often vaccine guidelines have been revised in recent months, some pharmacists have had a hard time keeping pace, said Mitchel Rothholz, chief of governance and state affiliates at the American Pharmacists Association. Pharmacy employees have coped with an ever-expanding workload but a deepening shortage of employees during the pandemic, he said.

"I don't know any provider who wants to turn away a patient," Rothholz said. "The CDC continues to make updates, and it's becoming very difficult for providers at the grassroots level to keep up. I can understand why a pharmacist would say, 'Corporate hasn't given us the green light.'"

Confusion about who is eligible for a fourth shot "was inevitable, although I'm not saying it's right or wrong," he said.

Yet many patients and their doctors are frustrated.

If patients keep up with the latest guidelines, they ask, why can't their pharmacy?

"It's ridiculous," said Dr. Dorry Segev, a transplant surgeon and researcher at Johns Hopkins University. "CDC makes it very clear that it's allowed, and even people who print out the CDC guidance and take it to their pharmacies are being turned away."

Charis Hill, 34, joined a chorus of immune-suppressed people venting their concerns on social media in recent days. When Hill tweeted Jan. 21 that Rite Aid should better educate its staff, the retailer tweeted back that day, saying, "We're very sorry you didn't have a great experience, Charis. Please check back with us early next month for more information regarding the fourth dose."

In a written statement, Rite Aid said it continually educates its staff as CDC advice changes, and "is looking into the response that was provided to the customer on social media."

Dr. Shikha Jain, an assistant professor of medicine at the University of Illinois Cancer Center in Chicago, said patients in rural areas often drive long distances to look for vaccines. One of her patients was "almost in tears" after being turned away. Jain tried to help by calling the pharmacy but was on hold so long that she had to hang up to see patients.

Jain said the CDC needs to do a better job educating doctors, pharmacists, and patients.

The CDC did not respond to a request for comment before publication.

Teresa Strahlman, 61, said she's immune-compromised due to medications she takes for lupus, an autoimmune disease. But the Maryland woman said she didn't realize she was eligible for a fourth dose until reading a KHN post on Facebook. "I had no idea, and I have a million doctors," Strahlman said. "No one has said anything to me."

The CDC estimates that 2.7% of adults — or 7 million people — are immunocompromised, a group that includes people with medical conditions that dampen their immune response, as well as those taking immune-suppressing drugs because of organ transplants, cancer, or autoimmune diseases.

Some immunocompromised people say that being turned away from a pharmacy is especially frustrating, given all that they have sacrificed during the pandemic.

Linda Rushing, 74, has given up attending church services in person, although she's deeply religious, because of a weakened immune system that leaves her prone to a variety of infections.

Rushing made three visits to local pharmacies before finding someone to administer her fourth shot.

"It's a tragedy to need help and not be able to get it," said Rushing, of Rowlett, Texas, whose daughter and granddaughter are also immunocompromised. "I don't want COVID. I don't want to give it to anybody, and I'm trying to do everything I can not to die from it."

Liz Szabo: lszabo@kff.org, @LizSzabo  

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