With Sexually Transmitted Infections Off the Charts, California Pushes At-Home Tests

KFF Health News, January 5, 2022

The provision could bring better disease monitoring to rural and underserved parts of the state.

This article was published on Wednesday, January 5, 2022 in Kaiser Health News.

By Rachel Bluth  

SACRAMENTO, Calif. — California has become the first state to require health insurance plans to cover at-home tests for sexually transmitted infections such as HIV, chlamydia and syphilis — which could help quell the STI epidemic that has raged nearly unchecked as public health departments have focused on covid-19.

The rule, part of a broader law addressing the STI epidemic, took effect Jan. 1 for people with state-regulated private insurance plans and will kick in sometime later for the millions of low-income Californians enrolled in the state's Medicaid program.

By making it easier and cheaper for Californians to self-administer tests in the privacy of their homes, the provision could bring better disease monitoring to rural and underserved parts of the state, reduce the stigma patients experience when seeking care and give them more control over their health, say experts on infectious diseases.

"This is the first law of its kind, and I'd say it's kind of cutting-edge," said Stephanie Arnold Pang, senior director of policy and government relations for the National Coalition of STD Directors. "We want to bring down every single barrier for someone to get STI testing, and out-of-pocket cost is a huge factor."

But being first has its downsides. Because the concept of insurance coverage for home STI tests is so new, the state's Medicaid program, Medi-Cal, could not establish by Jan. 1 the billing codes it needs to start paying for tests. Federal regulators also haven't approved the tests for home use, which could make labs reluctant to process them. And a state analysis predicts most in-network healthcare providers won't start prescribing home tests for at least a year until they adjust their billing and other practices.

Nevertheless, the situation is urgent and requires action, said state Sen. Richard Pan (D-Sacramento), a pediatrician who wrote the law.

"We have children born in California with syphilis," Pan said. "You'd think that went away in the Victorian era."

Even before covid, sexually transmitted infections hit all-time highs in the U.S. and California for six years in a row, according to 2019 data from the Centers for Disease Control and Prevention. Rates of congenital syphilis, which babies contract from their mothers, illustrate the severity of the STI epidemic: Cases were up 279% from 2015 to 2019 nationally and 232% in California. Of the 445 cases of congenital syphilis in California in 2019, 37 were stillbirths.

The pandemic only worsened the problem because health departments were overwhelmed responding to the covid emergency, and stay-at-home orders kept people away from clinics.

In surveys of public health programs across the country since May 2020, the National Coalition of STD Directors found that most respondents — up to 78% in one survey — have diverted some of their STI workforces to test and monitor covid. A report that accompanied the most recent survey found that some STIs were "completely unchecked" due to reductions in clinic hours, diversion of resources, shortages of testing kits and staff burnout.

Some at-home STI tests screen for a single disease but other kits can collect and send samples to check for a variety of infections. Depending on the test, patients collect a drop of blood with a lancet, or swab their mouth, vagina, anus or penis.

Some tests require patients to send samples to a lab for analysis, while some oral HIV tests give results at home in a few minutes.

Ivan Beas, a 25-year-old graduate student at UCLA, was getting tested frequently as part of a two-year research study. When clinics closed during the pandemic, researchers sent him a home kit.

The kit, which tests for HIV, hepatitis C, herpes, syphilis, chlamydia, gonorrhea and trichomoniasis, was packaged discreetly and came with easy instructions. It took Beas about 10 minutes to prick his finger, swab his mouth and send the samples to the lab.

Beas wanted to continue screening himself every few months after the study ended, he said, but the kit he used retails for $289, which is out of reach for him.

The last time he went to a clinic in person, "I spent two hours waiting to even be seen by a doctor because of how busy they are," he said. Until Medi-Cal begins covering home tests, he said, he will have to find time to get tested for free at a Planned Parenthood clinic.

"If insurance were to cover it, I'd definitely do it more," he said.

Under California's new law, plans regulated by the state must cover home STI tests when ordered by a healthcare provider.  

Privately insured Californians can take advantage of the coverage immediately. How much they will owe out-of-pocket for the tests — if anything — depends on the type of plan they have, whether their provider is in-network, and if they fall into a category the federal government has designated for free screening.

Medi-Cal patients almost never face out-of-pocket expenses, but they will have to wait for coverage because the Department of Healthcare Services, which administers Medi-Cal, is working with the American Medical Association and the federal government to create billing codes. The reimbursement rates for those codes will then need federal approval.

The state doesn't know how long that process will take, according to department spokesperson Anthony Cava.

The rule does not apply to the millions of Californians whose job-based health insurance plans are regulated by the federal government.

Other states and organizations have experimented with at-home STI tests. The public health departments in Alabama and the District of Columbia send free kits to residents who request them, but neither jurisdiction requires insurance coverage for them. The National Coalition of STD Directors is sending free kits to people through health departments in Philadelphia; Iowa; Virginia; Indiana; Puerto Rico; and Navajo County, Arizona. The list of recipients is expected to grow this month.

Iwantthekit.org, a project of Johns Hopkins University, has been sending free kits to Maryland residents since 2004, and to Alaskans since 2011. The program is funded by grants and works with local health departments.

Charlotte Gaydos, co-founder of the project, said that requests for test kits during the pandemic nearly tripled — and that she would expand to every state if she could bill insurance the way the California law mandates.

The tests fall into a murky regulatory area. While they have been approved by the Food and Drug Administration, none have been cleared for use at home. Patients are supposed to collect their own samples within the walls of a health facility, and some labs may not analyze samples collected at home.

Public health officials cited other potential challenges: Patients may not have the same access to counseling, treatment or referrals to other services such as food banks that they would receive at clinics. And although patients are supposed to self-report the results of their tests to public health authorities, some people won't follow through.

Vlad Carrillo, 31, experienced such trade-offs recently. Carrillo used to get tested at a San Francisco clinic, where they could get counseling and other services. But Carrillo lost their apartment during the pandemic and moved about seven hours away to Bishop, the only incorporated city in rural Inyo County.

"Being away from the city, it took me a whole year to find a way to get tested," Carrillo said.

Carrillo eventually got the kit through the mail, avoiding the stigma of going to the clinic in Bishop, which is "more focused on straight stuff," like preventing pregnancy. Without the test, Carrillo couldn't get PrEP, a medication to prevent HIV.

"Going without it for so long was really hard on me," Carrillo said.

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

As COVID Hits Nursing Homes' Finances, Town Residents Fight to Save Alzheimer's Facility

KFF Health News, January 4, 2022

The future of nursing homes is deeply uncertain as older adults and their families shy away from care in these institutions, where nearly 142,000 residents have died of COVID-19.

This article was published on Tuesday, January 4, 2022 in Kaiser Health News.

By Judith Graham  

When Marvin Querry, whose wife, Diane, lives at the Barone Alzheimer's Care Center in Nevada, Missouri, heard the center might close, he started an online petition protest and spent nearly $3,000 to run ads (pictured) in the local newspaper. (KHN photo illustration/Marvin Querry)

Marvin Querry, 86, was on his tractor, planting rye on his 770-acre western Missouri farm, when the call came in early November.

It was the social worker from Barone Alzheimer's Care Center, where Querry's wife, Diane, is a resident. The facility would be closing because of financial hardship, she said, reading from a statement.

It was an agonizing moment for Querry, a retired physics professor and former executive dean for academic affairs at the University of Missouri-Kansas City. "I was stunned," he said. "Where could I find another place as wonderful to care for Diane?"

It's rare to hear people talk about a nursing home the way they talk about this 40-bed facility in Nevada, Missouri — a city of nearly 8,300 people near the Kansas border — with deep affection, respect and gratitude.

"We couldn't ask for a more loving and thoughtful staff than those who work at Barone," a woman whose mother lives there wrote on a petition to save the facility. In a business where staff turnover is constant, many of Barone's staff members have been there for five years or more.

"The care there, it goes beyond words," said Kay Stevens, whose 94-year-old mother moved into Barone in May. "The residents are treated so well, and it's such a joyous environment."

But even a sterling reputation and deep community support can't overcome a stark reality: The future of nursing homes is deeply uncertain as older adults and their families shy away from care in these institutions, where nearly 142,000 residents have died of COVID-19.

With ongoing expenses related to the pandemic and beds sitting empty, 54% of nursing homes report operating at a financial loss, according to a national survey released in June by the American Healthcare Association, a long-term care trade organization. Only a quarter are confident they can make it through the next year or beyond. At least 134 nursing homes closed their doors in 2021, on top of 170 closures in 2020.

Although COVID relief funding has helped many nursing homes in the short term, "things are much more uncertain going forward," said David Grabowski, a professor of health policy at Harvard Medical School.

Barone's fortunes reflect these broader trends. Before the pandemic, all 40 beds were full, and there was a waiting list of 25 people. About 60% of patients paid privately for care; the other 40% were on Medicaid, the government's program for people who are poor. The facility was making money, although not a lot.

Then COVID began circulating, and an outbreak of 32 COVID cases and four associated deaths in the weeks after Thanksgiving in 2020 created enormous stress. Querry's wife, Diane, 76, was one of the residents who became ill, but she recovered.

Between January and October of last year, Barone's financial losses totaled $675,318, according to data from William Denman, city treasurer of Nevada, which owns the facility. Even more alarming, another city-owned nursing home, Moore-Few Care Center, which has 108 licensed beds, lost more than $1.1 million in the same period.

Moore-Few, which does not include a locked area for patients with dementia, experienced a COVID outbreak after a staffer came to work with symptoms in October 2020. In the following weeks, 47 residents contracted the virus, and 10 died. A subsequent investigation resulted in an "immediate jeopardy" citation from the Centers for Medicare & Medicaid Services, a signal of serious problems that pose a risk to residents and mandates quick action, and a fine of $144,693. Investigators found that the nursing home had not adequately screened staffers for COVID or prevented those with symptoms from working.

Since then, about half of Moore-Few's beds have remained empty.

Financial and operational problems of this sort "can't continue," said Denman, a retired businessman who grew up in Nevada. "We're going to lose both of these homes if we don't do something soon."

But there's considerable controversy over how to move forward.

Marvin Querry has become an activist — a role he never anticipated playing at this stage of life — leading the opposition to Barone's closure.

The day after he learned of the proposal to close the home, Querry asked several pointed questions at a meeting of a five-member board that oversees Nevada's nursing homes. More than 100 community members attended that meeting, many of them angry and distressed. The board ended up tabling plans to vote on the home's closure for now.

A few days later, with his daughter's help, Querry created an online change.org petition requesting detailed financial information about Nevada's nursing homes and protesting Barone's closure. Within a month, it had gathered more than 1,500 signatures.

Also, Querry attended city council meetings and ran ads in the local newspaper three times a week featuring the petition. "I've spent almost $3,000 on these ads. I'm willing to spend $30,000 — or more — because the care [at Barone] is unsurpassed."

He wants nothing less for Diane, 76, whom he's been married to for 47 years and who's lived at Barone for two years. Every evening, Querry goes there to feed her dinner.

Karen Hertzberg, who owns a local furniture store and whose husband, Steve, 68, moved to Barone in September, feels equally strongly about saving the facility. "We need time for conversation, for research, for finding funding," she told me. Steve has severe multiple sclerosis with related cognitive dysfunction and is completely dependent on assistance.

One option could be a new city tax that would pay for Nevada's city-owned long-term care facilities. When the city hospital faced financial trouble several years ago, voters passed a dedicated tax. It generates about $800,000 a year for the hospital, whose financial difficulties continue.

"We rallied to save the hospital, so why aren't we saving our seniors? We need to stand up and fight for this," said Jennifer Gundy, a lifelong resident of Nevada and executive director of On My Own, a center that helps older adults and people with disabilities live independently.

But what if current trends continue beyond the pandemic? What if families shun nursing homes and keep loved ones at home? And what if short-term solutions — grants for COVID-related funding, contributions from donors, new city funding — don't make up for financial shortfalls for long?

Faced with the controversy over Barone Care Center's potential closure, four members of Nevada's long-term care board resigned. As four new members joined the board in mid-December, Moore-Few's administrator and up to a dozen staffers also tendered their resignations. The sense of crisis seems more acute than before.

Officials are sending mixed messages. "Our intent is to do whatever has to be done and absolutely keep [Barone] open," said George Knox, Nevada's mayor. "I don't think anything is decided yet," said Judy Campbell, who chairs the city's long-term care board. "We just have to go back to square one and see if there's any chance of keeping Barone going."

In the meantime, community members are determined not to back down. "I have no idea what will happen, but I'm not giving up," Querry said. "I'm going to do everything I can to save this place that's so important to all of us."

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the healthcare system. Visit khn.org/columnists to submit your requests or tips.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

Why an HBCU Med School Decided to Put CARES Act Money Into Students' Pockets

KFF Health News, January 4, 2022

All told, 956 students received payments.

 

This article was published on Tuesday, January 4, 2022 in Kaiser Health News.

By Blake Farmer, Nashville Public Radio

NASHVILLE, Tenn. — Just before students at Meharry Medical College went home for Thanksgiving, Dr. James Hildreth, the school's president, emailed them a video message that he acknowledged seemed hard to believe. Or at least they had to give it a second listen.

"We'll gift each of you $10,000 in cash," he said, looking at the camera. "You heard me right."

They were told to expect a direct deposit the next day or pick up a check in person. Hildreth, an expert in infectious diseases who helped lead Nashville's pandemic response, explained that this gift with no strings attached was money from the CARES Act, a major covid-19 relief law passed by Congress in 2020. He asked only that they be "good stewards" of the windfall.

After deep consideration, Meharry's administration decided to give roughly a third of its CARES Act funding — $10 million — directly to its future doctors, dentists and public health researchers. All told, 956 students received payments.

Meharry's students had already been heavily involved in the pandemic response, staffing Nashville's mass covid testing and vaccination sites. But the money isn't so much surprise compensation for volunteer efforts as it is an investment in a future career — and an assist in overcoming financial hurdles Black students especially face to become medical professionals.

While Black Americans make up roughly 13% of the population, the Association of American Medical Colleges finds Black doctors account for just 5% of the nation's working physicians — a figure that has grown slowly over more than a century. And studies have found that Black patients often want to be cared for by someone whom they consider culturally competent in acknowledging their heritage, beliefs and values during treatment.

Meharry graduates more Black physicians than almost any other U.S. school. And half of its M.D.s enter the high-demand but lower-paying specialty of primary care.

"We felt that there was no better way to begin distributing these funds than by giving to our students who will soon give so much to our world," Hildreth said.

Cheers erupted in the library as students clicked the video link.

Andreas Nelson fell silent, he recalled later. He went to his banking app and stared in disbelief. "$10,000 was sitting just in my bank account. It was astonishing," he said. "I was literally lost for words."

The Chicago native is finishing a master's degree in health and science at Meharry with hopes of entering its dental school. The average student loan debt in the program totals more than $280,000. So, undoubtedly, 10 grand won't make much of a dent in the debt.

But the money in his pocket eases his top concern of making rent each month. Nelson said it feels as though he's being treated like an adult, allowing him to decide what his greatest needs are in getting through school.

"It's motivating," Nelson said. "Because that means they have trust in us to do with this money whatever the cause may be — whether it be student debt, investing or just personal enjoyment."

Across the board, students at HBCUs rely more on student loans than students at historically white institutions. Roughly 80% take out student loans, according to an analysis by UNCF, formerly known as the United Negro College Fund, and they borrow considerably more.

Meharry was founded a decade after the Civil War to help those who had been enslaved. But the 145-year-old institution has always struggled financially, and so have its students.

The reasons are rooted in the country's racist past, which has left the institutions with less money potentially available for scholarships than other universities. And students' families generally have less wealth to tap into since Black households across the country have averaged around $17,000 in net worth — about a tenth of the average for white families.                                                     

Meharry's average student debt is far higher than other area schools of medicine at Vanderbilt University and the University of Tennessee, representing both private and public institutions.

Virtually all colleges and universities received allotments under the CARES Act, but HBCUs have been much more aggressive about funneling substantial amounts directly to students, who tend to have greater need. More than 20 HBCUs have erased outstanding tuition balances. Some have canceled student fees.

But Meharry, one of the few stand-alone HBCU graduate schools, is a rare case in cutting checks for students.

"These young people are rising to medical school against all odds," said Lodriguez Murray, who leads public policy and government affairs at UNCF. "Of course, they have to borrow more because people who look like them have less."

During the pandemic, major philanthropists have taken new interest in supporting the few HBCU medical schools. Michael Bloomberg committed $100 million to four institutions, including Meharry, to help educate more Black doctors.

Students at Meharry can now apply for $100,000 scholarships. The $34 million from Bloomberg Philanthropies is also going toward other kinds of financial support.

The school is now offering, for no additional fee, expensive test-prep services through a Boston-based company, MedSchoolCoach. The service, which entails paying a doctor by the hour to help with studying, can cost thousands of dollars.

While the price is often out of reach for students tight on cash, acing the benchmark exams toward board licensure is key to landing coveted fellowships, qualifying for lucrative specialties or just finishing on time. And Meharry's four-year completion rate of roughly 70% is below most schools. The most up-to-date national average is around 82%.

For some, Murray said, a $10,000 windfall may make all the difference in whether they cross the finish line and become a doctor who can afford all their medical school debt.

"Many of those students are borrowing a lot of money to complete their dream, and to become relatively high earners in the future," Murray said. "The fact that these students are largely coming from lower socioeconomic backgrounds means that the funds that Meharry turned around and gave to the students are particularly impactful."

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

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

As Patients Fell Ill With Covid Inside Hospitals, Government Oversight Fell Short

KFF Health News, December 27, 2021

Hospitals with high rates of covid patients who didn’t have the diagnosis when they were admitted have rarely been held accountable due to multiple gaps in government oversight, a KHN investigation has found.

This article was published on December 23, 2021, on Kaiser Health News

By Lauren Weber and Christina Jewett

One by one, the nurses taking care of actress Judi Evans at Riverside Community Hospital kept calling out sick.

Patients were coughing as staffers wheeled the maskless soap opera star around the California hospital while treating her for injuries from a horseback fall in May 2020, Evans said.

She remembered they took her to a room to remove blood from her compressed lung where another maskless patient was also getting his lung drained. He was crying out that he didn’t want to die of covid.

No one had told her to wear a mask, she said. “It didn’t cross my mind, as I’m in a hospital where you’re supposed to be safe.”

Then, about a week into her hospital stay, she tested positive for covid-19. It left the 57-year-old hospitalized for a month, staring down more than $1 million in bills for treatment costs and suffering from debilitating long-haul symptoms, she said.

Hospitals, like Riverside, with high rates of covid patients who didn’t have the diagnosis when they were admitted have rarely been held accountable due to multiple gaps in government oversight, a KHN investigation has found.

While a federal reporting system closely tracks hospital-acquired infections for MRSA and other bugs, it doesn’t publicly report covid caught in individual hospitals.

Medicare officials, tapped by Congress decades ago to ensure quality care in hospitals, also discovered a gaping hole in their authority as covid spread through the nation. They could not force private accreditors — which almost 90% of hospitals pay for oversight — to do targeted infection-control inspections. That means Riverside and nearly 4,200 other hospitals did not receive those specific covid-focused inspections, according to a government watchdog report, even though Medicare asked accreditors to do them in March 2020.

Seema Verma, former chief of Medicare and Medicaid under President Donald Trump, said government inspectors went into nearly every nursing home last year. That the same couldn’t be done for hospitals reveals a problem. “We didn’t have the authority,” she told KHN. “This is something to be corrected.”

KHN previously reported that at least 10,000 patients nationwide were diagnosed with covid in hospitals last year after being admitted for something else — a sure undercount of the infection’s spread inside hospitals, since that data analysis primarily includes Medicare patients 65 and older.

Nationally, 1.7% of Medicare inpatients were documented as having covid diagnosed after being admitted for another condition, according to data from April through September 2020 that hospitals reported to Medicare. CDIMD, a Nashville-based consulting and data analytics company, analyzed the data for KHN.

At Riverside Community Hospital, 4% of the covid Medicare patients were diagnosed after admission — more than double the national average. At 38 other hospitals, that rate was 5% or higher. All those hospitals are approved by private accreditors, and 29 of them hold “The Gold Seal of Approval” from their accreditor.

To be sure, the data has limitations: It represents a difficult time in the pandemic, when protective gear and tests were scarce and vaccines were not yet available. And it could include community-acquired cases that were slow to show up. But hospital-employed medical coders decide whether a case of covid was present on admission based on doctors’ notes, and are trained to query doctors if it’s unclear. Some institutions fared better than others — while the American public was left in the dark.

Spurred by serious complaints, federal inspectors found infection-control issues in few of those 38 hospitals last year. In Michigan, inspectors reported that one hospital “failed to provide and maintain a sanitary environment resulting in the potential for the spread of infectious disease to 151 served by the facility.” In Rhode Island, inspectors found a hospital “​​failed to have an effective hospital-wide program for the surveillance and prevention” of covid.

KHN was able to find federal inspection reports documenting infection-control issues for eight of those 38 hospitals. The other 30 hospitals around the country, from Alabama to Arizona, had no publicly available federal records of infection-control problems in 2020.

KHN found that even when state inspectors in California assessed hospitals with high rates of covid diagnosed after admission, they identified few shortcomings.

“The American public thinks someone is watching over them,” said Lisa McGiffert, co-founder of the Patient Safety Action Network, an advocacy group. “Generally they think someone’s in charge and going to make sure bad things don’t happen. Our oversight system in our country is so broken and so untrustworthy.”

The data shows that the problem has deadly consequences: About a fifth of the Medicare covid patients who were diagnosed after admission died. And it was costly as well. In California alone, the total hospital charges for such patients from April through December last year was over $845 million, according to an analysis done for KHN by the California Department of Health Care Access and Information.

The Centers for Disease Control and Prevention has pledged funding for increased infection-control efforts — but that money is not focused on tracking covid’s spread in hospitals. Instead, it will spend $2.1 billion partly to support an existing tracking system for hospital-acquired pathogens such as MRSA and C. diff.

The CDC does not currently track hospital-acquired covid, nor does it plan to do so with the additional funding. That tracking is done by another part of the U.S. Department of Health and Human Services, according to Dr. Arjun Srinivasan, associate director for the CDC’s health care-associated infection-prevention programs. But it’s not made public on a hospital-by-hospital basis. HHS officials did not respond to questions.

The Scene at Riverside

In March 2020, Evans was alarmed by nonstop TV footage of covid deaths, so she and her husband locked down. They hadn’t been going out much, anyway, since losing their only child at the end of 2019 to another public health crisis — fentanyl.

At the time, concerns about covid were mounting among the staff at Riverside Community Hospital, a for-profit HCA Healthcare facility.

The hospital’s highly protective N95 masks had been pulled off the supply room shelves and put in a central office, according to Monique Hernandez, a shop steward for her union, Service Employees International Union Local 121RN. Only nurses who had patients getting aerosol-generating procedures such as intubation — which were believed at the time to spread the virus — could get one, she said.

She said that practice left the nurses on her unit with a difficult choice: either say you had a patient undergoing such procedures or risk getting sick.

Nurse unions were early adopters of the notion — now widely accepted — that covid is spread by minuscule particles that can linger in the air. Studies since have matched the genetic fingerprint of the virus to show that covid has spread among workers or patients wearing surgical masks instead of more protective masks like N95s.

On April 22, 2020, Hernandez and other nurses joined a silent protest outside the hospital where they held up signs saying “PPE Over Profit.” By that time, the hospital had several staff clusters of infection, according to Hernandez, and she was tired of caregivers being at risk.

In a statement, Riverside spokesperson David Maxfield said the hospital’s top priority has been to protect staff “so they can best care for our patients.”

“Any suggestion otherwise ignores the extensive work, planning and training we have done to ensure the delivery of high-quality care during this pandemic,” he said.

In mid-May, Judi Evans’ husband coaxed her into going horseback riding — one of the few things that brought her joy after her son’s death. On her second day back in the saddle, she was thrown from her horse. She broke her collarbone and seven ribs, and her lung was compressed. She was taken to Riverside Community Hospital.

There, many of her nurses wore masks they had previously used, Evans recalled. Other staffers came in without any masks at all, she said. A few days in, she said, one of the doctors told her it’s crazy that the hospital was testing her for MRSA and other hospital infections but not covid.

Maxfield said that the hospital began enforcing a universal mask mandate for staff and visitors on March 31, 2020, and, “in line with CDC, patients were and are advised to wear masks when outside their room if tolerated.” He stressed “safety of our patients and colleagues has been our top priority.”

After about a week in the hospital, Evans said, she spiked a fever and begged for a covid test. It was positive. There is no way to know for certain where or how she got infected but she believes it was at Riverside. Covid infections can take two to 14 days from exposure to show symptoms like a fever, with the average being four to five days. According to CDC guidance, infection onset that occurs two days or more after admission could be “hospital-associated.”

Doctors told her they might have to amputate her legs when they began to swell uncontrollably, she said.

“It was like being in a horror film — one of those where everything that could go wrong does go wrong,” Evans said.

She left with over $1 million in bills from a month-long stay — and her legs, thankfully. She said she still suffers from long-covid symptoms and is haunted by the screams of fellow patients in the covid ward.

By the end of that year, Riverside Community Hospital would report that 58 of its 1,649 covid patients were diagnosed with the virus after admission, according to state data that covers all payers from April to December.

That’s nearly three times as high as the California average for covid cases not present on admission, according to the analysis for KHN by California health data officials.

“Based on contact tracing, outlined by the CDC and other infectious disease experts, there is no evidence to suggest the risk of transmission at our hospital is different than what you would find at other hospitals,” Maxfield said.

A lawsuit filed in August by the SEIU-United Healthcare Workers West on behalf of the daughter of a hospital lab assistant who died of covid and other hospital staffers says the hospital forced employees to work without adequate protective gear and while sick and “highly contagious.”

The hospital “created an unnecessarily dangerous work environment,” the lawsuit claims, “which in turn has created dangerous conditions for patients” and a “public nuisance.”

Attorneys for Riverside Community Hospital are fighting the ongoing lawsuit. “This lawsuit is an attempt for the union to gain publicity, and we have filed a motion to end it,” said Maxfield, the hospital spokesperson.

The hospital’s lawyers have said the plaintiffs got covid during a spike in local cases and are only speculating that they contracted the virus at the hospital, according to records filed in Riverside County Superior Court.

They also said in legal filings that the court should not step into the place of “government agencies who oversee healthcare and workplace safety” and “handled the response to the pandemic.”

‘A Shortcoming in the Oversight System’

Decades ago, Congress tasked Medicare with ensuring safe, quality care in U.S. hospitals by building in routine government inspections. However, hospitals can opt to pay up to tens of thousands of dollars per year to nongovernmental accreditors entrusted by CMS to certify the hospitals as safe. So 90% do just that.

But these accrediting agencies — including the Joint Commission, which certified Riverside — are private organizations. Thus they are not required to follow CMS’ directives, including the request in a March 20 memo urging the accrediting agencies to execute targeted infection-control surveys aimed at preparing hospitals for covid’s onslaught.

And so they didn’t send staffers to survey hospitals for the specialized infection-control inspections in 2020, according to a June 2021 Health and Human Services Office of the Inspector General report.

Riverside, despite allegations of lax practices, holds The Gold Seal of Approval from the Joint Commission, which last inspected the hospital on-site in May 2018 before going in on Nov. 19 this year.

The inspector general’s office urged CMS to pursue the authority to require special surveys in a health emergency — lest it lose control of its mission to keep hospitals safe.

“CMS could not ensure that accredited hospitals would continue to provide quality care and operate safely during the COVID-19 emergency,” and could not ensure it going forward, the report said.

“We’re telling CMS to do their job,” the report’s author, Assistant Regional Inspector General Calvin Jones, said in an interview. “The covid experience really showed a shortcoming in the oversight system.”

CMS spokesperson Raymond Thorn said the agency agrees with the report’s recommendation and will work on a regulation after the public health emergency ends.

Accrediting agencies, however, pushed back on the inspector general’s findings. Among them: DNV Healthcare USA Inc. Its director of accreditation, Troy McCann, said there was not a gap in oversight. Although he said travel restrictions limited accreditors ability to fly across state lines, his group continued its annual reviews after May 2020 and incorporated the special focus on infection control into them. “We have a strong emphasis, always, on safety, infection control and emergency preparedness, which has left our hospitals stronger,” McCann said.

Angela FitzSimmons, spokesperson for the Accreditation Commission for Health Care, said that the accrediting organization’s surveys typically focus on infection control, and the group worked during the pandemic to prioritize hospitals with prior issues in the area of infection prevention.

“We did not deem it necessary to add random surveys that would occur at a cost to the hospital without just cause,” FitzSimmons said.

Maureen Lyons, a spokesperson for the Joint Commission, told KHN that, after evaluating CMS guidance, the nonprofit group decided it would incorporate the infection-control surveys into its surveys done every three years and, in the meantime, provide hospitals with the latest federal guidance on covid.

“Hospitals were operating in extremis. Thus, we collaborated closely with CMS to determine optimal strategies during this time of emergency,” she said.

The Joint Commission cited safety issues for its inspectors, who travel to the hospitals and need proper protective equipment that was running low at the time, as part of the reason for its decision.

Verma, the CMS administrator at the time, pushed back on accreditors’ travel safety concerns, saying that “narrative doesn’t quite fit because the state and CMS surveyors were going into nursing homes.”

Though Verma cautioned that hospitals were overwhelmed by the crush of covid patients, “doing these inspections may have helped hospitals bolster their infection-control practices,” she said. “Without these surveys, we really have no way of knowing.”

‘Immediate Jeopardy’

Medicare inspectors can go into a privately accredited hospital after they get a serious complaint. They found alarming circumstances when they visited some of the hospitals with high rates of covid diagnosed after a patient was admitted for another concern last year.

At Levindale Hebrew Geriatric Center and Hospital in Baltimore, the July 2020 inspection report says “systemic failures left the hospital and all of its patients, staff, and visitors vulnerable to harm and possible death from COVID-19.”

In response, hospital spokesperson Sharon Boston said that “we have seen a large decrease in the spread of the virus at Levindale.”

Inspectors had declared a state of “immediate jeopardy” after they investigated a complaint and discovered an outbreak that began in April and continued through the beginning of July, with more than 120 patients and employees infected with covid. And in a unit for those with Alzheimer’s and other conditions, 20% of the 55 patients who had covid died.

The hospital moved patients whose roommates tested positive for covid to other shared rooms, “potentially exposing their new roommate,” the inspection report said. Boston said that was an “isolated” incident and the situation was corrected the next day, with new policies put in place.

The Medicare data analyzed exclusively for KHN shows that 52 of Levindale’s 64 covid hospital patients, or 81%, were diagnosed with covid after admission from April to September 2020. Boston cited different numbers over a different time period: Of 67 covid patients, 64 had what she called “hospital-acquired” covid from March to June 2020. That would be nearly 96%.

The hospital shares space with a nursing home, though, so KHN did not group it with the general short-term acute-care hospitals as part of the analysis. Levindale’s last Joint Commission on-site survey was in December 2018, resulting in The Gold Seal of Approval. It had not had its once-every-three-years survey as of Dec. 10, 2021, according to the Joint Commission’s tracking.

Boston said Levindale “quickly addressed” the issues that Medicare inspectors cited, increasing patient testing and more recently mandating staff vaccines. Since December 2020, Boston said, the facility has not had a covid patient die.

At the state level, hospital inspectors in California found few problems to cite even at hospitals where 5% or more patients were diagnosed with covid after they were admitted for another concern. Fifty-three complaints about such hospitals went to the Department of Public Health from April until the end of 2020. Only three of those complaints resulted in a finding of deficiency that facility was expected to fix.

CDPH did not respond to requests for comment.

A New Chapter

Things are better now at Riverside Community Hospital, Hernandez said. She is pleased with the current safety practices, including more protective gear and HEPA filters for covid patients’ rooms. For Hernandez, though, it all comes too late now.

“We laugh at it,” she said, “but it hurts your soul.”

Evans said she was able to negotiate her $1 million-plus hospital bills down to roughly $70,000.

Her covid aftereffects have been ongoing — she said she stopped gasping for air and reaching for her at-home oxygen tank only a few months ago. She still hasn’t been able to return to work full time, she said.

For the past year, her husband would wake up in the middle of the night to check whether her oxygen levels were dipping. Terrified of losing her, he’d slip an oxygen mask on her face, she said.

“I would walk 1,000 miles to go to another hospital,” Evans said, if she could do it all over again. “I would never step foot in that hospital again.”

Methodology

KHN requested custom analyses of Medicare, California and Florida inpatient hospital data to examine the number of covid-19 cases diagnosed after a patient’s admission.

The Medicare and Medicare Advantage data, which includes patients who are 65 and older, is from the Centers for Medicare & Medicaid Services’ Medicare Provider Analysis and Review (MedPAR) file and was analyzed by CDIMD, a Nashville-based medical code consulting and data analytics firm. The data is from April 1 through Sept. 30, 2020. The data for the fourth quarter of 2020 was not yet available.

The data shows the number of inpatient Medicare hospital stays in the U.S., including the number of people diagnosed with covid-19 and the number of admissions for which the covid diagnosis was not “present on admission.” CMS considers some medical conditions that are not “present on admission” to be hospital-acquired, according to the agency. The data is for general acute-care hospitals, which may include a psychiatric floor, and not for other hospitals such as those in the Department of Veterans Affairs system or stand-alone psychiatric hospitals.

KHN requested a similar analysis from California’s Department of Health Care Access and Information of its hospital inpatient data. That data was from April 1 through Dec. 31, 2020, and covered patients of all ages and payer types and, in general, private psychiatric and long-term acute-care hospitals. Etienne Pracht, a University of South Florida researcher, provided the number of Florida covid patients who did not have the virus upon hospital admission for all ages and payer types at general and psychiatric hospitals from April 1 through Dec. 31, 2020. KHN subtracted the number of Medicare patients in the MedPAR data from the Florida and California datasets so they would not be counted twice.

To calculate the rate of hospitalized Medicare patients who tested positive for covid — and died — KHN relied on the MedPAR data for April through September. That data includes records for 6,629 seniors, 1,409 of whom, or 21%, died. California data for all ages and payer types from April through December shows a similar rate: Of 2,115 diagnosed with covid-19 after hospital admission, 435, or 21%, died. The MedPAR data was also used to calculate the national rate of 1.7%, with 6,629 of 394,939 covid patients diagnosed with the virus whose infections were deemed not present on admission, according to the CDIMD analysis of data that hospitals report to Medicare. It was also used to calculate which entities licensed as short-term acute care hospitals had 5% or more of their covid cases diagnosed within the hospital. As stated in the story, Levindale Hebrew Geriatric Center and Hospital in Baltimore was not included in that list of 38 because it shares space with a nursing home and had fewer than 500 total discharges.

Data that hospitals submit to Medicare on whether an inpatient hospital diagnosis was “present on admission” is used by Medicare for payment determinations and is intended to incentivize hospitals to prevent infections during hospital care. The federal Agency for Healthcare Research and Quality also uses the data to “assist in identifying quality of care issues.”

Whether covid-19 is acquired in a hospital or in the community is measured in different ways. Some nations assume the virus is hospital-acquired if it is diagnosed seven or more days after admission, while U.S. data counts cases only after 14 days.

Hospitals’ medical coders who examined patient records for the data analyzed for this KHN report focus on each physician’s admission, progress and discharge notes to determine whether covid was “present on admission.” They do not have a set number of days they look for and are trained to query physicians if the case is unclear, according to Sue Bowman, senior director of coding policy and compliance at the American Health Information Management Association.

KHN tallied the cases in which covid-19 was logged in the data as not “present on admission” to the hospital. Some covid cases are coded as “U” for having insufficient documentation to make a determination. Since Medicare and AHRQ consider the “U” to be an “N” (or not present on admission) for the purposes of payment decisions and quality indicators, KHN chose to count those cases in the grand total.

In 409 of 6,629 Medicare cases and in 70 of 2,185 California cases, the “present on admission” indicator was “U.” The Florida data did not include patients whose “present on admission” indicator was “U.” Medical coders have another code, “W,” for “clinically undetermined” cases, which consider a condition present on admission for billing or quality measures. Medical coders use the “U” (leaning toward “not present on admission”) and “W” (leaning toward “present on admission”) when there is some uncertainty about the case. KHN did not count “W” cases.

The Medicare MedPAR data includes about 2,500 U.S. hospitals that had at least a dozen covid-19 cases from April through September 2020. Of those, 1,070 reported no cases of covid diagnosed after admission for other conditions in the Medicare records. Data was suppressed due to privacy reasons for about 1,300 hospitals that had between one and 11 of such covid cases. There were 126 hospitals reporting 12 or more cases of covid that were “not present on admission” or unknown. For those, we divided the number of cases diagnosed after admission by the total number of patients with covid to arrive at the rate, as is standard in health care.

Inspection and Accreditation Analysis

To evaluate which of the 38 hospitals detailed above had federal inspection reports documenting infection-control issues, KHN searched CMS’ publicly available “2567” reports, which detail deficiencies for each hospital for 2020. For surveys listed online as “not available,” KHN requested and obtained them from CMS. KHN further asked CMS to double-check the remaining hospitals for any inspection reports that weren’t posted online. KHN also checked the Association of Health Care Journalists’ database http://www.hospitalinspections.org/ for each of the 38 hospitals for any additional reports, as well as CMS’ Quality, Certification and Oversight Reports site.

To check that each of these hospitals was accredited, KHN looked up each hospital using a site run by the Joint Commission and reached out to the accreditors DNV Healthcare USA Inc. and the Accreditation Commission for Health Care.

To tabulate infection-control complaints for hospitals at the state level in California, KHN used data available through the California Department of Public Health’s Cal Health Find Database. KHN searched the database for the hospitals that had higher than 5% of covid patients being diagnosed after admission, according to the California data, and tallied all complaints and deficiencies found involving infection control from April to December 2020.

Laws Shield Hospitals From Families Who Believe Loved Ones Contracted Covid as Patients

KFF Health News, December 27, 2021

After Amanda Wilson lost her son, Braden, 15, to covid-19 in early 2021, she tried to honor his memory. She put up a lending library box in his name. She plans to give the money she saved for his college education to other teens who love the arts and technology. But in one area, she hit a brick wall: attempting to force change at the California hospital where she believes her son contracted covid in December 2020.

This article was published on December 24, 2021, on Kaiser Health News

By Lauren Weber and Christina Jewett

After Amanda Wilson lost her son, Braden, 15, to covid-19 in early 2021, she tried to honor his memory. She put up a lending library box in his name. She plans to give the money she saved for his college education to other teens who love the arts and technology.

But in one area, she hit a brick wall: attempting to force change at the California hospital where she believes her son contracted covid in December 2020. While seeking treatment for a bleeding cyst, Braden was surrounded for hours by coughing patients in the emergency room, Wilson said. Yet, she said, she has been unable to get the hospital to show her improvements it told her it made or get a lawyer to take her case.

“I was pretty shocked,” Wilson said. “There’s truly no recourse.”

Throughout the pandemic, lawmakers from coast to coast have passed laws, declared emergency orders or activated state-of-emergency statutes that severely limited families’ ability to seek recourse for lapses in covid-related care.

Under such liability shields, legal advocates say, it’s nearly impossible to seek the legal accountability that can pry open information and drive systemic improvements to the infection-control practices that make hospitals safer for patients.

“Lawsuits are there for accountability and truth to be exposed,” said Kate Miceli, state affairs counsel for the American Association for Justice, which advocates for plaintiff lawyers. “These laws are absolutely preventing that.”

A previous KHN investigation documented that more than 10,000 people tested positive for covid after they were hospitalized for something else in 2020. Yet many others, including Braden Wilson, are not counted in those numbers because they were discharged before testing positive. Still, the KHN findings are the only nationally publicly available data showing rates of patients who tested positive for covid after admission into individual U.S. hospitals.

Those who have lost a family member say hospitals need to be held more accountable.

“My mom is not like one of those people who would say ‘Go sue them,’” said Kim Crail, who believes her 79-year-old mom contracted covid during an eight-day stay at a hospital in Edgewood, Kentucky, because she tested positive less than 48 hours after leaving. “But she just wouldn’t want it to happen to anyone else.”

‘You Put Your Trust in the Hospital’

At age 89, Yan Keynigshteyn had begun to fade with dementia. But he was still living at home until he was admitted to Ronald Reagan UCLA Medical Center in Los Angeles for a urological condition, according to Terry Ayzman, his grandson.

Keynigshteyn, a Soviet Union emigrant who did not understand English, found himself in an unfamiliar place with masked caregivers. The hospital confined him to his bed, Ayzman said. He did not understand how to navigate the family’s Zoom calls and, eventually, stopped talking.

He was tested regularly for covid during his two-week-plus stay, Ayzman said. On Keynigshteyn’s way home in an ambulance, his doctor got test results showing he had tested positive for covid. It can take two to 14 days from exposure to covid for patients to start showing symptoms such as a fever, though the average is four to five days. His grandson believes that because Keynigshteyn was in the hospital for over two weeks before testing positive, he contracted covid at Ronald Reagan UCLA Medical Center.

As the ambulance doors opened and Keynigshteyn finally saw his wife and other family members, he smiled for the first time in weeks, Ayzman said. Then the crew slammed the doors shut and took him back to the hospital.

A few days later, Keynigshteyn died.

“You put your trust in the hospital and you get the short end of the stick,” Ayzman said. “It wasn’t supposed to be like that.”

Ayzman wanted to find out more from the hospital, but he said officials there refused to give him a copy of its investigation into his grandfather’s case, saying it was an internal matter and the results were inconclusive.

Hospital spokesperson Phil Hampton did not answer questions about Keynigshteyn. “UCLA Health’s overriding priority is the safety of patients, employees, visitors and volunteers,” he said, adding that the health system has been consistent with or exceeded infection-control protocols at the local, state and federal level throughout the pandemic.

Ayzman reached out to five lawyers, but he said none would take the case. He said they all told him courts were unsympathetic to cases against health care institutions at the time.

“I don’t believe that a state of emergency should give a license to hospitals to get away with things scot-free,” Ayzman said.

The Current State of Legal Play

The avalanche of liability shield legislation was pitched as a way to prevent a wave of lawsuits, Miceli said. But it created an “unreasonable standard” for patients and families, she said, since a state-of-emergency raises the bar for filing medical malpractice cases and already makes many lawyers hesitant to take such cases.

Almost every state put extra liability shield protections in place during the pandemic, Miceli said. Some of them broadly protected institutions such as hospitals, while others were more focused on shielding health care workers.

Corporate-backed groups, including the American Legislative Exchange Council, the U.S. Chamber of Commerce Institute for Legal Reform, American Tort Reform Association and the National Council of Insurance Legislators, helped pass a range of liability shield bills across the country through lobbying, working with state partners or drafting forms of model legislation, a KHN review has found.

William Melofchik, general counsel for NCOIL, said member legislators drafted their model bill because they felt it was important to guard against a never-ending wave of litigation and to be “better safe than sorry.”

Nathan Morris, vice president of legislative affairs for the Chamber’s Institute for Legal Reform, said his group’s work had influenced states across the country to implement what he called timely and effective protections for hospitals that were trying to do the right thing while working through a harrowing pandemic.

“Nothing that we advocated for would slam the courthouse door in the face of someone who had a claim that was clearly legitimate,” he said.

The other two organizations did not answer questions about their involvement in such work by deadline.

Joanne Doroshow, executive director of the Center for Justice & Democracy at New York Law School, said such powerful corporate lobbying interests used the broader “health care heroes” moment to push through lawsuit protections for institutions like hospitals. She believes they will likely worsen patient outcomes.

“The fact that the hospitals were able to get immunity under these laws is pretty offensive and dangerous,” she said.

Some of the measures were time-limited or linked to public emergencies that have since expired, but, Miceli said, more than half of states still have some form of expanded liability laws and executive orders in place. Florida legislators are currently working to extend its protections to mid-2023.

Doctors’ groups and hospital leaders say they must have legal immunity in times of crisis.

“Liability protections can be incredibly important because they do encourage providers to continue working and to continue actually providing care in incredibly troubling emergency circumstances,” said Jennifer Piatt, a deputy director of the Western Region Office for the Network for Public Health Law.

Akin Demehin, director of policy for the American Hospital Association, said it’s important to remember the severe shortages in testing and personal protective equipment at the start of the pandemic. He added that the health care workforce faced tremendous strain as it had to juggle new roles amid personnel shortages, along with ever-evolving federal guidance and understanding of how the coronavirus spreads.

Piatt cautioned that appropriately calibrating liability shields is delicate work, as protections that are too broad can deprive patients of their ability to seek recourse.

Those wanting to learn more about how covid spreads within a U.S. hospital have few resources. Dr. Abraar Karan, now an infectious diseases fellow at Stanford, and other researchers examined covid transmission rates among roommates at Brigham and Women’s Hospital in Boston. But few hospitals have dug deep on the topic, he said, which could reflect the stretched-thin resources in hospitals or a fear of negative media coverage.

“There should be dialogue from the lessons learned,” Karan said.

‘Do Not Put Anything in Writing’

Crail and Kelly Heeb lost their mother, Sydney Terrell, to covid early in 2021. The sisters believe she caught it during her more-than-weeklong stay at St. Elizabeth Edgewood Hospital outside Cincinnati following a hernia repair surgery.

They said she spent hours in an ER separated from other patients only by curtains and did not wear a mask in her patient room while she recovered. She was discharged from the hospital complaining about tightness in her chest, the sisters said. Within 24 hours, she spiked a fever. The next day, she was back in the ER, where she tested positive for covid on Christmas Eve 2020, they said. After a difficult bout with the virus, Terrell died Jan. 8.

When Crail attempted to file a complaint detailing their concerns, she said a hospital risk management employee told her: “‘No, do not put anything in writing.’”

Crail filed cursory paperwork anyway. She received the hospital’s conclusion in the mail in an envelope postmarked Dec. 1, more than seven months after the April 27 date typed at the top of the letterhead. The letter stated the St. Elizabeth Healthcare oversight committee determined it was “unable to substantiate” that their mother contracted covid in the hospital due to high community transmission rates, incubation timing and unreliable covid tests. The letter did note that despite the hospital system’s extensive protocols, “the risks of transmission will always exist.”

Guy Karrick, a spokesperson for the hospital, did not comment on the sisters’ specific case but said “we have not and would not tell any patient or family not to put their concerns in writing.” He added that the hospital has been following all federal and state guidelines to protect its patients.

Braden’s mom, Amanda Wilson, had far more dialogue with the hospital where she thinks her son got covid. But it still left her with doubts that she made an impact.

When her son was in the Adventist Health Simi Valley ER in December 2020 in a bed separated by curtains, they could hear staffers periodically reminding coughing patients around them to keep on their masks. She and Braden kept their own masks on for the vast majority of their several-hours-long stay, she said, but staffers in their bay didn’t always have their own masks pulled up.

Hospital spokesperson Alicia Gonzalez said staffers “track infections that may occur in our facilities and we have no verified infection of any patient or visitor of covid-19 in our facility,” adding that the hospital is “dedicated to serving our community and ensuring the safety of all who are cared for at our hospital.”

Wilson, a mathematician who works in the aerospace industry, expected the hospital to be able to show her evidence of some of the changes she discussed with hospital officials, including its president. For one, she hoped the staffers would get trained by a physician with direct experience treating the covid complication that made her son fatally ill, called MIS-C, or multisystem inflammatory syndrome. She also had hoped to see proof that the hospital installed no-touch faucets in the ER bathroom, which would help limit the spread of infections.

Gonzalez said that hospital executives listened to Wilson’s concerns and met with her on more than one occasion and that the hospital has improved its internal processes and procedures as it has learned about transmissibility and best practices.

But Wilson said they wouldn’t send her photos or let her see the changes for herself. The hospital declined to list or provide evidence of the changes to KHN as well.

“It made me more angry,” Wilson said. “Here I tried to make it better for people. I couldn’t make it better for Braden, but for people who’d come to this hospital — it is the only hospital in our town.”

She said she reached out to a lawyer, who told her there would be no way to prove how Braden caught covid. She had no other way to force more of a reckoning over her son’s death. So, she said, she has turned to other ways to “leave little pieces of him out in the world.”

Covered California's Insurance Deals Range From ‘No-Brainer' to Sticker Shock

KFF Health News, December 21, 2021

Families of four with incomes of less than about $40,000 a year can pay no premiums and have low deductibles. For some others, health insurance in 2022 will cost more than in 2021 — in some cases, significantly more.

This story ran December 21, 2021 on Kaiser Health News

By Bernard J. Wolfson

If you purchase your own health insurance, it's time to choose your coverage for 2022. If you buy it through Covered California, the chances are better than ever that you will get a big discount on your monthly premium — or pay no premium at all.

Many middle-class families who previously paid full fare for their health plans got financial assistance this year through the American Rescue Plan, a law that significantly expanded federal tax credits that reduce the premiums consumers pay.

But hundreds of thousands of Californians who are eligible for the credits are not yet reaping the benefit. Among them are 575,000 uninsured people, most of whom could get coverage for $0 a month, and about 260,000 people who buy insurance outside the state's Affordable Care Act marketplace and could save hundreds of dollars a month by switching into it, according to estimates from Covered California.

"It's a lot of money that people don't realize they're leaving on the table," says Peter Lee, Covered California's executive director. "I don't know anyone who can comfortably pass on $10,000."

Enrollment for 2022 coverage through Covered California — as well as for individual and family health plans purchased outside the exchange — ends Jan. 31. Consumers can enroll anytime during the year if they've undergone a major life change, such as losing a job, moving, having a baby, getting married or being affected by a natural disaster.

The additional federal tax credits are slated to expire at the end of 2022, but the current version of President Joe Biden's roughly $2 trillion Build Back Better legislation, pending in Congress, would extend them through 2025.

If you are already in a Covered California plan you like, it might be tempting to simply renew it without checking other options. Resist that temptation. Insurers change their prices every year, and new companies may have entered the market in your region. So a different health plan could be a better deal than your current one.

But if you like the medical providers in your current network, make sure you will have access to them in any health plan you consider for next year.

The American Rescue Plan not only offers many Californians dramatically cheaper premiums but also makes Cadillac coverage available for free if their income is low enough.

In general, individuals and families with annual incomes between 138% and 150% of the federal poverty line — $17,775 to $19,320 for an individual and $36,570 to $39,750 for a family of four — can get the lowest level of coverage, known as bronze, for no monthly premium in 2022. But they would also pay no premium if they chose a particularly generous plan known as silver-94. The individual version of the plan has a medical deductible of just $75, no deductible for prescription drugs and an $800 annual cap on how much enrollees pay out-of-pocket before 100% of their medical costs are covered. In the bronze plan, by comparison, the medical deductible for an individual is $6,300, with an out-of-pocket spending limit of $8,200 and a separate pharmacy deductible of $500.

Covered California and all insurance agents worth their salt are encouraging people in bronze plans who meet the zero premium income criteria to make that switch.

"I call it the no-brainer plan," says Edsel D'souza, a partner at the Citrust Insurance Agency in Culver City. "When people hear about it, they can't believe it's that good."

But not all Covered California enrollees have such a happy surprise awaiting them. Under a provision in the American Rescue Plan, about 120,000 enrollees got the silver-94 plan for $1 a month this year if they collected unemployment benefits for even one week in 2021. Many — and perhaps all — of those enrollees will lose that discount in 2022 and are facing sticker shock or bracing for a return to a lower level of coverage.

"I have people who were in bronze, got the unemployment boost, and we switched them to a silver-94, so now they're running around getting all kinds of tests and procedures done before the end of the year," says Kevin Knauss, an insurance agent in Granite Bay.

D'souza says he helped a family of four in which one of the parents had received unemployment benefits for part of 2021, enabling them to move into a Covered California plan that cost $344 per month. But they will get no subsidy in 2022, D'souza says, and the monthly premium will nearly quadruple, to $1,269.

According to D'souza's calculations, a 40-year-old single person who lives in West Los Angeles, has an income of $40,000, and is paying $1 a month in 2021 for a silver-94 plan after being unemployed for part of the year would see the monthly premium jump to nearly $200 in 2022 — for a much less generous silver plan.

Shopping and signing up for coverage with Covered California can be tricky, and it's not hard to run into problems.

Knauss notes, for example, that Covered California looks at your income in the month you apply. If you are applying in December and don't have any income this month, you might be pushed into Medi-Cal, the government-run insurance program for people with low incomes, even though your annual income is above the eligibility threshold. It can be time-consuming and frustrating to revert to Covered California.

Another common problem, Knauss says, affects people who have employer insurance that ends Dec. 31. If this applies to you, be aware that you will get no subsidy for 2022 if you fill out an application this month and check "yes" when asked whether you have job-based insurance. You need to check "no" even though that's not technically true at the time, Knauss says.

To avoid some of these pitfalls, find an insurance agent in your area who will walk you through all the options. Agents won't charge you a penny.

You can find one on the Covered California website (www.coveredca.com). You can also fill out a form on the site to get a quick phone call from an insurance agent or another exchange-certified enroller. And you can get enrollment help by calling Covered California at 800-300-1506.

A word of caution: Some websites imitate the Covered California site, but their purpose is usually to generate business leads for insurance agents.

Jonathan Edewards, D'souza's business partner at Citrust, says one of his clients thought he was filling out an application with Covered California and then got 20 calls from insurance agents within an hour. "You have to know that coveredca.com is the official website of Covered California," Edewards says, "and everything else is suspect."

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

Crash Course: Injured Patients Who Sign ‘Letters of Protection’ May Face Huge Medical Bills and Risks

KFF Health News, December 21, 2021

Advocates say the letters throw a lifeline to low-income people who need vital medical care for injuries caused by the negligence of others and don’t have the money or insurance coverage to pay for it.

This story ran December 21, 2021 on Kaiser Health News
 
 
Jean Louis-Charles couldn’t afford spine surgery to ease nagging neck and back pain after a car crash. So he signed a document, promising to pay the bill with money he hoped to get from a lawsuit against the driver who caused the collision.

That never happened.

Louis-Charles, 68, died hours after the operation at a South Florida outpatient surgery center in March 2019. The surgery center had put him in an Uber with his wife, Marie Julien, according to depositions. After a 60-mile ride home, he collapsed, court records show.

Her husband’s death left Julien to deal with more than $100,000 in medical debt, as described in the “letter of protection,” or LOP, that Louis-Charles had signed.

In signing an LOP, people generally pledge to cover the costs of their care even if it exceeds what they win in a lawsuit or other settlement — and even if the prices are far higher than most doctors would charge.

The agreements are legal and binding in many states, though Florida appears to be the epicenter of their use in personal injury cases. Advocates say the letters throw a lifeline to low-income people who need vital medical care for injuries caused by the negligence of others and don’t have the money or insurance coverage to pay for it. Doctors and surgery centers that accept LOPs say they often wait years for a lawsuit to settle before being paid, if at all.

A KHN investigation found that letters of protection can saddle patients with medical debt — and drive a personal injury care system that operates with little oversight despite widespread complaints of grossly inflated billings and other problems that can place patients at risk.

Marie Julien blamed Dr. Kingsley R. Chin — a controversial Hollywood, Florida, surgeon who has accepted LOP payments for more than a decade — for her husband’s death after the spinal fusion procedure. Last year, she filed a malpractice suit against Chin alleging that Louis-Charles died after he “was discharged home while still in pain and with signs and symptoms of post-operative complications.” In court papers, Chin denied any negligence.

“We felt that the way the whole thing happened was very bizarre,” Julien, 71, a certified nursing assistant, recalled in a deposition taken in the case.

A ‘Terrible Situation’

Just before 8 a.m. on New Year’s Day 2018, Louis-Charles’ car was stopped at a red light near his home. Suddenly a white police vehicle, driven by a Palm Beach County Sheriff’s Office detective, backed into his Toyota Corolla, hitting the passenger side door, according to a police report.

In her deposition, Julien said Chin operated on her husband’s shoulder in 2018. But that didn’t help much, and Chin recommended more extensive surgery, she said. “I wasn’t happy at all with that idea,” she added.

Julien said she relented because Louis-Charles’ pain was getting worse “day by day” and he had confidence in the surgeon. The Aventura Surgery Center in Hallandale, Florida, where Chin had served as medical director, sent an Uber to collect the couple the morning of March 12, 2019, Julien said.

During the two-hour spinal fusion, Chin replaced three disks with an implant he invented, according to his deposition. The patient spent an hour or so in a recovery room before a nurse wheeled him out to a waiting Uber just after 3 p.m., according to Chin’s testimony.

Louis-Charles couldn’t speak, but signaled he was in pain and struggled to breathe during the hourlong ride home, according to Julien’s deposition. She helped him walk through the front door of their Riviera Beach home. Once inside he collapsed, she testified.

A fire rescue crew rushed him to a hospital in West Palm Beach, where he died just after 5:30 p.m., according to a Palm Beach County Medical Examiner’s autopsy report. The medical examiner ruled the death an accident caused by “post-surgical bleeding with airway compression.”

In his deposition, Chin said that Louis-Charles “looked great” heading out to the car and that traveling along the urban Interstate 95 corridor the driver was “at any given time probably within 10 minutes or so” from a “major hospital or emergency room.”

Chin called the outcome a “terrible situation” and told Julien’s lawyer during the deposition: “I just hope you can appreciate how much I regret what happened.”

Asked how her husband’s death has affected her life, Julien said: “How can you find words to explain such a thing?” The couple wed in 1987 in Miami after moving from their native Haiti, where he worked as a house carpenter.

“It’s been almost two years now. I have not been able to sleep on [the] bed” she shared with him, she said.

In late September, Julien and Chin settled the suit under confidential terms and the bills were “written off,” according to Kevin Smith, an attorney who represented Julien. Chin has denied any liability.

‘A Mixed Bag’

Though little-known to the public, letters of protection are commonly used to finance major medical care in personal injury cases, including costly orthopedic surgery.

Attorneys who refer injured clients to willing doctors say the liens are their best tool for ensuring clients not only gain access to care, but also are in a position to win fair settlements from insurance companies that fight to minimize their liability and costs.

An LOP form used by some Florida medical providers says they agree to wait for payment as a “courtesy” to the injured person, adding in boldface: “We understand insurance companies have unlimited resources, will hire defense lawyers and defense experts that will cause our payment to be delayed for months or years.”

The business community and insurers counter that LOP providers grossly inflate their medical fees to give juries a false picture of the costs of medical care.

“The sole purpose of the LOP, why it exists, is to drive up verdicts and settlements,” Lauren McBride, a lawyer for Publix Super Markets, a chain with more than 800 stores in Florida, testified in a state legislative hearing in February 2019.

McBride said that nearly two-thirds of “slip-and-fall” injury claims in Publix stores involve letters of protection. In more than half those cases, the injured person had some form of insurance but declined to use it, she said. In some cases, injured people traveled long distances for costly care they could have received closer to home at far less expense, she said. She also argued that LOPs give doctors an incentive to overtreat patients “to keep driving up medical bills” — and persuade juries to award big verdicts.

Kevin Leahy, an Austin, Texas, lawyer who has researched the practice there and represented clients on both sides of the debate, said LOPs deserve more scrutiny. “It’s a mixed bag,” he said. “There are definitely abuses going on. There are also hurt people getting care they need to get better.”

Leahy said LOPs have helped create a “liability-based” health care network with few checks on its financial dealings or other standards. He called it “unregulated, opaque and not fully accurate about charges.”

Across the country, LOPs have been tied to a range of alleged medical overcharges or other billing abuses, court records show.

Nearly 200 women from 42 states, for example, have joined a class-action suit that alleges doctors and lawyers talked them into signing LOPs promising to pay for surgical removal of pelvic mesh — whether they needed it removed or not.

The women allege that the doctors billed sky-high rates and told them their insurance would not cover the cost, so signing an LOP was the only way to safeguard their health. Private insurance would have paid about $8,000 for these services, far less than the $76,000-plus the women were charged under the LOP, according to the suit, filed in late August. The case is pending. Six doctors have filed motions to dismiss the case.

In a 2020 federal civil case, evidence emerged that a Texas spine surgeon charged nearly $400,000 under an LOP for procedures that Medicare would reimburse at less than $20,000, court records state.

Reviewing court cases in Florida, KHN found dozens of examples in which patients who signed LOPs alleged they were later sued for payment of excessive fees or received substandard medical care.

‘Unnecessary and Dangerous’

On the day of his spinal surgery, Louis-Charles signed a letter of protection that read in part: “While I am injured and need care, I cannot financially afford to pay your bill at the time services are rendered, I therefore, grant this provider a lien on my claim against any and all proceeds from any settlement, insurance benefits or judgment.”

The documents said he would be charged “what is usual and customary for our area.” But the fees were much higher than private health insurance would cover or what the Medicare fee schedule provides for.

The Aventura Surgery Center, co-owned by Miami personal injury attorney Sagi Shaked, billed nearly $100,000 for the operation, court records show. Two other Shaked-affiliated companies billed more than $35,000 for surgical supplies and anesthesia, according to the court records. Shaked did not respond to numerous requests for comment. In his deposition, Chin said he no longer operates at the Aventura Surgery Center.

Mark Woodard, 54, who was rear-ended in an April 2017 car crash in Fort Lauderdale, had three spine operations at the Aventura Surgery Center performed by Chin under a letter of protection.

His bills topped $430,000, including $179,500 for the surgery center, $177,972 billed by Chin’s medical office and $39,327 for implants from SpineFrontier, a Massachusetts medical device company Chin owns, court records show.

“These charges are way out of line,” said Michael Arrigo, a medical billing expert in California asked by KHN to review Woodard’s bills. Arrigo said “usual and customary” charges would be less than one-fourth of what was billed.

Woodard, who has worked as a painter and maintenance technician at beachfront hotels in Fort Lauderdale, argues in his lawsuit that his injuries from the crash were “nothing more than cervical and lumbar sprains and strains … such that no reasonable physician would have performed surgery other than for monetary purposes.”

According to Woodard’s lawsuit, Chin persuaded him to have multiple operations and during one tore a 1-centimeter hole through a nerve root, leaving him in “extreme agony and excruciating pain.”

The suit, filed in March 2021, alleges the surgery center offered Chin a “safe haven to perform his unnecessary and dangerous surgeries.” It also alleges that Chin “was unable to perform surgery at any hospital in the state of Florida and most if not all surgery centers where he had applied had either denied him privileges or he had his privileges revoked at multiple hospitals.” In court filings, Shaked has denied the allegations and any liability.

Chin also has denied any negligence in court filings and in a deposition called the fees he charged “reasonable within the community.” Woodard’s lawsuit is pending in Broward County Circuit Court.

Chin has been sued repeatedly for medical negligence, including several cases involving LOPs. He has been sanctioned by physician-licensing boards in three states, unrelated to his use of LOPs.

In early December, the Florida Department of Health, which licenses doctors, issued Chin a “letter of concern” and fined him $8,000. The action settled a state administrative complaint alleging that in August 2019 Chin sent home a 73-year-old man who suffered from complications of spinal surgery who should have been transferred “to a higher level of care in an inpatient setting (such as a hospital).” Chin disputed the allegations.

Separately, federal agents arrested Chin in early September in Fort Lauderdale on kickback charges as CEO at SpineFrontier, which sells spinal implants he invented and used in operations on Louis-Charles and Woodard. Chin has denied the civil allegations and has pleaded not guilty to the criminal charges.

In October, a federal judge ordered Chin to post a $500,000 bond secured by his Florida home. He is free to travel within the country “for business purposes only” and may travel one time per month to Jamaica “only for the purpose of practicing medicine there,” the order states. Chin has active medical licenses in Florida, Arizona, New Jersey, New York and in Jamaica, according to documents he filed with the court.

A ‘Complete Shock’

By its own account, the Broward Outpatient Surgical Center and its affiliates in Pompano Beach, Florida, have treated more than a thousand patients under letters of protection. But the billing practices — one lawsuit called its fees “astronomically unreasonable and inflated” — have been criticized in court filings for years. These cases often settle under confidential terms.

One patient argued in a lawsuit that injured patients were “bounced around” a web of affiliated clinics for services that included chiropractic care, pain injections, physical therapy and, finally, surgery, all done with no caps on the costs. The center denied the allegations, and the case has since been settled.

Albert Frevola, an attorney for the center, said that prior to treatment patients are given a price list and sign an agreement to pay the bills out of any settlement of their personal injury claims. He said the center serves many patients “who can’t afford to get medical care. It’s a service that is valuable and needed.”

Some three dozen former patients have filed a recent mass tort lawsuit alleging medical malpractice and billing fraud by the surgery center and its owners, chiropractors Brian and Craig Bauer, who are brothers. The suit also names spine surgeon Dr. Merrill Reuter, court records show. Neither Reuter nor his lawyer responded to requests for comment.

The patients allege they visited the center after a car crash or other accident and were persuaded to have spinal surgery. In some cases, the operations either were billed as more complex than they were, or not done at all, according to the suit. Patients often have run up bills of $100,000 or more under LOPs, court records show. “Due to the fact that personal injury patients rarely, if ever, use their private health insurance for such health care services, the Bauers and the Bauer entities were able to get away with charging inflated amounts,” according to the suit.

Frevola, who represents the brothers, said they “flatly deny” the allegations and “are sad and distressed that these accusations are being made by the same people they gave great care and medical treatment to.”

In a separate malpractice case, Terrell Harris, 37, alleged he was guided down a “treatment path” after a car crash in July 2017 that ended in surgery at prices “far beyond the scope of reason, let alone custom.” The center denied the allegations and filed a counterclaim accusing Harris of failing to pay for his care under the LOP.

The suit is one of eight pending in Broward County Circuit Court that make similar claims, including that of a woman who alleged she had the same pain after spinal surgery as she had beforehand. Nearly five years later, to her “complete shock,” an MRI found no evidence the operation she was billed for had been done, according to the suit.

In a February 2020 court filing in one of the cases, the center and Brian Bauer denied the allegations and called them “frivolous and scandalous.” They filed a counterclaim demanding to be paid for their services. The case is pending.

Warring Creditors

When fees are inflated under an LOP, patients can take home more money under an insurance settlement or jury verdict. But if a case settles for less than the sum of those bills, patients may be on the hook to pay the balance.

Lawyers who typically co-sign the LOPs try to persuade medical providers to reduce their fees, which often happens. When that fails, however, lawyers file a court action called an interpleader, which asks a judge to decide who gets what among warring creditors.

KHN reviewed dozens of Florida court cases in which medical creditors holding LOPs demanded payment in full. While many of these cases settled under confidential terms, court records show some accident victims ended up mired in debt or saw their damage awards drastically reduced by outsize medical billings and legal fees. In some cases, lawyers took home more than their injured clients.

That happened to Jose Merced, who fell and hurt himself after stepping into a hole outside his apartment in the Orlando area. He received a $75,000 settlement but incurred bills of more than $850,000 for operations and other medical costs, which he contested as “highly inflated,” court records show. The bills included more than $700,000 in orthopedic surgical and facility fees.

In August 2020, a judge allowed just over $35,000 to pay for the surgeries. Merced was awarded $10,000, while his lawyer got nearly $27,000, just over $18,000 of it for professional fees and the rest for expenses.

In some interpleader cases, lawyers asked judges for one-third of the total settlement for their fees, plus expenses, which can add hundreds, if not thousands, of dollars more to their share.

A law group founded by South Florida personal injury lawyer Robert Fenstersheib filed at least 50 interpleader cases in Broward County Circuit Court between January 2019 and October of this year. Fenstersheib, who was a fixture of local television ads as the “lawyer who listens,” was shot to death by his son in a murder-suicide in September 2020, though his Fenstersheib Law Group still operates under his relatives.

Many of the LOP patients now suing the Broward Outpatient Surgery Center and its owners were clients of the Fenstersheib firm, court records show. The center and the law firm did business for years, but the center sued the law firm in 2019 alleging the lawyers failed to pay it millions of dollars owed under LOPs. The law firm responded that it was a victim of a $6.5 million embezzlement by former employees who pocketed settlement money meant for the center. The suit was settled under confidential terms this year.

Federal prosecutors filed criminal charges against two former Fenstersheib employees in connection with the theft. In late November, one of the men, Michael Wihlborg, a 47-year-old high school dropout who had worked for the law firm for nearly two decades, admitted receiving more than $2.1 million in stolen funds from the scheme; he pleaded guilty to one count of conspiracy to commit wire fraud and three counts of filing a false income tax return, court records show. He faces up to 29 years in prison, according to court records. Co-defendant Matthew Matlock pleaded guilty to similar charges on Dec. 15, court records show. The law firm had no comment.

Ethics Question

Some lenders also accept LOPs as collateral for patients who borrow money to tide them over while their personal injury case winds through the courts, which typically takes years. Interest charges pile up fast.

A Miami man who was injured after a pile of wood fell on him at a home improvement store borrowed $51,400 from a finance company backed by an LOP in September 2014. He owed the company $140,322 three years later because of an interest rate of 18% charged every six months, court records show.

Doctors also can generate cash from letters of protection. While they argue they must wait years for payment, some spine surgeons sell the liens on a burgeoning medical debt market.

Court records in Florida show millions of dollars of these liens have changed hands when doctors sold them. Buyers paid 10% to 25% of the total amount of the bill and gambled they would be able to collect a tidy profit once a patient’s lawsuit was settled.

The ethics of doctors wheeling and dealing in patient bills and having a financial stake in the outcome of litigation has been questioned. An American Medical Association policy says such deals are unethical because “there is the ever-present danger that the physician may become less of a healer and more of an advocate or partisan in the proceedings.”

Dr. Scott Lederhaus, a retired California neurosurgeon who has reviewed personal injury cases for the defense, said some patients argue in depositions that under an LOP they never saw bills, so they had no idea of the extent of the medical costs they were incurring over time.

Lederhaus said there is little agreement on what is a reasonable medical fee and, as a result, doctors “are able to charge whatever they want” in personal injury cases.

And it remains unclear whether the No Surprises Act, which Congress passed last year amid a national outcry over huge and unexpected medical bills, offers patients who signed LOPs any protection.

“A lot of these doctors are under the impression they can do whatever they want and there’s not going to be any oversight by anyone,” Lederhaus said.

NICU Bill Installment Plan: That’ll Be $45,843 a Month for 12 Months, Please

KFF Health News, December 21, 2021

After baby Dorian Bennett arrived two months early and spent more than 50 days in the neonatal ICU, his parents received a bill of more than $550,000—despite having insurance.

This story ran December 21, 2021, on Kaiser Health News
 

Close to midnight on Nov. 12, 2020, Bisi Bennett was sitting on the couch in her pajamas and feeling uncomfortable. She was about seven months pregnant with her first child, Dorian, and the thought that she could be in labor didn’t even cross her mind.

Then, she felt a contraction so strong it knocked her off the couch. She shouted to her husband, Chris, and they ran to the car to start the 15-minute drive to AdventHealth hospital in Orlando, Florida. About halfway through the trip, Bennett gave birth to Dorian in her family’s Mitsubishi Outlander. Her husband kept one hand on his newborn son’s back and one hand on the wheel.

Born breech, meaning his head emerged last, Dorian wasn’t crying at first, and the terrified new parents feared something was wrong. Chris Bennett turned on the SUV’s flashers and flagged down a passing emergency vehicle. The EMS team escorted the family to the hospital.

“He was still connected to me with the umbilical cord when they rolled the two of us together into the hospital,” Bisi said. “They cut the cord, and the last thing I heard was, ‘He has a pulse,’ before they wheeled me away.”

“I just cried tears of relief,” she said.

Dorian stayed in the neonatal intensive care unit until Jan. 7, 2021, for almost two full months. While Dorian was in the hospital, Bisi wasn’t worried about the cost. She works in the insurance industry and had carefully chosen AdventHealth Orlando because the hospital was close to her house and in her insurance network.

Then the bills came.

The Patient: Dorian Bennett, an infant born two months premature. He has health insurance through his mother’s employer, AssuredPartners, where she works as a licensed property insurance agent.

Medical Service: A neonatal intensive care unit stay of 56 days. Dorian needed highly technical, lifesaving respiratory and nutritional care until his organs matured. He also received laboratory, radiology, surgery, cardiology and audiology services and treatments.

Service Provider: AdventHealth Orlando in Orlando, Florida. It is a part of the AdventHealth system, a large nonprofit and faith-based group of health care providers with locations across Florida and several other states.

Total Bill: AdventHealth Orlando billed $660,553 for Dorian’s NICU care. Because of an insurance snafu, the “patient responsibility” portion of the bill sent to the Bennetts was $550,124. They were offered an installment payment plan of $45,843 a month for 12 months.

View note

What Gives: Under the 2010 health law, nonprofit hospitals are required to provide financial assistance to help patients pay their bills, and payment plans can be part of that assistance. But the Bennett family’s experience shows the system is still far from friendly to patients.

The installment amount offered to the Bennetts — $45,843 — resembles an annual salary more than a reasonable monthly payment. The laughably unrealistic plan was apparently automatically generated by the hospital’s billing system. A spokesperson for the hospital, David Breen of AdventHealth, did not answer KHN’s questions about its billing software or why a five-digit monthly payment was not flagged by the hospital as a problem that might need extra attention.

The size of the Bennetts’ bill stems from two overlapping issues: Baby Dorian was born in 2020 and needed hospital care into 2021, and Bisi Bennett’s employer shifted its health plan to a different company in January 2021. She informed AdventHealth about the change.

As someone who works in the insurance industry, Bennett was pretty sure that she understood the mix-up and that the charge of more than half a million dollars was unjustified.

But as Dorian turned a year old last month, the family still had bills pending and a tangle of red tape to fight.

AdventHealth bundled the 2020 and 2021 dates of Dorian’s NICU stay and then billed both insurance plans for the whole stay. Both insurance plans said the bill contained dates of care when Dorian was not covered, so neither paid the hospital. The shift from one year to the next flummoxed three large business entities, which seemed unmotivated to resolve the problem quickly.

“A bill this large is a huge crisis for the family, but it’s not a huge crisis for the insurance company or for the hospital,” said Erin Fuse Brown, an associate professor of law at Georgia State University who studies health care policy.

In 2020, Dorian was covered under a UnitedHealthcare plan, which for in-network providers had a $6,000 deductible and $6,000 out-of-pocket maximum for the family.

In 2021, Bisi Bennett’s employer switched its third-party administrator of its self-funded plan from UnitedHealthcare to UMR. The deductible and out-of-pocket maximum did not change.

Although UMR is owned by UnitedHealthcare, the two companies did not communicate well about the case.

“It’s indicative of all the ways the system fails the patient,” Fuse Brown said. “Even the one who does everything right.”

Through the nearly yearlong fight over the bill, the Bennetts were also caring for Dorian, who left the hospital with lingering gastrointestinal issues, and managing Chris’ treatment for stage 4 neuroendocrine cancer, which was diagnosed in April. At one point, Bisi said, she felt she was going crazy.

“They’re in charge of billing, and I shouldn’t be the one having to tell them, ‘Bill my one insurance for dates in 2020 and bill my other insurance for dates in 2021,’ but I did,” she said. “I kept having the same conversation over and over.”

Resolution: Bisi Bennett immediately noticed and understood the calendar issue when she received the billing statements in spring 2021. She started by calling the hospital and was told the problem would be corrected in March. Yet, in September, she got the same half-a-million-dollar bill.

UnitedHealthcare spokesperson Maria Gordon Shydlo, who also fielded KHN’s questions for UMR, said the insurance company told AdventHealth to revise the bill with correct dates in the spring.

Breen, the spokesperson for AdventHealth Orlando, confirmed to KHN that the billing error stemmed from the change in insurers from 2020 to 2021. In a statement, Breen said medical billing can be a complex process and the hospital “understand[s] this has been a confusing and challenging experience for Ms. Bennett, and we apologize for the frustration this has caused.”

AdventHealth Orlando did not submit a revised bill with corrected dates until KHN contacted the hospital in October 2021.

After UHC and UMR reprocessed the 2020 and 2021 claims, the original bill of more than $550,000 was knocked down to $300.

In his statement, Breen said that the Bennetts’ case sparked AdventHealth to identify and address issues in its system and that the hospital plans to improve the billing and communications process for future patients, particularly when there is a change in insurance.

The Takeaway: Much of our fragmented health care system is on autopilot, with billing software that generates confusing or, in this case, absurd bills and payment plans.

Related Links

Bisi Bennett did everything right: She chose an in-network hospital and informed it of the changes to her health insurance. She followed up when she saw there was an error. But her case didn’t reach a resolution until a reporter called on her behalf.

If you are fighting a bill that you believe contains an error, call all the entities involved — the hospital, insurers, other providers — and don’t forget about your company’s human resources department. It may be able to pressure insurers to resolve an error faster than you can.

Most states have a department of consumer services that can help you file a complaint with the appropriate oversight entity. Staff members at state agencies can help you figure out what is going on. Tell the medical providers you are reporting them to the state.

Still, it is a frustrating, uphill battle, especially when patients have improper bills hanging over their heads for many months and are at risk of having the bills sent to a collection agency or having their credit score dinged. There should be far more transparency in billing and a set time limit for dispute resolution, experts say.

“This shows how little leverage or power a patient has in this situation,” Fuse Brown said. “You almost have to go outside the system and put external pressure.”

Vaccine Promoters Struggle to Get People Boosted in California’s Fields

KFF Health News, December 20, 2021

The need for boosters and the looming threat of the omicron variant have made COVID communication extra challenging.

This story ran December 20, 2021 on Kaiser Health News.

 

By Heidi de Marco

Since the start of the pandemic, Luz Gallegos and her team of 56 advocates for immigrants have battled the scorching sun, illiteracy and deadly propaganda in the fields and fruit groves of the Coachella Valley.

As they fanned out to educate farmworkers on how to protect themselves from covid-19, they quickly learned that rumors and disinformation often account for most of the news farmworkers in the area are getting about the disease. The need for boosters and the looming threat of the omicron variant have made covid communication extra challenging.

“Now, we’re debunking the myths with the boosters. It’s like a never-ending story,” said Gallegos, executive director of the TODEC (Training Occupational Development Educating Communities) Legal Center, based in Coachella.

Gallegos and her team huddle in the mornings to discuss a strategy on how to diffuse misinformation before it spreads. “Once we start hearing rumors, we try to get ahead of them and create messaging to debunk it before they start penetrating the fields like they did when we first started vaccinating in January.”

In January, the word in the fields was that covid vaccination would make you sterile. Now, people hear from friends and social media that the vaccines can turn you into a monkey, change your gender or clone you.

Gallegos and Riverside County health workers managed earlier in the year to get vaccines into the arms of most farmworkers in the valley, where dates, citrus and grapes are the dominant crops. That has eased the sales job for some of her crew of TODEC employees and volunteers.

“People that got vaccinated, they feel like they’re still here, they’re still alive,” she said. “People see science now.”

But equity issues that were evident in the first round of vaccines are more evident now, including access to health care, language barriers and misinformation, Gallegos said. Some workers don’t understand why they need a follow-up shot. Others are newcomer migrants who haven’t been vaccinated against covid at all.

Community health organizations have struggled to provide booster shots for the Latino community — whose members account for more than half of covid cases in California. By September, about 80% of eligible Latinos had received at least one shot, the same rate as whites. But of the 23.4 million people 65 and older who had received a booster dose by Dec. 13, only 7.8% were Latinos (who make up nearly 10% of that age group), according to the Centers for Disease Control and Prevention. Latinos of other ages were also relatively unboosted.

“Latinos don’t know who to turn to for accurate information,” said Gilberto Lopez, an assistant professor at Arizona State University who has been working on vaccine communication. “The government hasn’t been doing the best job, the big national TV channels haven’t been doing that good of a job, and community organizations are working at a hyper-local level.”

One basic problem: Credible vaccine information and the science that supports it is not readily available in Spanish or other languages, said Dr. Yelba Castellon-Lopez, an assistant clinical professor in family medicine at UCLA Health. “People are afraid to contract the virus in health care settings. Many avoided seeking care even when they were sick for fear of being put on ventilators, afraid they would never make it out of the hospital.”

The county has partnered with TODEC to send health care providers out to the fields and hold open vaccination and booster clinics on Fridays. This answers immigrants’ fears of going to the doctor and their concerns that side effects from the shot will cause them to miss work.

“Fridays gives them the opportunity to actually recover,” said Gallegos.

Castellon-Lopez has been conducting webinars for patients and community members to dispel myths and explain the shifting reality of the covid epidemic. “What we’re learning about covid is changing every day and that makes it difficult,” she said. “I think people appreciate having access to doctors who look like them and speak the language.”

Disinformation on Spanish AM radio, social media and messaging apps like WhatsApp is fueling continued vaccine hesitancy among Latinos, according to a recent survey conducted by Change Research and the Latino Anti-Disinformation Lab. It found that almost 4 in 10 respondents had seen information that made them think the covid vaccines were not safe or effective.

Latino educators are seeking to smother misleading propaganda with culturally relevant, easy-to-understand, accurate information.

Lopez, at Arizona State University, created the Covid Health Animation Project, which makes cartoons that address covid misinformation. But he thinks health communicators need to inject some bawdiness into their scripts to get people’s attention.

“The type of comedy, the type of messaging, the wording we use, it’s G-rated,” said Lopez. He just published an animation that drops a few cuss words here and there. “That’s the way this population talks. We need to use some of the language that they use to reach out to the community that’s not getting vaccinated.”

Language barriers remain a consistent issue, especially for Indigenous-language speakers, said Odilia Romero, executive director of Comunidades Indígenas en Liderazgo (CIELO), a Los Angeles nonprofit.

Pablo Ek Oxte, a 52-year-old plumber from a small pueblo in Yucatán, Mexico, rolled up his sleeve for a booster shot on a recent Saturday morning after hearing about the vaccine clinic in a public service announcement produced by CIELO in his native Mayan language. The group has posted a series of vaccination cartoons in various Indigenous languages on social media sites.

“I relied on the information from CIELO,” said Oxte, who has asthma and diabetes. Although he speaks some Spanish, “I appreciate the information in my language,” he said.

In Oxnard, California, Francisco Didier Ulloa and Bernardino Almazán host a show on Radio Indígena in Spanish and Mixteco, an Indigenous Mexican language.

“A lot of our Indigenous brothers don’t speak Spanish, so it was necessary to convey the information in a way that they would listen and understand,” said Ulloa.

The Los Angeles County Department of Public Health has increased its social media memes and is testing strategies to narrow the vaccination gap between white and Latino residents. The state partnered with political cartoonist Lalo Alcaraz to create a series of cartoons and animations promoting vaccination and booster information.

“We want people to see themselves and their families reflected in these images and maybe do a double take and think twice about their own family’s situation,” said Alcaraz. “Maybe it changes their mind about the vaccine.”

The Vaccine Rollout Was a Success. But Events Within and Beyond Biden’s Control Stymied Progress.

KFF Health News, December 20, 2021

A look at what happened in 2021 and whether Biden’s efforts have made a difference.

This story ran December 20, 2021 on Kaiser Health News.

 
Eleven months ago, President Joe Biden assumed office during one of the most critical moments of the covid-19 pandemic. Case counts and death rates were shockingly high. The vaccine rollout, which had started under former President Donald Trump, was disjointed. People were generally sequestered in their homes, and kids were relegated to remote learning.

Biden promised to change all that. He said he would differ from Trump in that he would listen to the scientists, encourage the use of masks and give the federal government a stronger role in addressing the pandemic. He also pledged to deliver the “most efficient mass vaccination plan in U.S. history” and to get 100 million covid shots administered in his first 100 days.

How well did Biden do? We asked four public health experts who said the president’s vaccine rollout, overall, was excellent, but his messaging was off at certain points, and other setbacks — both within and beyond his control — stymied progress against covid-19.

After all, cases in the U.S. are again surging, largely due to the delta and omicron variants. In some places, these numbers, as well as hospitalization tallies, are approaching the highest levels in months. This month, the U.S. surpassed 800,000 covid-related deaths since the pandemic started, and the 1 million mark is in view. The reopening of Broadway shows — something viewed by many as a sign that normalcy was returning — is facing interruptions as breakthrough cases among cast members cause intermittent performance cancellations. The sports world is facing its own covid-related disturbances. Colleges have announced they will hold final exams remotely and are canceling winter graduations.

All of this calls into question how much progress has been made against covid. Let’s take a look at what happened in 2021 and whether Biden’s efforts have made a difference.

Even before taking office, Biden set an initial target of getting 100 million doses of vaccine administered in his first 100 days. While there was initial uncertainty about this target, it turned out to be an easily achievable goal that took only 58 days.

Still, vaccine distribution unfolded by fits and starts. At first, only certain populations were eligible for shots. And when Biden announced he was ordering states to open up eligibility to all adults May 1, demand outstripped vaccine supply in many locations. By summer, though, most who wanted a vaccine could get one — free of charge.

That push “was extraordinary,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “The Biden administration increased the number of people to get shots, they increased the number of places to get shots, they reduced the number of disparities for those getting shots,” he said.

Indeed, getting almost half of the U.S. population fully vaccinated in the first six months of 2021 resulted in a huge drop in covid cases, hospitalizations and deaths by early summer. Recent data from the Commonwealth Fund indicates that the covid vaccination program in the U.S. prevented 1 million deaths and 10 million hospitalizations.

Yet, those two optimistic signs — high vaccine availability and low covid cases — led the Biden administration to prematurely assert triumph over the virus, said Dr. Leana Wen, a professor of health policy and management at George Washington University. This was just one of several messaging missteps made by Biden and his administration in 2021, said the experts.

“They had declared victory right when delta was starting to surge,” Wen said.

Wen pointed to the Centers for Disease Control and Prevention’s “confused” messaging, starting with an announcement in May that those who were fully vaccinated no longer needed to wear masks indoors or outdoors, or practice physical distancing, even though those strategies had proved useful in combating the virus.

The change in mask guidance came at a pivotal time. The dangerous delta variant was beginning to take hold throughout the U.S., and public health officials were only starting to understand that those who had been vaccinated could still spread the virus. As delta boosted case counts in midsummer, the CDC had to walk back its guidance to recommend that vaccinated people resume wearing masks indoors if they lived in an area with substantial or high transmission. This remains the recommendation. Yet, that initial announcement opened a door for many states and localities to repeal their mask requirements and never reinstate them, despite continued high levels of transmission nationwide.

“The unmasking order back in May was too hastily done,” Benjamin said. “That was a misstep.”

Also, Biden’s announcement in mid-August that booster shots would be available by Sept. 20 to all Americans preceded both the Food and Drug Administration’s recommendation and the CDC’s guidance on boosters for everyone — another stumble. The FDA didn’t authorize boosters for all adults until November.

“I think people saw that as him making a political statement,” Benjamin said. “He knew that was where we were going, where the science was taking us. He got ahead of it.”

Overall, though, Biden followed the science, said the experts. Plus, implementing regular covid media briefings with scientists and public health leaders, and allowing Dr. Anthony Fauci, his chief medical adviser, to be front and center and not contradicting his advice, represented a meaningful change from the previous administration, when daily briefings were held but speakers often dismissed scientific evidence in favor of untested treatments and the president, himself, would dismiss the pandemic’s severity.

Biden also used the power of his office to advance certain public health measures. He issued vaccine mandates for federal employees and contractors, health care workers and certain companies. This has increased the number of people vaccinated, though the mandates, except for the one aimed at government workers, are on hold while objections work their way through the court system.

And, despite state rollbacks of mask mandates, the president has continued to require masking in areas under his control, including within the interstate transportation and air travel industries and in federal buildings. He also signed a $1.9 trillion covid relief law in March that provided financial assistance to people in the form of stimulus checks, child tax credits and additional unemployment benefits, as well as aid to states and local governments.

However, one area in which government efforts have been severely lacking is covid testing, said every public health expert we consulted.

“We need more availability of at-home rapid tests. There shouldn’t be shortages,” said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, which represents state and local public health agencies.

The Biden administration has invoked the Defense Production Act to ramp up production of rapid tests, and is providing tests free of charge to community health clinics and requiring private insurance companies to reimburse consumers for tests they buy.

It could do more, said Jen Kates, director of global health and HIV policy at KFF.

“They still haven’t gone to the next step and bought tests and sent them to every household, to really blanket the country with tests,” Kates said. That would prove especially vital if the U.S. does indeed experience a winter surge due to delta and omicron as anticipated.

Variants, especially delta, have caused more serious disease symptoms than other forms of the covid virus, exacerbating the challenge of battling the pandemic this year. Still, data shows that covid-related death rates were far higher among the unvaccinated than the vaccinated. The volume of people unwilling to get the shot because of vaccine hesitancy or misinformation may have contributed to the high number of covid deaths in 2021, which have surpassed 2020, said Kates.

In addition, covid vaccines weren’t widely available to everyone in the U.S. until May. Plus, during 2020, much of the U.S. was locked down at home, while many activities have resumed in 2021, with increased opportunities for viral spread.

Still, under Biden, according to the latest metrics, more than 61% of the U.S. population — and 72% of adults — have been fully vaccinated against covid.

“I think we should really be celebrating the 70% more,” Plescia said. “For adult vaccinations, we never get anywhere close to that number with other vaccines, like influenza.”

Yet, as the nation stares down omicron, the country braces for increasing cases amid continued uncertainty over when the pandemic will finally end.

Experts agreed the U.S. has made positive gains in its efforts against covid this year, but there is more work to do. Testing, continuing to encourage vaccinations and boosters in the U.S., and providing shots to the world — to help prevent future variants — are the only ways to reach a point where covid becomes endemic, they said.

“We are in a different place. Last year we needed vaccines. Now we need to get to the point where testing is the norm,” Wen said. “This is how we’re going to live with covid in our lives in the future and is how we as America will be able to move on.”

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