Therapists are concerned about a price transparency provision that requires most licensed medical practitioners to give patients detailed upfront cost estimates.

This article was published on Thursday, February 3, 2022 in Kaiser Health News.

By Julie Appleby

Groups representing a range of mental health therapists say a new law that protects people from surprise medical bills puts providers in an ethical bind and could discourage some patients from care.

The therapists take no issue with the main aim of the legislation, which is to prevent patients from being blindsided by bills, usually for treatment received from out-of-network medical providers who work at in-network facilities. Instead, they are concerned about another part of the law — a price transparency provision — that requires most licensed medical practitioners to give patients detailed upfront cost estimates, including a diagnosis, and information about the length and costs involved in a typical course of treatment. That's unfitting for mental healthcare, they say, because diagnoses can take time and sometimes change over the course of treatment.

Finally, if they blow the estimate by at least $400, the law says uninsured or self-pay patients can challenge the bills in arbitration.

Arguing that the rule is burdensome and unnecessary, mental health providers wrote a Jan. 25 letter to the Department of Health and Human Services, seeking an exemption from the "good faith" estimates for routine mental and behavioral health services. The letter was signed by 11 groups, including the American Psychological Association, the National Association of Social Workers, the American Psychiatric Association, and the Psychotherapy Action Network.

Some also worry that the law will allow insurance companies to play a larger role in dictating what even non-network mental health therapists can charge, although policy experts say it isn't clear how that could happen. Although exact figures are not available, it's estimated that one-third to one-half of psychologists are not in-network with insurers, the psychologists' association said. And those numbers do not include other practitioners, such as psychiatrists and licensed clinical social workers, who are also out of network.

"We got thrown into this bill, but the intention [of the law] was not mental health but high-cost medical care," said Jared Skillings, chief of professional practice with the American Psychological Association. "We're deeply concerned that this [law] inadvertently would allow private insurance companies to set regional rates across the country that, for independent practitioners, would be a race to the bottom."

Therapy costs vary widely around the U.S. and by specialty, but generally range from $65 an hour to $250 or more, according to the website GoodTherapy.

The good faith estimates must be given this year to uninsured or self-pay patients for medical or mental healthcare services. They were included in the No Surprises Act as part of a broader effort to give patients a good idea of cost, both per visit and for a course of treatment, in advance.

Therapists say their professional codes of ethics already require disclosure to patients of per-visit costs. Requiring diagnostic billing codes in the estimate before even seeing a patient — as they interpret the rule — is unethical, they argue, and tallying up what might be weeks or even months of treatment costs could keep some patients from undergoing care.

"If people see a large dollar amount, they might be intimidated or scared into not getting help at all," said Linda Michaels, a private practice therapist in Chicago and co-chair of the Psychotherapy Action Network.

The counterargument, though, is that one of the law's aims was to provide patients with pricing information — for mental health services or medical care — that is less opaque and more similar to what they're used to when shopping for other types of goods or services.

Benedic Ippolito, an economist at the American Enterprise Institute, said he is sympathetic to medical providers' concerns about the extra administrative burden. But "giving consumers a better sense of financial obligation they are exposed to and imposing some cost pressure on providers are both reasonable goals," he said.

Even among providers, there is no universal agreement on how burdensome the estimates will be.

"It's not an unreasonable thing, frankly, for psychiatrists, not just plastic surgeons or podiatrists, to say, 'If you want me to do this and you're not covered by insurance or whatever, it will cost you X amount for the whole episode of care and this is what you get in return,'" said Dr. Robert Trestman, chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine. Although he serves on an American Psychiatric Association committee, he was voicing his own opinion.

The Centers for Medicare & Medicaid Services said mental health providers are not exempt from the rules about good faith estimates, in a written statement to KHN. It added, however, that the agency is working on "technical assistance geared toward mental health providers and facilities." Federal agencies often issue additional clarification of rules, sometimes in the form of FAQs.

The No Surprises Act took effect on Jan. 1. Its thrust was to bar medical providers from sending what are called surprise or "balance" bills to insured patients for out-of-network care provided in emergencies or for nonemergency situations at in-network facilities. Common before the law passed, such bills often amounted to hundreds or thousands of dollars, representing the difference between the amount insurers paid toward out-of-network care and the often much higher amounts charged.

Now, insured patients in most cases will pay only what they would have been billed for in-network care. Any additional amount must be worked out between their insurer and the provider. Groups representing emergency doctors, anesthesiologists, air ambulance providers, and hospitals have filed lawsuits over a Biden administration rule that outlines the factors independent arbitrators should consider when deciding how much an insurer must pay the medical provider toward disputed bills.

Most mental health services, however, aren't directly touched by this part of the directive because treatment is not typically performed in emergency situations or in-network facilities.

Instead, the complaint from mental health providers focuses on the good faith estimates.

Additional rules are expected soon that will spell out how upfront estimates will be handled for people with health coverage. In their letter to HHS, the behavioral health groups say they fear the estimates will then be used by insurers to limit treatment for insured patients, or influence pay negotiations with therapists.

Several policy experts say they do not think the law will affect mental health reimbursement in most cases.

"Mental health professionals will have the exact same ability to bill out-of-network, to have patients agree to whatever market price is for their services," said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, who has long studied balance billing issues. "Nothing about the No Surprises Act restricts that."

Some of the therapy groups' concerns may stem from misreading the law or rules implementing it, say policy experts, but they still reflect the confusion providers share surrounding the rollout of the law.

As for how to handle pre-treatment diagnoses that are needed to deliver good faith estimates, CMS said in its email to KHN that providers could estimate costs for an initial screening, then follow up with an additional estimate after a diagnosis.

"No one is going to be forced to make a diagnosis of a patient they have not met," Adler said.

Julie Appleby: jappleby@kff.org, @Julie_Appleby

One-quarter (25%) of nursing homes that sent tests to a lab waited an average of three or more days for results as of Jan. 16.

This article was published on Wednesday, February 2, 2022 in Kaiser Health News.

By Rachana Pradhan

More nursing homes are waiting longer for COVID-19 test results for residents and staffers, according to federal data, making the fight against record numbers of omicron cases even harder.

The double whammy of slower turnaround times for lab-based PCR tests and a shortage of rapid antigen tests has strained facilities where quickly identifying infections is crucial for keeping a highly vulnerable population safe.

A KHN analysis of data from the Centers for Medicare & Medicaid Services finds that 25% of nursing homes that sent tests to a lab waited an average of three or more days for results as of Jan. 16. In early December, that number was 12%.

At Lutheran Life Villages in Fort Wayne, Indiana, the long wait for results renders PCR tests "useless," President Alex Kiefer said. "If we send somebody off to get a PCR test, sometimes it takes two days for them to get an appointment. And then it takes two, three, four days to get a read."

So Kiefer's organization mainly relies on rapid antigen tests. But on Jan. 12, long-term care sites in the state were alerted to shortages of Abbott Laboratories' rapid BinaxNOW antigen tests, according to the Indiana Department of Health. Lutheran Life Villages was using 125 rapid tests a day, including on vaccinated people. Now as transmission rates remain high, "we are scrounging to try to find enough," Kiefer said. He called the state shipments sporadic. "The scariest thing is, if we get to a point where we can't get those, we will have to rely on PCRs, and the timing of that is just really challenging," Kiefer said.

Federal officials require the country's 15,000 nursing homes to submit data on COVID in their facilities; KHN's analysis of testing speeds is based on reports of turnaround times in early December and mid-January from about 10,900 homes. Nursing home residents have high vaccination rates — more than 87% are fully inoculated, and 67% have received boosters. Still, experts warn, delays can pose significant safety risks. For one, in the time it takes to receive results, outbreaks can emerge undetected. And with omicron, breakthrough infections appear to cause more severe symptoms for older people.

This many nursing homes haven't waited three or more days for test results since March 2021, CMS data show.

Broadly, PCR tests are considered the gold standard for accuracy and are more likely to be used for regular surveillance testing because rapid tests can miss asymptomatic cases. The drawback is that labs can take days to return PCR results under normal circumstances, let alone when testing demand and staffing shortages delay processing. 

Dr. Naveen Patil, deputy state health officer of the Arkansas Department of Health, said the state recommended that long-term care facilities shift to PCR tests during COVID outbreaks because they are more reliable, even when plenty of antigen tests are available.

"But now," he said, "most of them are doing PCR because they don't have adequate supply of antigens."

The Biden administration, which is sending 1 billion rapid COVID tests to U.S. households, has been shipping long-term care facilities 2.5 million tests a week. But that supply has proved measly against omicron's winter surge, which has fueled even greater infections among nursing home residents, according to CDC data.

The American Healthcare Association, which lobbies for nursing homes and assisted living facilities, recently said the administration plans to send the sector an additional 5 million rapid tests in the coming weeks, but the industry says that's not nearly enough. A spokesperson for the U.S. Department of Health and Human Services did not respond to questions about the new shipments.

Two years into the pandemic, nursing homes are still managing a crisis. Testing is "a bit of a mess," said David Grabowski, a long-term care expert and health policy professor at Harvard Medical School. "It's déjà vu all over again."

Industry workers say rapid test shortages also complicate their efforts to honor residents' right to receive visitors while ensuring the virus doesn't come in with them.

A survey in early January by LeadingAge, which lobbies for nonprofit nursing homes and other care providers for older adults, found that 76% of nursing homes had adequate testing supplies, but facilities said restocking was getting harder. The American Healthcare Association asked the Biden administration to increase the sector's testing supplies and related equipment. The group estimates the sector needs 5 million tests per week.

Dr. Swati Gaur, medical director for New Horizons Nursing Facilities in Georgia, said some facilities "are having to kind of pivot to PCR" tests because of antigen test shortages.

Before omicron arrived, Tina Sandri, CEO of Forest Hills of DC in Washington, would get PCR test results back in about a day. In January, that turnaround time increased to two or three days. Sandri's company, which operates skilled nursing and assisted living facilities, relies on PCR testing to have more confidence that they'll catch asymptomatic cases.

"Those antigen test kits are really hard to get," she added. "We would need hundreds of them every single day, and there just aren't enough of them for us to use as a practical solution." Their most valuable use, Sandri said, would be for employees to test themselves at home after an exposure or infection before returning to work.

COVID infections among nursing home residents and staff members have begun to decline nationally, but the total in the week ending Jan. 23 — 42,584 resident cases — surpasses the numbers from last winter's surge, when initial doses of the COVID vaccine were becoming available. In the past month, the number of resident deaths has increased each week — and was 1,298 for the week ending Jan. 23. That is well below the 4,100 deaths reported in the same week a year ago, CDC data shows.

Long-term care facilities that aren't worried about COVID testing say they can reliably get test results in less than a day or two. And they have ample supplies of rapid antigen tests from federal shipments.

"I maybe get two or three shipments a week" of rapid tests, said Karen Venis, CEO of Sayre Christian Village in Lexington, Kentucky. The lab that processes Sayre's PCR test samples — which they use for routine surveillance — sends staffers to test residents and workers twice a week. Results are typically provided within 24 hours, and Venis estimated they use about 100 antigen tests a week, saving them mostly for people with symptoms.

"We've got the support that we need," she said.

For Kiefer in Indiana, though, using more PCR tests isn't tenable.

"That's how we were making decisions early on in the pandemic," he said. "It was difficult to do everything."

At least with rapid tests, he said, "we can take action right away."

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

Amid a nationwide shortage of mental health professionals, universities are competing with hospitals, private practices, and the telehealth industry.

This article was published on Tuesday, February 1, 2022 in Kaiser Health News.

By Mark Kreidler

Early in his first quarter at the University of California-Davis, Ryan Manriquez realized he needed help. A combination of pressures — avoiding COVID-19, enduring a breakup, dealing with a disability, trying to keep up with a tough slate of classes — hit him hard.

"I felt the impact right away," said Manriquez, 21.

After learning of UC-Davis' free counseling services, Manriquez showed up at the student health center and lined up an emergency Zoom session the same day. He was referred to other resources within days and eventually settled into weekly group therapy.

That was September 2020. Manriquez, now president of the student union, considers himself lucky. It can take up to a month to get a counseling appointment, he said, and that's "at a school that's trying really hard to make services available."

Across the country, college students are seeking mental health therapy on campus in droves, part of a 15-year upswing that has spiked during the pandemic. U.S. Surgeon General Vivek Murthy in December issued a rare public health advisory noting the increasing number of suicide attempts by young people.

Colleges and universities are struggling to keep up with the demand for mental health services. Amid a nationwide shortage of mental health professionals, they are competing with hospital systems, private practices, and the burgeoning telehealth industry to recruit and retain counselors. Too often, campus officials say, they lose.

At UC-Davis, Dr. Cory Vu, an associate vice chancellor, said the campus is competing with eight other UC system universities, 23 California State universities, and multiple other health systems and practices as it tries to add 10 counselors to its roster of 34.

"Every college campus is looking for counselors, but so is every other health entity, public and private," he said.

According to data compiled by KFF, more than 129 million Americans live in areas with a documented shortage of mental healthcare professionals. Roughly 25,000 psychiatrists were working in the U.S. in 2020, according to the Bureau of Labor Statistics. The KFF data indicates that more than 6,500 additional psychiatrists are needed to eliminate the shortfall.

On campuses, years of public awareness campaigns have led to more students examining their mental health and trying to access school services. "That's a very good thing," said Jamie Davidson, associate vice president for student wellness at the University of Nevada-Las Vegas. The problem is "we don't have enough staff to deal with everyone who needs help."

About three years ago, administrators at the University of Southern California decided to respond aggressively to the skyrocketing demand for student mental health services. Since then, "we've gone from 30 mental health counselors to 65," said Dr. Sarah Van Orman, the university's chief medical officer for student health.

The result? "We're still overwhelmed," Van Orman said.

Van Orman, past president of the American College Health Association, said the severity of college students' distress is rising. More and more students come in with "active suicidal ideation, who are in crisis, with such severe distress that they are not functioning," Van Orman said. For counselors, "this is like working in a psychiatric ER."

As a result, wait times routinely stretch into weeks for students with nonemergency needs like help dealing with class-related stress or the transition to college. Professionals at campus counseling centers, meanwhile, have seen both their workloads and the serious nature of individual cases rise dramatically, prompting some to seek employment elsewhere.

"This is an epidemic in its own right," Van Orman said, "and it has exploded over the last two years to the point that it is not manageable for many of our campuses — and, ultimately, our students."

The pandemic has exacerbated the challenges students face, said UNLV's Davidson. Lockdown measures leave them feeling isolated and disconnected, unable to establish crucial relationships and develop the sense of self that normally comes with campus life. They also lose out on professional opportunities like internships and fall behind on self-care like going to the gym.

A study by the Center for Collegiate Mental Health at Pennsylvania State University found that among 43,000 students who sought help last fall at 137 campus counseling centers, 72% said the pandemic had negatively affected their mental health. An online survey of 33,000 students last fall found that half of them "screened positive for depression and/or anxiety," according to Boston University researcher Sarah Ketchen Lipson.

Even before the pandemic, university counseling center staff members were overwhelmed, Northwestern University staff psychiatrist Bettina Bohle-Frankel wrote in a recent letter to The New York Times. "Now, overburdened, underpaid and burned out, many therapists are leaving college counseling centers for less stressful work and better pay. Many are doing so to protect their own mental health."

On average, a counselor position at UC-Davis requiring a master's or doctorate degree pays $150,000 a year in salary and benefits, but compensation can vary widely based on experience, Vu said. Even at that rate, Vu said, "we sometimes cannot compete with Kaiser [Permanente], other hospital settings, or private practice."

Tatyana Foltz, a licensed clinical social worker in San Jose, California, spent three years as a mental health services case manager at Santa Clara University. "I absolutely enjoyed working with the college students — they're intelligent, dynamic, and complex, and they are working things out," Foltz said. But she left the university a few years ago, lured by the flexibility of private practice and frustrated by a campus system that Foltz felt did not reflect the diverse needs of its students.

Foltz returned to campus in December to support Santa Clara students as they protested what they said were inadequate services on campus, including insufficient numbers of diverse counselors representing Black, Indigenous, and LGBTQ+ communities and other people of color. The protests followed the deaths of three students during the fall quarter, two by suicide.

"It should not be taking student deaths to get us better mental health resources," said junior Megan Wu, one of the rally's organizers. After the rally, the chair of Santa Clara's board of trustees pledged several million dollars in new funding for campus counseling.

Replacing therapists who leave universities is difficult, Davidson said. UNLV currently has funding for eight new counselors, but the salaries it can offer are limiting in a competitive hiring market.

Universities are getting creative in their attempts to spread mental health resources around on their campuses, however. UC-Davis embeds counselors in student-utilized groups like the Cross-Cultural Center and the LGBTQIA Resource Center. Stanford University's Bridge Peer Counseling Center offers anonymous counseling 24/7 to students who are more comfortable speaking with a trained fellow student.

Mental health services that can be accessed online or by phone, which many schools did not offer before the pandemic, may become a lifeline for colleges and universities. Students often prefer remote to on-site counseling, Davidson said, and campuses likely will begin offering their counselors the option to work remotely as well — something that private practices and some medical systems have done for years.

"You have to work hard and also smart," Foltz said. "You need numbers, but you also need the right mix of counselors. There is a constant need to have culturally competent staff members on a university campus."

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

Mark Kreidler: @MarkKreidler

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

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

By Linda Marsa  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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