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.”

Local Pharmacists Fill Rx Void as Big Brands Pull Out of Rural Areas

KFF Health News, December 20, 2021

Closures provide opportunities for regional chains or pharmacists willing to strike out on their own.

This article was published December 20, 2021, by Kaiser Health News.
 

 

Bill Mather, a pharmacist in the small Iowa city of Greenfield, wanted to make sure his neighbors could fill their prescriptions without driving long distances or enduring long wait times.

So when pharmacy chains and big-box stores began expanding into rural markets, he sold his drugstore in 2007 to Pamida, a grocery chain owned by the Shopko department store company, hoping that would keep his practice alive. Then, in 2019, when Shopko declared bankruptcy, shuttering more than 360 stores, he and another Shopko pharmacist helped open a new drugstore for the city of about 2,000 people.

Across the country, pharmacists like Mather are filling the voids left when large drugstore chains and big-box stores with pharmacies pull out of small communities. In some areas, pharmacists who were let go when big chains closed are now opening new drugstores, often in the same locations. In other areas, pharmacy owners from neighboring towns are opening new branches. Without them, numerous communities would have been left with no pharmacy.

It didn’t used to be this way. Big-box stores like Shopko started to move aggressively into the pharmacy market 30 years ago, hoping customers would fill their carts while the store filled their prescriptions. Large chains established beachheads in small towns by acquiring independent pharmacies or driving them out of business.

According to the Bureau of Labor Statistics, the number of pharmacists employed at big-box stores peaked at more than 31,800 in 2012. But as online sales and mail delivery of consumer goods and prescription drugs grew, the big-box stores had no reason to stay. By 2019, the number of big-box pharmacists had dropped to fewer than 18,000. (The bureau no longer reports the number.)

“The big-box stores came into smaller and smaller communities, and they, in essence, outcompeted all the other pharmacies in the area,” said David Zgarrick, a pharmacy professor at Northeastern University in Boston. “Now they’re completely gone and with them the pharmacy services and everything else they provided. They left a vacuum in a lot of these places.”

With CVS Health’s recent announcement that it will close 300 stores a year over the next three years, more towns could lose another tier of pharmacies: the big drugstore chains. CVS has not yet said which stores will close.

“We’re considering a number of factors when making these decisions, including local market dynamics, population shifts, store density, and the needs of underserved communities,” said Mike DeAngelis, a CVS Health spokesperson. “In fact, reaching underserved populations has been a priority for us all through the pandemic, such as the access to testing and vaccines we’ve provided.”

Kathleen Bashur, a spokesperson for the National Association of Chain Drug Stores, said chain pharmacies of all types and sizes play a significant role in meeting the health and wellness needs of communities throughout the nation. “The decision to close a store is a difficult one,” she said.

Zgarrick attributes much of the decline in big-box pharmacies to Amazon and other online merchants that undercut the profitability of their non-pharmacy sales. In the past, big-box stores could treat pharmacies as loss leaders and make up that revenue with sales of other goods. Now, Zgarrick said, big-box stores have to ask tough questions about how to allocate their space: “‘At the end of the day, how are we going to make the most money per square foot? Is it by having a pharmacy or by selling tires?’”

Nelson Lichtenstein, a University of California-Santa Barbara history professor who has chronicled the rise of Walmart, said big-box stores are constantly reevaluating their store locations, closing less profitable stores and opening new ones in places where they think they can make money.

“They just keep a kind of slow churn,” he said.

The cost of building a big-box store is about $10 million, Lichtenstein said, and such stores can net $200 million in annual revenue. Pulling out of a location is therefore not a huge loss for a big company if revenues falter.

“So they will shut down the stores and leave a devastated town because the Walmart put the other guys out of business,” he said.

Walmart did not answer questions about its closures.

The growth in online options for all kinds of items, spurred by people shopping from home during the covid-19 pandemic, has put further pressure on big-box stores.

“Now they’re less likely to do that roaming shopping than they were five years ago,” said Adam Hartung, a business strategy consultant with Spark Partners. “They’re not going to say, ‘Oh, let’s pick up a prescription and, while we’re at it, let’s walk through the store and look at vacuum cleaners.’ That doesn’t happen anymore.”

Hartung said that the U.S. retail market has an excess of shops, by as much as 40% compared with other countries, and that more big-box stores are likely to close in the coming years.

But closures provide opportunities for regional chains or pharmacists willing to strike out on their own.

In Orofino, Idaho, the mayor, the chamber of commerce and many residents appealed to pharmacist Rod Arnzen after Shopko pulled out. So Arnzen began delivering to Orofino from his store 23 miles away in Kamiah. He then opened a branch in Orofino in the building left behind by the pharmacy that had previously sold its business to Shopko.

Andy Pottenger, who owns a pharmacy 45 miles away in Lewiston, Idaho, added a second pharmacy in Orofino, population about 3,000, after receiving hundreds of responses to an ad he had placed in the local paper to gauge interest.

“It was overwhelming,” he said. “That kind of cemented the idea that we should do it.”

In Montana, Mike Matovich, a third-generation pharmacist, opened stores in Roundup and Hardin after Shopko closures there.

“It’s a pretty good-sized community and has a hospital and clinic in town,” Matovich said of Roundup, “and all of a sudden people are driving 50 miles one way to fill an antibiotic for a sick child.”

Matovich has seen what can happen when a rural community loses its only pharmacy.

“If there’s a hospital clinic and a pharmacy there, they’re going to do fairly well,” Matovich said. “Once you lose one or the other, the communities start to struggle because people start leaving to be closer to health care.”

For the residents of Greenfield, Iowa, Shopko’s decision meant they had to scramble. Shopko had sold the pharmacy records to a Walgreens 50 miles away. Some people turned to the Hy-Vee grocery stores in the nearby Iowa cities of Atlantic or Winterset, or to the Walmart in Creston — each at least a half-hour drive away. Others switched to mail order.

“It was sheer chaos,” former Shopko pharmacist Rachel Hall said. “People were trying to figure out what to do, where they should send their prescriptions.”

Mather, Hall and the rest of the Greenfield staff were given just one week’s notice after being told they had nothing to worry about. Their pharmacy had been among the chain’s fastest-growing locations.

“We literally had trophies from Shopko that we threw away when we left,” Hall said.

Former Shopko executives contacted by KHN declined interview requests. Shopko Optical, which operates in 11 states, said it is no longer affiliated in any way with Shopko Stores and declined to comment.

Mather and Hall didn’t want to give up on Greenfield. They reached out to NuCara, a chain with 30 retail pharmacies across five states, and it agreed to help them open a drugstore in their city.

NuCara opened pharmacies in two other communities that Shopko vacated. In the Minnesota cities of Cokato and North Branch, NuCara partnered with pharmacists who had previously sold their pharmacies to Shopko, said Brett Barker, vice president of pharmacies for NuCara.

In Greenfield, Hall and Mather were forbidden from telling customers about the new NuCara drugstore until Shopko officially closed its doors. Hall said Shopko management wanted to maintain the value of the customer files it was selling to Walgreens. So Hall and Mather asked the local chamber of commerce to get the word out.

They found temporary space at the local hospital, which relocated its billing office to accommodate them. A year later, they moved back into their former location in the old Shopko building, leasing the space from new owners, who were running a household goods store there.

After serving three generations of Greenfield customers, Mather was relieved the town still had a pharmacy. But he couldn’t get past how Shopko had ended things.

“The way they slammed the door, I was really unhappy about that,” Mather said. “It wasn’t fair to all the people at the Greenfield pharmacy and the people of Greenfield. Shopko couldn’t have cared less.”

Yet the move brought Mather full circle. Greenfield still has a pharmacy, just as when he started at Murdy Drug in 1968. It’s just a different storefront, with a new name on the sign.

As Hospitals Fill Up, Paramedics Spend More Time Moving Patients, Less on Emergencies

KFF Health News, December 17, 2021

In recent years, interfacility transports or transfers, also known as IFTs, have become increasingly common for GVH Paramedics, forcing the team to drive far outside its already vast zone.

This article was published December 17, 2021, by Kaiser Health News.

By Helen Santoro

GUNNISON, Colo. — The night after Thanksgiving, a small ambulance service that covers a huge swath of southwestern Colorado got a call that a patient needed an emergency transfer from the hospital in Gunnison to a larger one with an intensive care unit 65 miles away in Montrose.

The patient — a 78-year-old man — was experiencing atrial fibrillation, an irregular heartbeat that usually isn’t life-threatening. But for patients like this one with chronic health conditions, a history of cardiac issues and high blood pressure, the condition can cause a stroke or heart failure.

Workers from Gunnison Valley Health Paramedics rolled the patient, who was on a gurney, out of the hospital and into the frigid night air. AnnieGrace Haddorff, the emergency medical technician on call, helped load the patient into the ambulance and jumped into the driver’s seat. Paramedic Alec Newby got into the back and hooked the patient up to a blood pressure cuff; a pulse oximeter, which measures heart rate and blood oxygen saturation; and an electrocardiogram, which records the heart’s electrical activity.

“Your heart is obviously pissed off,” Newby told the man as the ECG confirmed the atrial fibrillation.

The ambulance pulled onto U.S. Highway 50 for the one-hour-and-15-minute drive past clusters of homes among rolling hills of sagebrush, the expansive Blue Mesa Reservoir and the gaping Black Canyon of the Gunnison, with its craggy spires.

The patient was stable enough for the long drive, which covered only a sliver of GVH Paramedics’ 4,400-square-mile service area. It is more than twice the size of Delaware and is the largest response zone for an ambulance service in all of Colorado. A typical fire or emergency medical service response area ranges from 100 to 400 square miles.

In recent years, interfacility transports or transfers, also known as IFTs, like this one have become increasingly common for GVH Paramedics, forcing the team to drive far outside its already vast zone. Before the pandemic, the number of transfers rose because the population of Gunnison County was steadily increasing, more tourists were being drawn to places like the popular Crested Butte ski resort, and GVH Paramedics had expanded its services to larger metropolitan hospitals outside Gunnison County.

But now the team is being called to move patients more frequently, and greater distances, because the hospital beds in the relatively close cities of Montrose and Grand Junction are filled with covid-19 patients. The team is regularly required to drive patients to Denver, which is around three hours and 40 minutes from Gunnison.

Officials from the ambulance service worry that they might find themselves unable to respond to an emergency because their resources, which include six ambulances but only enough staff to operate three of those vehicles, are tied up on a long-haul transfer.

What were once 2½- or three-hour trips to Montrose are now far longer excursions, “and that takes resources from this community,” said CJ Malcolm, chief of emergency services. “We were doing that pre-covid, but now the state is so impacted, it’s like a daily part of our lives.”

Before the pandemic, all the ambulances would be simultaneously out on 911 calls or IFTs less than 10 times a year. Now, Malcolm said, it is happening with greater frequency. In those cases, GVH Paramedics leans on the emergency response team in Crested Butte, about 28 miles from Gunnison, or the response to the patient is delayed.

In 2018, GVH Paramedics made 166 IFTs, requiring nearly 40,000 miles of travel and a total of 987 hours of ambulance operation, according to data collected by the team. Last year concluded with 260 IFTs, over 70,000 miles of travel and a total of 1,486 hours of ambulance operation. That’s a 50% increase in time on the road.

“Anytime we have one or two ambulances out on an IFT, this leaves a massive tract of land with only one ambulance to respond,” Malcolm said. “This is a moderately terrifying position to be put into when we can easily have two or three 911 calls in a row.”

In August, for example, Gunnison Valley Health hospital transferred more than 60 patients, 37 of whom were transported by GVH Paramedics. That means that at least once a day that month, a GVH Paramedics crew was taking a patient out of town, Malcolm said. And if crew members aren’t scheduled to be back in Gunnison by 1 a.m., they must spend the night in a hotel to avoid driving along treacherous mountain roads while overly tired.

GVH Paramedics’ service area covers almost all of Gunnison County, a large portion of Saguache County and sections of Montrose and Hinsdale counties. It contains mountain ranges, canyons and wide expanses of high desert. With around 6,600 full-time residents and a university, Gunnison is the largest town the team serves. The surrounding towns — including Tin Cup, Pitkin and Ohio City — are villages with a couple of hundred people or former mining towns where the artifacts from the boom times outnumber the residents.

GVH Paramedics’ 21 full-time staff members and 10 to 20 individuals who work as needed have certifications in wildland firefighting and backcountry medicine skills, including swift-water, ice and avalanche rescue. To deal with the increased demands from IFTs, they have added an extra staff member to each shift, and off-duty staffers are being called in to assist.

As the pandemic drags on, the number of IFTs will probably continue to increase. By mid-November, the number of people in the hospital with covid-19 in Colorado was staggeringly high, approaching the December 2020 peak of 1,847. Hospitalizations remained above 1,500 through the end of the month. As a result, 93% of the state’s acute care hospital beds and 94% of ICU beds were being used as of Nov. 30, according to data from the Colorado Department of Public Health and Environment.

“I don’t think we see the capacity concerns easing anytime soon,” said Cara Welch, senior director of communications at the Colorado Hospital Association.

Adding to the strain are people seeking care they delayed because of the pandemic and other respiratory viruses, such as respiratory syncytial virus, circulating in the state, Welch said.

Kelly Thompson, chief of operations of CareFlight of the Rockies, an air ambulance service that operates in Colorado and other parts of the West, agreed with this assessment. “We’ve already been transporting large numbers of kids with RSV that are sick, and you have covid on top of all of this,” Thompson said. “It’s a big concern. This is the time when we have a lot of sick people.”

In early November, to manage escalating concerns about hospital capacity, Colorado hospitals and health systems activated tier 3 of the state's patient transfer system — the highest level. That means covid and non-covid patients can be moved without their consent from a hospital that doesn’t have enough capacity to one with more space. Hospitals can also send sicker patients to medical centers with more specialized care.

As the GVH Paramedics crew members approached Montrose with their patient over the recent holiday weekend, Newby called the hospital to let the staff know they were arriving. They pulled up to the emergency room entrance, and Newby and Haddorff rolled the patient into a hospital room. The Montrose hospital staff took over, moving the patient from the gurney to a hospital bed as Newby updated them on the patient’s medical records.

Soon they were back in the ambulance, headed for home. “IFTs can be stressful,” said Haddorff as she maneuvered the twisty mountain road bathed in moonlight.

Seeking Refills: Aging Pharmacists Leave Drugstores Vacant in Rural America

KFF Health News, December 17, 2021

Pharmacies were once routinely bequeathed from one generation to the next, but, in interviews with more than a dozen pharmacists, many said the pressure of running an independent drugstore have them pushing their offspring toward other careers.

This article was published December 17, 2021, by Kaiser Health News.

By Markian Hawryluk

Ted Billinger Jr. liked to joke that he would work until he died. That turned out to be prophetic.

When Billinger died of a heart attack in 2019 at age 71, he was still running Teddy B’s, the pharmacy his father had started more than 65 years earlier in Cheyenne Wells, Colorado. With no other pharmacist to work at the store, prescriptions already counted out and sealed in bottles were suddenly locked away in a pharmacy that no one could enter. And Cheyenne Wells’ fewer than 800 residents were abruptly left without a drugstore.

Pharmacies were once routinely bequeathed from one generation to the next, but, in interviews with more than a dozen pharmacists, many said the pressure of running an independent drugstore have them pushing their offspring toward other careers. And when they search for a buyer, they often find that attracting new pharmacists, especially to rural settings, is difficult. With a large group of pharmacists nearing retirement age, more communities may lose their only drugstore.

“It’s going to be harder to attract people and to pay them,” said David Kreling, a professor emeritus at the University of Wisconsin-Madison School of Pharmacy. “If there’s not a generational thing where someone can sit down with their son or daughter and say that they could take the store over, there’s a good chance that pharmacy will evaporate.”

Tom Davis, Billinger’s friend and co-owner of Kiowa Drug in Eads, Colorado, stepped in to sort out the mess in Cheyenne Wells. With permission from the State Board of Pharmacy, the county sheriff let Davis into Teddy B’s in the eastern Colorado town to take an inventory of the remaining drugs. Customers who had dropped off their prescriptions before Billinger died were able to pick up their medications.

Davis then bought the pharmacy from Billinger’s estate. He runs it as a convenience store and six days a week delivers prescriptions to it from Eads, 44 miles away.

“By the time you paid a pharmacist, the location there was borderline unprofitable,” Davis said.

He has received numerous requests to open pharmacies in other eastern Colorado towns, but making that work financially would be difficult. Reimbursements from insurance plans have dwindled, and customer bases have eroded as health insurers push patients toward mail-order deliveries.

“I fill prescriptions every day where my reimbursement is less than the cost of the drug,” Davis said. “In other settings, you might tell a patient, ‘We don’t have that in stock,’ or ‘Why don’t you go down the street to the chain?’ But down here, we just take care of our patients, and we just eat it.”

He can survive, he said, because, after 48 years, he no longer has any business debt.

“I look at my bottom line,” Davis said. “With the amount of profit that I had at the end of the year, that would not have been enough if I was having to pay a mortgage.”

Studies have found the number of pharmacists nationally to be sufficient, even more than enough, to meet current needs, although supply and demand don’t always line up. Finding pharmacists is more difficult in rural areas.

“Once they get a taste of the big city,” Kreling said, “it’s hard to get them back to the farm.”

Workforce data also shows worrisome trends. Concerns about a shortage of pharmacists led the federal government to pour money into pharmacy schools in the 1970s, creating a temporary bump in the number of graduates. The people in that bulge in the pharmacist pipeline have hit retirement age.

“Many of them owned independent pharmacies, and they were working in rural communities,” said University of Minnesota pharmacy professor Jon Schommer, who studies workforce issues.

Now, as the demand for pharmacists to provide testing and vaccinations during the covid-19 pandemic increases, drugstore chains are offering incentives — such as large salaries, signing bonuses and help paying off school loans — that are often more enticing than anything a rural pharmacy could muster.

How pharmacy graduates envision their careers has also shifted. Many no longer want to own a pharmacy and are content to work at pharmacy chains or other health care organizations, according to several pharmacy school professors. As of 2018, only about half of pharmacists worked in traditional retail drugstores.

That makes rural recruitment more difficult.

Denise Robins had worked at R&R Family Pharmacy in Springfield, Colorado, for 18 years when the owner retired. She and three family members bought the drugstore in a last-ditch effort to keep it open.

“None of us are pharmacists, so that made it a little tougher,” Robins said. “We just knew it was really going to make it hard for people here if they had to travel an hour to get to a pharmacy.”

But finding a pharmacist to work in the southeastern Colorado town of fewer than 1,400 people was a challenge. The first pharmacist Robins found commuted 48 miles one way from Lamar. But after a year and a half, the trip became too much.

She then hired someone who wanted to work for only a year, to make enough money to travel. Then Robins interviewed two University of Colorado pharmacy school graduates. She hired one, but that didn’t work out. So she called back the second candidate, who still had not found a permanent job. He had two young kids, and he and his wife were working opposite schedules. He took the job two years ago and has remained there since.

In Berryville, Virginia, pharmacist Patricia White opened Battletown Pharmacy in 2011 because she wanted to carry on the family business. Her father had owned a local pharmacy and had recently died. But when turning a profit with Battletown proved a struggle, White decided to retire.

She lined up two potential buyers, but neither went through with the sale. She then hoped to transfer the pharmacy to a recent graduate but didn’t want to saddle him with a failing business.

“I told him he couldn’t make any money, and he said, ‘Thanks for being honest,’” White recalled.

Closing seemed like the only palatable option. Battletown shut down at the end of August. “I did not want to sell out to a chain,” she said. “That’s always been my mentality.”

When a chain buys a pharmacy, it doesn’t always decide to run it. Instead, it might close the pharmacy and transfer the pharmacy’s prescription files to one of its outlets. Retiring pharmacists who spent decades serving a community generally don’t want to see that happen, said David Zgarrick, a Northeastern University pharmacy professor.

“They’d like to sell their pharmacy to another pharmacist who would continue to run it very much in the same manner,” he said.

Some plan ahead, hiring another pharmacist and offering that person an equity stake in the business. Over time, the new pharmacist can buy out the owner. Many independent pharmacist-owners plan to live off the profits from selling their pharmacy, its inventory and its prescription records.

“Their pharmacy is their retirement savings,” Zgarrick said.

But, Zgarrick said, the added pressure from the pandemic may be pushing more pharmacists into retirement. And a long-running bull stock market may mean some pharmacists have enough in their retirement portfolios to call it quits without a sale.

In Eads, Davis, 70, still loves being a pharmacist. He and his brother co-own seven pharmacies and have started to plan for retirement by hiring five young pharmacists and allowing them to buy ownership stakes in those pharmacies over time.

He had wondered how long he could keep the Kiowa pharmacy running, though. With fewer than 700 residents, Eads may be the smallest town in Colorado with a pharmacy. Combining Davis’ customer base with Cheyenne Wells’ may have saved pharmacy access for both communities.

“So maybe where we could have lost two pharmacies in the area, we’ve been able to exist. We’re stronger now than we had ever been,” Davis said. “That wasn’t the original plan. We cared about those people and just wanted to take care of them.”

'The Charges Seem Crazy': Hospitals Impose a 'Facility Fee' — For a Video Visit

KFF Health News, December 17, 2021

Hospitals say the fees, which can add hundreds of dollars or even more than $1,000 to a patient’s bill, are necessary to cover the high cost of keeping a hospital open and ready to provide care 24/7.

This article was published December 17, 2021, by Kaiser Health News.

By Michelle Andrews

When Arielle Harrison’s 9-year-old needed to see a pediatric specialist at Yale New Haven Health System in June, a telehealth visit seemed like a great option. Since her son wasn’t yet eligible to be vaccinated against covid-19, they could connect with the doctor via video and avoid venturing into a germy medical facility.

Days before the appointment, she got a notice from the hospital informing her that she would receive two bills for the visit. One would be for the doctor’s services. The second would be for a hospital facility fee, even though she and her son would be at home in Cheshire, Connecticut, and never set foot in any hospital-affiliated building.

Harrison, 40, who works in nonprofit communications, posted on Twitter about the unwelcome fee, including an image of Marge Simpson of TV’s The Simpsons with a disgusted look on her face, captioned “GROANS.”

She called the billing office the next morning and was told the facility fee is based on where the doctor is located. Since the doctor would be on hospital property, the hospital would charge a facility fee of between $50 and $350, depending on her insurance coverage.

“It’s just one of many examples of how this is a very difficult system to use,” Harrison said, referring to the intricacies of U.S. health care.

Hospital facility fees  have long come under criticism from patients and consumer advocates. Hospitals say the fees, which can add hundreds of dollars or even more than $1,000 to a patient’s bill, are necessary to cover the high cost of keeping a hospital open and ready to provide care 24/7.

But it’s not only hospital visits that result in facility fees. Over the past several years, hospitals have been on a buying binge, snapping up physician practices that often then begin charging the fees, too. Patients seeing the same doctor for the same care as at earlier visits are now on the hook for the extra fee — because of a change in ownership.

Charging a facility fee for a video visit where the patient logs in from their living room is even more of a head-scratcher.

“The charges seem crazy,” said Ted Doolittle, who heads up Connecticut’s Office of the Healthcare Advocate, which provides help to consumers with health coverage issues. “It rankles, and it should.”

Facility fees for video appointments remain rare, health finance experts say, even as the use of telehealth has soared during the covid pandemic. Medicare has allowed hospitals to assess a small fee for certain beneficiaries who get telehealth care at home during the ongoing national public health emergency, and people in private health plans may also be charged for them.

Harrison, however, was lucky. Doolittle reached out to her after seeing her tweet to offer his office’s assistance. In Connecticut, hospitals are prohibited from charging facility fees for telehealth visits.

Connecticut imposed what may be the only state ban on telehealth facility fees as part of a broader law passed in May that was intended to help residents access telehealth during the pandemic. The prohibition on facility fees sunsets at the end of June 2023.

Pat McCabe, senior vice president of finance at Yale New Haven Health System, said he can’t explain why Harrison received a notice that she’d be charged a facility fee for a telehealth visit. He speculated that her son’s appointment might have been coded incorrectly. Under the new law, he said, the health system hasn’t charged any telehealth patients a facility fee.

But such fees are justified, McCabe said.

“It offsets the cost of the software we use to facilitate the telehealth visits, and we do still have to keep the lights on,” he said, noting that the providers doing telehealth visits are on hospital sites that incur heat and power and maintenance charges.

The American Hospital Association didn’t respond to requests for comment about the rationale for facility fees for telehealth care.

As the pandemic began overwhelming the health system last year, hospitals essentially closed their doors to most non-covid patients.

Telehealth visits, which made up about 1% of medical visits before the pandemic, jumped to roughly 50% at its height last year, said Kyle Zebley, vice president of public policy at the nonprofit American Telemedicine Association, which promotes this type of care. Those appointments have dropped off and now make up roughly 15% of medical visits across all types of coverage.

Before the pandemic, the Centers for Medicare & Medicaid Services severely limited telehealth coverage for Medicare fee-for-service beneficiaries. But with seniors more vulnerable during the pandemic, the agency loosened telehealth rules temporarily. As long as the public health emergency continues, the agency is allowing Medicare beneficiaries in urban areas to receive such care, which was previously covered only in rural areas. And patients can get telehealth care at home rather than having to go to a medical facility for the video appointment, as was previously required. The agency also beefed up covered telehealth services and expanded the types of providers who are allowed to offer them.

Medicare lets hospital outpatient departments bill about $27 for telehealth visits for certain beneficiaries receiving care at home. Patients are generally responsible for 20% of that amount, or about $5, although providers can waive patient cost sharing for telehealth, said Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF.

At the beginning of the pandemic, patients with commercial health plans were often not charged a copay for telehealth visits, said Rick Gundling, a senior vice president at the Healthcare Financial Management Association, a membership group for health care finance professionals. But lately, “those fees have been coming back,” he said.

Facility fees for telehealth visits in commercial plans averaged $55 for the year that ended June 30, before insurance discounts, according to data from Fair Health, a national independent nonprofit that maintains a large database of insurance claims. In 2020, just 1.1% of commercial telehealth claims included a facility fee, according to Fair Health. That’s lower than for 2019, when the figure was 2.5%.

Experts predict telehealth will remain popular, but it’s unclear how those visits and any accompanying facility fees will be handled in the future.

McCabe said he expects the Yale New Haven Health System to reinstitute the facility fees when state law permits it.

“There are real costs in the health system to provide those services,” he said.

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