Critics of the Medicare Advantage program have long argued that the government is too generous in paying the private plans.

This article was published on Thursday, October 28, 2021 in Kaiser Health News.

By Michelle Andrews  

"Did you think we wouldn't notice?" an older woman says, speaking into the camera. "You thought you could sneak this through?" an older man later adds. Others warn that Washington is "messing with" their Medicare Advantage health coverage and trying to raise their premiums.

But the television ad, paid for by Better Medicare Alliance, a research and advocacy group for Medicare Advantage plans, doesn't spell out what cuts congressional lawmakers might be trying to slip past unsuspecting seniors.

Concerned that viewers could be confused and alarmed about coverage changes, we asked the Better Medicare Alliance for specifics about the sneaky moves the organization aims to alert people to. It's not just one ad. The organization has launched a $3 million TV, radio and online advertising campaign, according to advertising tracker AdImpact.

In response, the group offered this emailed comment from its president and CEO, Mary Beth Donahue.

"Better Medicare Alliance is airing messages encouraging Congress to guard against cuts to seniors' Medicare Advantage coverage, whether through benchmark policies in the reconciliation bill or other avenues."

While still light on specifics, Donahue's comment offered an important detail not mentioned in the ad. The group is concerned about coverage cutbacks through "benchmark policies in the reconciliation bill."

Now we were getting somewhere. In the Democrats' climate and social-spending bill being hammered out in Congress, one key healthcare proposal would add dental, hearing and vision coverage to the traditional Medicare program.

The provision, championed by Sen. Bernie Sanders (I-Vt.), is estimated to cost $350 billion over 10 years. As Democrats have labored to winnow their $3.5 trillion social-spending bill to make it palatable to moderates in the party, it's unclear whether the Medicare benefits expansion will make it into the final version.

Assuming it does, here's where benchmark calculations, and presumably the Better Medicare Alliance's concerns, come into play.

Traditional Medicare vs. Medicare Advantage

First, some background. Most Medicare beneficiaries are in the so-called traditional Medicare program, in which members generally pay 20% of the cost of medical services after meeting a deductible. A separate plan covers prescription drugs. Enrollees can visit any doctor, hospital or other medical provider participating in the program, the vast majority of whom do nationwide. Many beneficiaries buy supplemental Medigap policies that cover their cost-sharing obligations and fill in other financial gaps.

However, a growing number of Medicare beneficiaries — more than 26 million, or 42% of Medicare enrollees — are in Medicare Advantage plans. Cost sharing is generally lower in these private-sector managed-care plans than in traditional Medicare, but the networks of doctors and hospitals are smaller, too. Many Medicare Advantage plans offer supplemental benefits such as dental, vision and hearing coverage, although the level of coverage varies widely.

"Traditional Medicare is a lousy program, and that's why Medicare Advantage has really taken off over the last five or 10 years," said Joseph Antos, a senior fellow at the American Enterprise Institute. "Medicare Advantage looks like the coverage you used to have [before joining Medicare] and there [isn't] confusing cost sharing that most people don't understand. Whereas with traditional Medicare, there are different deductibles and holes in coverage."

The Benchmark

The federal Medicare program pays Medicare Advantage plans a set amount per member. Medicare Advantage health plans submit bids annually to federal officials that reflect how much they estimate it will cost to provide a package of benefits covering hospitalization (Medicare Part A) and outpatient services (Medicare Part B) to enrollees. Those bids are compared against a "benchmark," which is based on the average spending per beneficiary in the traditional Medicare program, with geographic adjustments.

Plans that bid below the benchmark, as most do, receive a rebate they can use to reduce beneficiary cost sharing, subsidize premiums or pay for supplemental benefits like dental, vision and hearing.

The Benchmark Controversy

Groups like the Better Medicare Alliance say they support providing dental, hearing and vision coverage to all Medicare beneficiaries. But they're worried that congressional leaders won't factor the cost of new traditional Medicare benefits into the benchmark, resulting in lower rebates from the program, which could threaten other supplemental benefits that Medicare Advantage members enjoy, such as meals and transportation services, gym memberships and in-home care.

It's not evident that lawmakers are considering excluding the benefit from the benchmark, however.

"I feel like this is the industry flexing its muscles and sending loud signals, but it's not clear that Congress has any intention to modify payments as part of this legislation," said Tricia Neuman, executive director of the program on Medicare policy at KFF.

Still, excluding the new benefits from the Medicare benchmark has generated interest as one way to pay for the pricey new benefits. According to one analysis, excluding the cost of the new benefits from the benchmark would reduce the fiscal cost by an estimated 41%, compared with a scenario that included the cost in the benchmark.

"This is because federal payments to [Medicare Advantage] plans would rise only modestly if the benchmarks excluded the new benefits, whereas they would rise substantially if the benchmarks included them," according to the analysis by Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy.

Since rebates would fall, Medicare Advantage plans would have less to spend on supplemental benefits. But dental, vision and hearing would no longer be considered supplemental and would need to be incorporated into plans' estimate of regular Medicare coverage costs, Fiedler noted.

That shift would mean that the rebate dollars that plans currently devote to dental, vision and hearing could be used for other supplemental benefits, which could shield those other benefits from substantial reductions, Fiedler said.

An analysis commissioned by AHIP, an industry group, estimated that incorporating a dental, vision and hearing benefit without adjusting the benchmark would have a substantial impact, resulting in a 48% decline in the national average rebate amount, or $58 per member per month.

No Sympathy

Critics of the Medicare Advantage program have long argued that the government is too generous in paying the private plans. When the Medicare program began incorporating private plans in the 1970s, part of the rationale was that the private plans could provide care more efficiently and save the program money. That hasn't happened. In a June report to Congress, the Medicare Payment Advisory Commission estimated that the government pays 4% more for beneficiaries enrolled in Medicare Advantage than for those in traditional Medicare.

MedPAC recommended a 2% reduction in capitated payments to Medicare Advantage plans.

In addition, in a September report, the Office of Inspector General for the Department of Health and Human Services found that 20 of 162 Medicare Advantage companies used patient chart reviews and health risk assessments to boost their payments disproportionately compared with their enrollment size.

Losing Their Competitive Advantage

A big selling point for Medicare Advantage plans has been that they provide coverage for valuable benefits that the traditional Medicare program does not. In 2021, 94% of Medicare Advantage enrollees in individual plans are in plans with some level of dental coverage, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

But "some" coverage doesn't necessarily mean comprehensive coverage. In a separate analysis, KFF found that Medicare beneficiaries faced high out-of-pocket costs for dental and hearing services, no matter what type of plan they had. In 2018, average out-of-pocket spending on dental care for traditional Medicare enrollees was $992. Medicare Advantage members spent modestly less out-of-pocket: $766.

In 2010, when the Affordable Care Act reduced Medicare Advantage plan payments to bring them in line with traditional Medicare, some in the industry predicted plans would pull out and benefits would be cut. That didn't happen.

"The truth is Medicare Advantage has grown rapidly since then and extra benefits have proliferated," Neuman said. So, if the payment methodology changes because of the addition of dental, hearing and vision benefits, "it's hard to say what would really happen."

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

A quick exam to evaluate labor in a small triage room can generate substantial charges.

This article was published on Wednesday, October 27, 2021 in Kaiser Health News.

By Rae Ellen Bichell

Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn't prepare her for the resources the conservation biologist would owe after the birth of her second son.

Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colorado, because it was the only entrance open.

Despite the weird COVID vibe — the emptiness, the quiet — everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse offering to wheel her to the labor and delivery department. She even took a selfie, smiling, as she entered the delivery room.

"I was just thrilled that he was here and it was on his due date, so we didn't have to have an induction," she said. "I was doing great."

Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.

Wells Salerno expected the bill for Gus' birth to be heftier than that for her first child, Hank, which had cost the family a mere $30. She was a postdoctoral fellow in California with top-notch insurance when Hank was born, about four years earlier. They were braced to pay more for Gus, but how much more?

Then the bill came.

The Patient: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.

Medical Service: A routine vaginal delivery of a full-term infant.

Total Bill: $16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.

Service Provider: Poudre Valley Hospital in Fort Collins, Colorado, operated by UCHealth, a nonprofit health system.

What Gives: In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.

The total bill was huge, but what really made Wells Salerno's eyes pop was a line for the highest level of emergency services. It didn't make any sense. Was it for checking in at the ER desk, as she'd been instructed to? She recalls going through security there on her way to labor and delivery, yet there was a $2,755 charge for "Level 5" emergency department services — as if she had received care there like a patient with a heart attack or fresh from a car wreck. It is the biggest item on the bill other than the delivery itself.

Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California-San Francisco and a practicing ER doctor, said Level 5 charges are supposed to be reserved for serious cases — "a severe threat to life, or very complicated, resource-intense cases" — not for patients who can walk through a hospital on their own. Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required.

But over the past 20 years, hospitals and doctors have learned there's great profit in upcoding visits. After all, the insurer isn't in the exam room to know what transpired. An investigation by the Center for Public Integrity found that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent homefrom the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5 steadily grew from 23% to 34% for patients with commercial insurance.

After repeated calls questioning the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with KHN, explaining that "the emergency room charge is actually the OB triage little area before they take you to the labor and delivery room." 

A customer service representative later explained it was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken — although none of that was performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately — and are routine, not emergency, procedures.

Some hospitals provide that package of services via an "obstetrical emergency department." OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they aren't physically located anywhere near the ER.

Health care staffing company TeamHealth — owned by the investment company Blackstone, and known for marking up ER bills to boost profit — essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In a white paper, the company said an OB-ED is an "entrepreneurial approach to strengthening hospital finances" because with "little to no structural investment" it allows hospitals to "collect facility charges that are otherwise lost in the obstetrical triage setting."

The OB Hospitalist Group, which is owned by a private equity company, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitals "leave a lot of money on the table" by billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.

An Arizona facility said its revenue increased $365,000 per quarter after turning their obstetric triage area into an OB-ED. Poudre Valley Hospital's website doesn't list "OB-ED" as part of the facility's offerings, though UCHealth documents do reference OB-ED beds in other facilities.

KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other area moms after getting a whopping charge — for the 10 minutes she spent in the triage room, while fully dilated and in active labor.

In Wells Salerno's case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. "Being seen there in OB-ED did not impact this bill whatsoever," said Dan Weaver, a spokesperson with UCHealth.

But in one of the other moms' cases, it did: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.

Ge Bai, a professor of accounting and health policy at Johns Hopkins University, said it's a "questionable" billing practice, and one that can matter to those who don't have the same kind of insurance as Wells Salerno, or have none at all.

Dr. Mark Simon, chief medical officer with OB Hospitalist Group, said OB-EDs can help women avoid being admitted to the hospital too early in labor, ensuring timelier, more appropriate care.

UCHealth's Weaver said they can also help pregnant patients with actual emergencies like preterm labor, preeclampsia or vaginal bleeding get quick care from specialists available 24/7, often without having to be admitted to the hospital. But at hospitals like Poudre Valley, healthy women having healthy births also get routine "OB-ED" treatment, without their knowledge.

Weaver said the only time someone in labor would not go through the OB-ED — and therefore the only time they would not receive the emergency charge — is if they have a scheduled induction or cesarean section or are directly admitted from a provider's office.

Hsia, the UCSF researcher and ER doctor, is unconvinced: "If they're actually going to charge a special fee that you didn't get directly admitted from your physician, that's absolutely ridiculous."

Wells Salerno's "OB-ED" exam was performed by her clinician, but the OB-ED charge still showed up on her bill.

Resolution: After trying to determine that the charge wasn't a mistake, Wells Salerno eventually threw in the towel and paid the bill.

"I was at a very vulnerable time during pregnancy and immediately postpartum," she said. "I just felt like I had kind of been taken advantage of financially at a time when I couldn't muster the energy to fight back."

The fact that two healthy brothers could come with such different price tags isn't surprising to Dr. Michelle Moniz. "There is no clinical reason that we have this level of variation," said Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Her research shows that people with private insurance pay anywhere from nothing to $10,000 for childbirth.

"You don't get what you pay for," said Wells Salerno, who maintains that — despite their price difference — both of her children are equally "awesome."

Data from the Colorado Division of Insurance shows that Poudre Valley typically received about $12,000 for similar births in 2020, about 43% more than the typical Colorado hospital. So the more than $14,000 Wells Salerno and her insurer paid is very high.

The Takeaway: Anything in our health system labeled as an emergency room service likely comes with a big additional charge.

Expectant parents should be aware that OB-EDs are a relatively new feature at some hospitals. Ask whether your hospital has that kind of charge and how it will affect your bill. Ahead of time, ask both the hospital and your insurer how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a price comparison tool for common medical procedures, including vaginal delivery.

If you do require a genuine ER encounter, look at your bill to see how it was coded, Levels 1 to 5 — and protest if your visit was misrepresented. Ask, "Has this bill been upcoded?" You are the only one who knows how much time you spent with a medical provider and how much care was given. Here's a chart that will help with the proper definition of each level.

Know that victory is possible. At least one mom won the battle and got the emergency charge removed from her Poudre Valley Hospital birth bill. It took hours on the phone with UCHealth, a lot of confidence and countless repetitions of the birth story — and how an emergency charge for a routine delivery just didn't, and doesn't, make sense.

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

Rae Ellen Bichell: rbichell@kff.org, @raelnb

Granting Medicare broad authority to intervene in setting prices has divided Democrats.

This article was published on Wednesday, October 27, 2021 in Kaiser Health News.

By Victoria Knight and Rachana Pradhan and Elizabeth Lucas  

The Biden administration and Congress are embroiled in high-stakes haggling over what urgent priorities will make it into the ever-shrinking social spending bill. But for the pharmaceutical industry there is one agenda: Heading off Medicare drug price negotiation, which it considers an existential threat to its business model.

The siren call to contain rising drug costs helped catapult Democrats to power, and the idea is popular among voters regardless of their politics. Yet granting Medicare broad authority to intervene in setting prices has nonetheless divided the party.

And so, as it normally does, the drug industry gave generously to members of Congress, according to new data from KHN's Pharma Cash to Congress database. Contributions covering the first half of this year show that some of its biggest donations were delivered with surgical-strike precision to sympathetic or moderate Democratic lawmakers the industry needs to remain in its corner.

Campaign donations to members of Congress — which must be reported to the Federal Election Commission — are the tip of the iceberg, signaling far greater activity in influence peddling that includes spending millions on lobbying activities and advertising campaigns.

Unusually, in the first half of this year Republicans and Democrats in Congress were virtually neck and neck in pulling in drug industry money, according to a KHN analysis of campaign contributions. In prior years, Republicans dominated giving from that sector, often by huge margins.

Pharmaceutical companies and their lobbying groups gave roughly $1.6 million to lawmakers during the first six months of 2021, with Republicans accepting $785,000 and Democrats $776,200, the Pharma Cash to Congress database shows. Since the 2008 cycle, the industry has generally favored Republicans. The exception was 2009-10, the last time Democrats controlled both chambers of Congress and the White House.

Democrats again narrowly hold both the House and Senate, and political scientists and other money-in-politics experts said the contributions likely reflect who is in power, which lawmakers face tougher reelection bids next year, and who has outsize sway over legislation affecting the industry's bottom line.

Several pharmaceutical companies paused contributions to Republican lawmakers who voted against certifying the results of the 2020 election, blunting the GOP's total fundraising haul and overall industry giving compared with other years.

The drug industry's campaign contributions are markedly strategic, said Steven Billet, an associate professor at the Graduate School of Political Management at George Washington University.

"This is a really well-organized commercial sector," Billet said. "If I'm one of these PACs, I've surveyed the landscape at the front end of the process, decided on our agenda and budget, and figured out who I may be able to get to and who I wouldn't be able to get to."

Of the top 10 recipients of funding, Republican lawmakers accounted for six; Democrats, four. Rep. Scott Peters (D-Calif.) received the most money of any member of Congress, with $63,900 in contributions in the first half of the year. Peters, whose San Diego-area district includes multiple drug companies, has consistently accepted money from drugmakers since he took office in 2013, according to KHN's database. Right behind Peters was Rep. Cathy McMorris Rodgers (R-Wash.), who received $50,000 from the industry in the first six months of 2021. McMorris Rodgers was chosen this year to be the most senior Republican on the House Energy and Commerce Committee, which has significant influence on pharmaceutical issues. Peters sits on the same committee.

"They're typically going to saturate the committees that are relevant to their industry," said Nick Penniman, CEO of Issue One, a nonprofit that advocates reforming money's influence in politics.

Next in line was Sen. Robert Menendez (D-N.J.), who accepted $49,300, the most of any senator this year despite not facing reelection until 2024. The vote of Menendez, a longtime ally of the industry, would be crucial for Democrats to pass any proposal giving the government greater control over drug prices. The pharmaceutical industry is a major employer in New Jersey, home to headquarters of behemoths like Johnson & Johnson, Merck, Novo Nordisk and Sanofi.

Menendez said he's waiting to see the proposal, "which I expect will include language to allow Medicare to negotiate drug prices."

"The focus of any proposal must be lowering patient costs," he said, "and that will drive my analysis."

Among other moderate Democrats is Sen. Kyrsten Sinema (D-Ariz.), whose vote also is critical to passage. She received $108,500 in pharma contributions in 2019-20, according to the KHN database. However, in the first half of this year, she received only $8,000. She has not said publicly where she stands on the current pricing proposal.

As Billet sees it, the pharmaceutical industry knew allowing Medicare to negotiate drug prices would likely be on the table, and drug companies shored up members, such as Peters and Menendez, who have sided with them in the past. Plus, "right now, the Democrats are driving the train, and because of that they're going to get a few more contributions," Billet added.

Peters received funds from nearly two dozen companies or industry groups, including Eli Lilly, Takeda Pharmaceutical, Pfizer, Merck, GlaxoSmithKline, EMD Serono and Amgen. Menendez's donors included Boehringer Ingelheim, Sanofi, Pfizer, Merck, Gilead Sciences, Eli Lilly, Teva and Novo Nordisk. A spokesperson for Peters did not respond to request for comment.

Controlling drug prices has broad support among adults regardless of political party, according to polling from KFF (KHN is an editorially independent program of KFF). But facing industry opposition, Democrats have yet to agree on a plan as lawmakers weigh which policies make it into a massive domestic spending bill to expand the social safety net and address climate change. Central to the industry's argument is that greater government intervention in setting prices would harm new drug development; however, drug pricing experts generally say this argument is overblown. Republicans remain unanimously opposed, which means Senate Democrats can't afford any defections to advance legislation.

Fourth in industry contributions was Sen. Catherine Cortez Masto (D-Nev.), a freshman lawmaker on the powerful Senate Finance Committee, which oversees legislation pertaining to federal health programs like Medicare. Cortez Masto received $46,000, with cash flowing in from companies like Eli Lilly, Merck, Pfizer, Johnson & Johnson and Mallinckrodt Pharmaceuticals, the latter of which filed for bankruptcy in 2020 after being swamped with litigation over its alleged role in the opioid crisis. One of her recent aides, Eben DuRoss, was hired as a lobbyist this year by the Pharmaceutical Research and Manufacturers of America, or PhRMA, federal disclosures show.

Cortez Masto is up for reelection next year in a battleground state that's been competitive between Republicans and Democrats in recent elections. She was narrowly elected in 2016, and recent polling showed she held a small lead against her expected Republican challenger in 2022, former Nevada attorney general Adam Laxalt.

But her contributions dwarf those of other Senate Democrats in close races. For example, in the first half of this year, Sen. Maggie Hassan (D-N.H.), who also sits on the Senate Finance Committee, reported having accepted $6,000.

Two other lawmakers in competitive seats, Sen. Raphael Warnock (D-Ga.) and Sen. Mark Kelly (D-Ariz.), didn't receive funding from the pharmaceutical sector.

Sarah Bryner, research director of OpenSecrets, a nonprofit that tracks money in politics, noted several reasons Cortez Masto would pull in more money. In addition to her committee seat and competitive race, politically she's more moderate than progressive lawmakers who have been bigger agitators against the drug industry.

"She's not seen as an extremist, which is the kind of person who would typically take in more money" from political action committees, Bryner said.

Cortez Masto was also a recent past chair of the Democratic Senatorial Campaign Committee and therefore heavily involved in the party's national fundraising efforts to preserve Democrats' Senate majority. Those relationships with corporate and other donors could be leveraged for her own race, Bryner said. "Once you've made all the relationships, it's not like they just disappear," she said.

Still, the freshman Democrat has openly supported allowing Medicare to negotiate prescription drug prices, in contrast to Menendez, who voted against the idea in 2019. The Nevada senator recently told KHN that she "absolutely" backs the policy and that the pharma cash flowing into her campaign coffers doesn't influence her decisions.

"I've already supported it in Finance and actually voted to pass legislation to do just that," Cortez Masto said. "We need to reduce the healthcare costs for so many in this country, and that's what I'm focused on doing, including reducing prescription drug costs."

Peters — who unseated a Republican in 2012 — was one of four moderate House Democrats who in September voted against a plan to give Medicare broad authority to negotiate prescription drug prices. They backed a narrower alternative that includes caps on out-of-pocket spending and limits the scope of Medicare's negotiating authority to a smaller set of medications.

The money Peters and McMorris Rodgers got from drugmakers ($63,900 and $50,000, respectively) significantly jumped from the same periods in past cycles. In the first half of 2019, Peters received $19,500, and during those same quarters in 2017 he got $36,000. McMorris Rodgers' haul for the first six months of 2019 was $2,500, and two years earlier it was $3,000. However, Menendez received more funding in the first half of 2019 ($52,000) than this year.

That some drugmakers — including Pfizer, Johnson & Johnson, Gilead and Eli Lilly — as well as PhRMA and the Biotechnology Innovation Organization, another lobbying group for the industry, paused contributions to Republicans after the events of Jan. 6 seems at least in part to account for overall pharma contributions dropping in comparison with other years. In the first half of 2019 drugmakers gave $3.7 million, and in the first half of 2017 they gave about $4.4 million, versus 2021's $1.6 million.

However, other drug company PACs and their industry groups kept up contributions or failed to void checks they'd issued to those who refused to certify the election results, according to a KHN analysis of the FEC data.

They include Merck, Novo Nordisk, GlaxoSmithKline, AstraZeneca, Genentech, Boehringer Ingelheim, Amgen, Teva, EMD Serono and the Association for Accessible Medicines, which all gave $1,000 or more to at least one of the 147 Republicans who voted to overturn the election results.

Direct contributions to lawmakers' political accounts are only one way for the industry to channel cash to Congress. Companies also give money to trade associations and 501(C)(4)s, which are nonprofits that often function as "dark money" groups because they are not required to disclose their donors.

"We know that they're giving; they didn't stop giving. Their giving went underground," said Carlos Holguin, research director for the Center for Political Accountability, a nonprofit that tracks money in politics.

Groups also funnel money into advertising — in September, PhRMA announced a seven-figure ad campaign opposing Democrats' drug pricing plan — or into advocacy groups from which it may eventually trickle down to political candidates.

Another factor? Hail Mary COVID-19 vaccines, developed and distributed in record time, that may have shored up goodwill with lawmakers. Or that, despite everything lawmakers have said about lowering drug costs, the industry suspects drug pricing legislation will stall once again and don't want to spend their political capital on the issue.

"I think, frankly, drugmakers know they've won the match when it comes to drug pricing. This whole question of the cost of pharmaceuticals, it has come up for literally decades now and they have successfully shut it down, year after year," Penniman said. "At a certain point, they know they have driven the nail far enough in the wood and they don't need to do much more."

Victoria Knight: vknight@kff.org, @victoriaregisk

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

Elizabeth Lucas: elucas@kff.org, @eklucas

The shortage of beds and mental health workers has collided with an increasing, pandemic-driven demand for mental health treatment.

This article was published on Tuesday, October 26, 2021 in Kaiser Health News.

By Andy Miller

Many patients dealing with mental health crises are having to wait several days in an ER until a bed becomes available at one of Georgia's five state psychiatric hospitals, as public facilities nationwide feel the pinch of the pandemic.

"We're in crisis mode,'' said Dr. John Sy, an emergency medicine physician in Savannah. "Two weeks ago, we were probably holding eight to 10 patients. Some of them had been there for days."

The shortage of beds in Georgia's state psychiatric facilities reflects a national trend linked to staffing deficits that are cramping services in the public mental health system. The bed capacity problem, which has existed for years, has worsened during the COVID-19 pandemic, creating backlogs of poor or uninsured patients as well as people in jails who are awaiting placement in state facilities.

Many state workers, such as nurses, are leaving those psychiatric units for much higher pay — with temp agencies or other employers — and less stressful conditions. The departures have limited the capacity of state-run psychiatric units for patients, who often are poor or uninsured, forcing some people with serious mental illness to languish in hospital emergency rooms or jails until beds open up in the state systems, according to local leaders of the National Alliance on Mental Illness.

"Such patients are sometimes strapped down or held in isolation, and often receive little or no mental health services," said Roland Behm, a board member of the Georgia chapter of the American Foundation for Suicide Prevention.

Nationally, the shortage of beds and mental health workers has collided with an increasing, pandemic-driven demand for mental health treatment.

"ERs have been flooded with patients needing psychiatric care," said Dr. Robert Trestman, chairperson of the American Psychiatric Association's Council on Healthcare Systems and Financing. "The current crisis is unprecedented in the extent, severity and sweep of its national impact."

Virginia has severely curtailed admissions to state mental hospitals because of staffing shortages amid increased demand for services. "I have never seen an entire system bottleneck this bad," said Kathy Harkey, executive director of the National Alliance on Mental Illness' Virginia chapter. The strain is spilling over into the private system, she added.

A Texas advisory committee reported in July that a near-record number of people were on the waitlist for state hospital beds for forensic patients, meaning those involved in the court system who have mental illness.

Last month, National Guard soldiers returned to Oregon's largest public psychiatric facility to shore up the workforce there.

In Maine, a committee of criminal justice and mental health officials has been working on adding state psychiatric beds and finding placements for people who need treatment for mental illness but are being held in jails.

The well-insured normally can choose private facilities or general hospital psychiatric wards, Trestman said. But in many cases, those beds are now filled, too.

Like the medical system overall, the behavioral health system is "under a great deal of strain," said Dr. Brian Hepburn, head of the National Association of State Mental Health Program Directors. The workforce shortage is especially acute at inpatient or residential behavioral health facilities, he said, and that pressure extends to private providers.

States are now focused on suicide prevention and crisis services to reduce pressure on emergency rooms and inpatient services, Hepburn added.

In Georgia, roughly 100 beds in the state's five psychiatric hospitals — or about 10% — are empty because there's no one to take care of the patients who would occupy them. Space in short-term crisis units is also squeezed. The turnover rate for hospital workers was 38% over the past fiscal year, according to the state Department of Behavioral Health and Developmental Disabilities.

Beyond hospitals, Melanie Dallas, CEO of Highland Rivers Health, which delivers behavioral health services in northern Georgia, said the challenge of dealing with higher demand amid such a diminished number of staffers is unprecedented in her 33 years in the field. "Everybody is exhausted."

Nationally, scores of nurses and other mental health workers have left state jobs.

It's "hard work and it's grueling," said Hannah Longley, community program director of the Maine chapter of the National Alliance on Mental Illness. State work doesn't offer "a significant salary and benefit package."

A state hospital nurse in the U.S. typically makes $40 to $48 an hour, while the rate for a temp agency nurse runs $120 to $200, Trestman said.

"A lot of people are chasing the COVID money," said Netha Carter, a nurse practitioner who works in an Augusta, Georgia, state facility for developmentally disabled people. She said that temp agencies are offering "triple the pay" given by state facilities, though she's staying put because she likes the kind of work she's doing.

Kim Jones, executive director of NAMI in Georgia, said she has received more calls about people with mental health needs who can't get long-term hospital services as the bed backlog increases.

Such waits for care can worsen patients' conditions. Several years ago, Tommie Thompson's son Cameron waited 11 months to get a state hospital bed in Atlanta while in jail. "By the time he got to the hospital, he was totally psychotic," Thompson said.

The backlog in public services is playing out in jails across Georgia, with more people being kept behind bars because mental health facilities are swamped.

The Georgia Sheriffs' Association said its members have relayed their difficulties in placing people in state-run treatment. "A lot of these folks don't need to be in jail, but they're stuck in there," said Bill Hallsworth, the association's coordinator of jail and court services. "There's no place to put them."

Hospital ERs also are feeling the shortage of state beds, said Anna Adams, a senior vice president of the Georgia Hospital Association. People with mental illness arriving in the ER "tend to be at the end of the line," said Robin Rau, CEO of Miller County Hospital in rural southwestern Georgia.

Rau said the bed backlog is horrible. "COVID has just exacerbated everything."

Need Help?

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

Andy Miller: amiller@kff.org, @gahealthnews