Major Insurers Running Billions of Dollars Behind on Payments to Hospitals and Doctors

KFF Health News, October 6, 2021

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Jay Hancock 

Anthem Blue Cross, the country's second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.

Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute "egregious" policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. "There's this sense of 'Everyone's distracted. We can get this through,'" she said.

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.

Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they'll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with COVID surges — even after the industry has received tens of billions of dollars in emergency assistance from the federal government.

"We recognize there have been some challenges" to prompt payments caused by claims-processing changes and "a new set of dynamics" amid the pandemic, Anthem spokesperson Colin Manning said in an email. "We apologize for any delays or inconvenience this may have caused."

Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.

For all Virginia hospitals, Anthem's late, unpaid claims amount to "hundreds of millions of dollars," the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.

Nationwide, the payment delays "are creating an untenable situation," the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. "Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies" needed to fight COVID.

Complaints about Anthem extend "from sea to shining sea, from New Hampshire to California," AHA CEO Rick Pollack told KHN.

Substantial payment delays can be seen on Anthem's books. On June 30, 2019, before the pandemic, 43% of the insurer's medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% — a difference of $2.5 billion.

Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.

Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.

The treatments were "experimental" and "not medically necessary," Anthem said, according to Thurber. She spent much of the summer trying to get the insurer to pay up — placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.

"It's so egregious. It's a game they're playing," said Thurber, 51, whose cancer was diagnosed in November. "Trying to get true help was impossible."

Privacy rules prevent Anthem from commenting on Thurber's case, said Anthem spokesperson Colin Manning.

When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn't pay up.

Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves — not support staffers — speak to insurance gatekeepers. "This requires providers to literally leave the patient['s] bedside to get on the phone with Anthem," AHA said in its letter.

Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in-network, amounting to a "bait and switch" on Anthem members, AHA officials said.

"Demanding that patients be treated outside of the hospital setting, against the advice of the patient's in-network treating physician, appears to be motivated by a desire to drive up Empire's profits," the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.

Anthem officials pushed back in a recent letter to the AHA, saying the insurer's changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.

Severe problems with Anthem's new claims management system surfaced months ago and "persist without meaningful improvement," AHA said in its letter.

Claims have gotten lost in Anthem's computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes "an unmanageable disruption that threatens to undermine our financial footing," VCU said.

United denied $31,557 in claims for Emily Long's care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for "medical necessity" — an "incredibly aggravating" response on top of the distress of the accident, Long said.

The Brooklyn hospital that treated Long was "paid appropriately under her plan and within the required time frame," said United spokesperson Maria Gordon Shydlo. "The facility has the right to appeal the decision."

United's unpaid claims came to 54% as of June 30, about the same level as two years previously.

When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer's entire prior-authorization database had gone down for weeks, said Conlisk, who lives in California.

"There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly," Gordon Shydlo said.

When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.

"Really a ton of uncertainty associated with this environment," John Gallina, the company's chief financial officer, said on a conference call in July. "We've tried to be extremely prudent and conservative in our approach."

During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem and other insurers accelerated billions in hospital reimbursements.

The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled.

Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds "have been a lifeline, but they don't make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience," Pollack said.

Several health systems declined to comment about claims-payment delays or didn't respond to a reporter's queries. Among individual hospitals "there is a deep fear of talking on the record about your largest business partner," AHA's Smith said.

Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she's not confident her Anthem policy will do a better job next time of covering the cost of her care.

"It makes me not want to go to the doctor anymore," she said. "I'm scared to get another mammogram because you can't rely on it."

Jay Hancock: jhancock@kff.org, @JayHancock1

Opinion: The Pandemic Forced My Transgender Wife to Fight Our Insurer Over Hormones

KFF Health News, October 5, 2021

The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Helen Santoro   

GUNNISON, Colo. — For the past eight years, my wife, Ky Hamilton, has undergone gender-affirming hormone therapy. As a transgender woman, she injects Depo-Estradiol liquid estrogen into her thigh once a week. This drug has allowed her to physically transition as a woman, and each vial, which lasts around five weeks, was completely covered by insurance.  

That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in Colorado's Affordable Care Act marketplace. We discovered that our new insurance from Anthem doesn't cover Depo-Estradiol and it would cost $125 out-of-pocket per vial. With both of us — and our four pets — depending heavily on Ky's weekly $649 unemployment check, such medical expenses proved difficult. And as of Sept. 6, those unemployment checks ran out.

"I'm absolutely stressed. I don't know what to do," Ky said in August as we tried to find a solution.

Because of Ky's physical transition as a transgender woman, her body doesn't make the testosterone it once used to. So, without the medication, she would essentially go through menopause. A decline in estrogen levels can also cause transgender women to lose the physical transitions they've achieved, resulting in gender dysphoria, which is psychological distress from the mismatch between their biological sex and their gender identity.

Unfortunately, Ky's experience is shared by many other transgender Americans. The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults, who reported at higher rates than non-LGBTQ adults that they lost their jobs during the crisis. Consequently, enrollment surged in ACA plans and Medicaid, the state-federal health program for low-income people. Yet many of those plans don't fully cover gender-affirming care, partly because of conservative policies and lack of scientific research on how crucial this care is for transgender patients.

According to a survey by Out2Enroll, a national initiative to connect LGBTQ people with ACA coverage, 46% of the 1,386 silver marketplace plans polled cover all or some medically necessary treatment for gender dysphoria. However, 7% have trans-specific exclusions, 14% have some exclusions, and 33% don't specify.

"It's this whack-a-mole situation where plans for the most part do not have blanket exclusions, but where people are still having difficulty getting specific procedures, medications, etc., covered," said Kellan Baker, executive director of the Whitman-Walker Institute, a nonprofit that focuses on LGBTQ research, policy and education.

Twenty-three states and Washington, D.C., include gender-affirming care in their Medicaid plans. But 10 states exclude such coverage entirely. In 2019, an estimated 152,000 transgender adults were enrolled in Medicaid, a number that has likely grown during the pandemic.

Yet even in states such as California that require their Medicaid programs to cover gender-affirming care, patients still struggle to get injectable estrogen, said Dr. Amy Weimer, an internist who founded the UCLA Gender Health Program. While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must request treatment authorizations to prove their patients need the drug. Weiner said those are rarely approved.

Such "prior authorizations" are an issue across Medicaid and ACA plans for medications including injectable estrogen and testosterone, which is used by transgender men, Baker said.

The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed for transgender women to physically transition, isn't commonly used by non-trans women undergoing hormone therapy to treat menopause or other issues, Weimer said.

It also may be because cheaper options, including daily estrogen pills, exist, but these increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said. Consequently, many of Weimer's patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get monthly.

While such insurance gaps have existed for long before the pandemic, the current crisis seems to have amplified the matter, according to Weimer.

The ACA prohibits discrimination based on race, color, national origin, age, disability and sex in health programs and activities that receive federal financial assistance. The Trump administration significantly narrowed the power of that provision, including eliminating health insurance protections for transgender people.

However, in June 2020, before the Trump regulations could take effect, the Supreme Court ruled in Bostock v. Clayton County, Georgia, that employment discrimination based on sex includes sexual orientation and gender identity.

This landmark decision has served as a crucial tool to address LGBTQ discrimination in many aspects of life, including healthcare. As of July, for example, Alaska Medicaid can no longer exclude gender-affirming treatment after Swan Being, a transgender woman, won a class-action lawsuit that relied in part on the Bostock decision.

The Biden administration announced in May that the U.S. Department of Health and Human Services Office for Civil Rights will include gender identity and sexual orientation in its enforcement of the ACA's anti-discrimination provision. The next month, Veterans Affairs health benefits were expanded to include gender confirmation surgery.

But for now, the pressure is still on patients like Ky to fight for their health benefits.

Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of covered drugs for its ACA plans, though many of its private employer-sponsored plans cover it.

Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls — and just before unemployment ran out — Anthem finally authorized her Depo-Estradiol. That brings her out-of-pocket cost to $60 per vial for the next year. It's still expensive for us right now, but we'll find a way to make it work.

"The reality is that trans people are more likely to be in poverty and don't have the time or knowledge to spend four months fighting to get their estradiol like I did," Ky said.

Solitary Confinement Condemns Many Prisoners to Long-Term Health Issues

KFF Health News, October 5, 2021

 

Instead of craving the company of others after release from social isolation, many former prisoners want just the opposite.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Katja Ridderbusch    

ATLANTA — Sometimes, Pamela Winn isn't sure how to connect with people, even those she loves, like her 9-month-old granddaughter. When the baby is in her arms, "I sit there quietly, and I don't know what to say. What to do," she said, her eyes filling with tears. "My socializing skills are just not there anymore."  

On days like these, Winn, who lives south of Atlanta, is haunted by the memory of her 6-by-9-foot prison cell, where she spent eight months in solitary confinement more than 10 years ago. She said she now feels "safest when I'm by myself."

It's a common paradox of solitary confinement, said Craig Haney, a professor of social psychology at the University of California-Santa Cruz. Instead of craving the company of others after release from social isolation, many former prisoners want just the opposite.

"Solitary forces prisoners to live in a world without people," he said. "And they adapt to it."

Research has long shown that solitary confinement — isolating prisoners for weeks, months, years and sometimes decades — has devastating effects on their physical and mental health. Once released, either to the general prison population or to the outside world, they can face a suite of problems, like heart damage and depression. They're often hypersensitive to light, sound, smell or touch. Like Winn, they may struggle to read social cues. People, Haney said, "become a source of anxiety rather than support."

And the coronavirus pandemic may have made the situation worse.

Before the pandemic, the estimated number of people in solitary confinement in the U.S. ranged from 50,000 to 80,000 on any given day, though many advocacy organizations believe counts are underestimated. The Centers for Disease Control and Prevention states that medical isolation — the separation of people with a contagious disease from the rest of the population — should not hinge on solitary confinement. Yet, at the height of the pandemic last year, up to 300,000 incarcerated individuals were in solitary, according to estimates from Solitary Watch and The Marshall Project, non-profits focused on criminal justice.

"Jails and prisons, like many organizations, acted in fear," said Tammie Gregg, deputy director of the American Civil Liberties Union's National Prison Project. "They thought the way to keep people from infecting each other was to simply put them in solitary."

Solitary confinement can serve many goals, from punishment to protection. And it is called many things — protective custody, restrictive or secure housing, administrative or disciplinary segregation, or simply "the Hole."

"The conditions are essentially the same: It's the extreme deprivation of any meaningful social contact," Haney said.

In the so-called Mandela Rules, named for South African leader Nelson Mandela, who was imprisoned for 27 years, the United Nations associates solitary confinement lasting longer than 15 consecutive days with a form of torture. More than half of all U.S. states have introduced or passed some type of legislation restricting or regulating the use of solitary confinement — like limiting the practice for juveniles, for example. But it is still widely used in American jails and prisons.

Inmates in solitary typically live in a small cell for up to 23 hours a day. They have little sensory stimulation, like sunlight. Access to reading materials, educational programming and personal property is limited or nonexistent. Prisoners may get one hour in a recreational yard, an equally isolated area typically enclosed or surrounded by concrete walls, with a secured high window that opens for fresh air.

An analysis by researchers with the University of Colorado and Human Rights Watch suggests that more than half of all prison suicides occur in solitary confinement. A study conducted by the New York City Department of Health and Mental Hygiene found that the rate of self-harm among those in solitary is 10 times that of the general prison population.

The isolation can be particularly destabilizing for people with preexisting mental health conditions, often exacerbating underlying issues that cause people to end up behind bars in the first place. "It's a downward spiral," said Haney.

A Florida State University study published earlier this year found that prisoners with mental illness, especially bipolar disorder, severe depression and schizophrenia, were up to 170% more likely to be placed in solitary for extended periods. In many prisons, experts worry, mental health treatment is nonexistent, making matters worse.

But even among people without a history of mental health problems, it may be impossible to predict who is susceptible to the harmful effects of solitary confinement, including suicide.

Pamela Winn, a registered nurse by training, was incarcerated in 2008 and later convicted to a 6½-year federal prison sentence for healthcare fraud. As the now-53-year-old African American woman with red-colored curls sits in her ranch home, her mind goes back to what she said was the darkest time of her life.

When she entered a federal holding facility south of Atlanta, she said, she was a healthy woman. She was also six weeks pregnant. One day, she fell as she was trying to step into a van while shackled. Three months later, she miscarried and was put into solitary confinement for what she was told was medical observation.

After a few months, she was transferred to a municipal prison, where she was placed into solitary again, this time for protection. For a total of eight months, at two facilities, she lived in tiny cells, with iron beds, thin foam mattresses, and metal sinks with toilets attached.

"No window. No mirror. No clock. No concept of time," she said. She was allowed to leave her cell for one hour a day. She could shower three times a week if staffers were available.

In the beginning, she replayed the traumatic memory of the night she lost her baby. Eventually, she joined in when other inmates screamed in their cells.

"I acted out. I threw stuff against the wall. I was angry," she said. Before she went to sleep, she prayed for God to take her. "But I kept waking up."

In Haney's experience, prisoners who develop a strategy to withstand the excruciating loop of idleness have a better chance of surviving. Some individuals force themselves to maintain a routine, to act as if there is a coherence in their life, "even though there isn't," he said.

Winn said she developed a strategy: She would start the day by praying. She would picture what her two teenage sons were doing. She would do sit-ups and mental exercises, like remembering street names. After solitary, she served most of her sentence in a federal prison in Florida and was released in 2013.

Her time in solitary scarred her for life, she said. To this day, she has high blood pressure. Paranoia is a constant companion; her house is surrounded by a solid wooden fence with a security gate, and she has two Rottweilers. Small spaces make her anxious, and she can't tolerate strangers getting too close, such as in a coffee shop line.

While she struggles to connect with her granddaughter, Winn keeps a journal, hoping that one day, when her granddaughter is old enough, she'll understand.

"She can read it and learn about everything that's in my heart and on my mind … if I'm still here, if I'm not here, wherever I am."

Both Haney and Gregg said jails and prisons have alternatives to long-term, extreme isolation. Mentally ill prisoners who engage in disciplinary infractions should be put into a treatment-oriented unit, said Haney.

For someone who acts violently, solitary confinement should be only a short-term solution aimed at acutely de-escalating the outburst, said Gregg. Afterward, those individuals should go to units that provide programming to address the root cause of their behavior. This may mean separation from the general prison population, but less time in total isolation.

A similar model could also apply to prisoners in solitary for their own safety, such as former Minneapolis police officer Derek Chauvin, who is serving a 22½-year-prison sentence for the murder of George Floyd. They could be placed in smaller units with individuals who have undergone a thorough risk assessment, and with access to education and training, Haney said.

Prisoner advocates are hopeful that solitary confinement in the U.S. will eventually be a concept of the past. In April, New York became the first state to codify the U.N.'s Mandela Rules that ban solitary after 15 consecutive days, when the Halt Solitary Confinement Act was signed into law. The legislation will take effect next April.

After Winn's release from prison, she founded RestoreHER, a nonprofit that advocates to end the mass incarceration of women of color, and pregnant people, in particular. She also helped enact laws in Georgia and North Carolina that bar the shackling of pregnant women.

"What I'm doing now gives me some redemption," she said.

Racism a Strong Factor in Black Women's High Rate of Premature Births, Study Finds

KFF Health News, October 5, 2021

Black women are about 1.6 times as likely as whites to give birth more than three weeks before the due date.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Anna Maria Barry-Jester  

The tipping point for Dr. Paula Braveman came when a longtime patient of hers at a community clinic in San Francisco's Mission District slipped past the front desk and knocked on her office door to say goodbye. He wouldn't be coming to the clinic anymore, he told her, because he could no longer afford it.  

It was a decisive moment for Braveman, who decided she wanted not only to heal ailing patients but also to advocate for policies that would help them be healthier when they arrived at her clinic. In the nearly four decades since, Braveman has dedicated herself to studying the "social determinants of health" — how the spaces where we live, work, play and learn, and the relationships we have in those places, influence how healthy we are.

As director of the Center on Social Disparities in Health at the University of California-San Francisco, Braveman has studied the link between neighborhood wealth and children's health, and how access to insurance influences prenatal care. A longtime advocate of translating research into policy, she has collaborated on major health initiatives with the health department in San Francisco, the federal Centers for Disease Control and Prevention and the World Health Organization.

Braveman has a particular interest in maternal and infant health. Her latest research reviews what's known about the persistent gap in preterm birth rates between Black and white women in the United States. Black women are about 1.6 times as likely as whites to give birth more than three weeks before the due date. That statistic bears alarming and costly health consequences, as infants born prematurely are at higher risk for breathing, heart and brain abnormalities, among other complications.

Braveman co-authored the review with a group of experts convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts and neurologists. They examined more than two dozen suspected causes of preterm births — including quality of prenatal care, environmental toxics, chronic stress, poverty and obesity — and determined that racism, directly or indirectly, best explained the racial disparities in preterm birth rates.

(Note: In the review, the authors make extensive use of the terms "upstream" and "downstream" to describe what determines people's health. A downstream risk is the condition or factor most directly responsible for a health outcome, while an upstream factor is what causes or fuels the downstream risk — and often what needs to change to prevent someone from becoming sick. For example, a person living near drinking water polluted with toxic chemicals might get sick from drinking the water. The downstream fix would be telling individuals to use filters. The upstream solution would be to stop the dumping of toxic chemicals.)

KHN spoke with Braveman about the study and its findings. The excerpts have been edited for length and style.

Q: You have been studying the issue of preterm birth and racial disparities for so long. Were there any findings from this review that surprised you?

The process of systematically going through all of the risk factors that are written about in the literature and then seeing how the story of racism was an upstream determinant for virtually all of them. That was kind of astounding.

The other thing that was very impressive: When we looked at the idea that genetic factors could be the cause of the Black-white disparity in preterm birth. The genetics experts in the group, and there were three or four of them, concluded from the evidence that genetic factors might influence the disparity in preterm birth, but at most the effect would be very small, very small indeed. This could not account for the greater rate of preterm birth among Black women compared to white women.

Q: You were looking to identify not just what causes preterm birth, but also to explain racial differences in rates of preterm birth. Are there examples of factors that can influence preterm birth that don't explain racial disparities?

It does look like there are genetic components to preterm birth, but they don't explain the Black-white disparity in preterm birth. Another example is having an early elective C-section. That's one of the problems contributing to avoidable preterm birth, but it doesn't look like that's really contributing to the Black-white disparity in preterm birth.

Q: You and your colleagues listed exactly one upstream cause of preterm birth: racism. How would you characterize the certainty that racism is a decisive upstream cause of higher rates of preterm birth among Black women?

It makes me think of this saying: A randomized clinical trial wouldn't be necessary to give certainty about the importance of having a parachute on if you jump from a plane. To me, at this point, it is close to that.

Going through that paper — and we worked on that paper over a three- or four-year period, and so there was a lot of time to think about it — I don't see how the evidence that we have could be explained otherwise.

Q: What did you learn about how a mother's broader lifetime experience of racism might affect birth outcomes versus what she experienced within the medical establishment during pregnancy?

There were many ways that experiencing racial discrimination would affect a woman's pregnancy, but one major way would be through pathways and biological mechanisms involved in stress, and stress physiology. In neuroscience, what's been clear is that a chronic stressor seems to be more damaging to health than an acute stressor.

So it doesn't make much sense to be looking only during pregnancy. But that's where most of that research has been done: stress during pregnancy and racial discrimination, and its role in birth outcomes. Very few studies have looked at experiences of racial discrimination across the life course.

My colleagues and I have published a paper where we asked African American women about their experiences of racism and we didn't even define what we meant. Women did not talk a lot about the experiences of racism during pregnancy from their medical providers; they talked about the lifetime experience, and particularly experiences going back to childhood. And they talked about having to worry, and constant vigilance, so that even if they're not experiencing an incident, their antennae have to be out to be prepared in case an incident does occur.

Putting all of it together with what we know about stress physiology, I would put my money on the lifetime experiences being so much more important than experiences during pregnancy. There isn't enough known about preterm birth, but from what is known, inflammation is involved, immune dysfunction, and that's what stress leads to. The neuroscientists have shown us that chronic stress produces inflammation and immune system dysfunction.

Q: What policies do you think are most important at this stage for reducing preterm birth for Black women?

I wish I could just say one policy or two policies, but I think it does get back to the need to dismantle racism in our society. In all of its manifestations. That's unfortunate, not to be able to say, "Oh, here, I have this magic bullet. And if you just go with that, that will solve the problem."

If you take the conclusions of this study seriously, you say, well, policies to just go after these downstream factors are not going to work. It's up to the upstream investment in trying to achieve a more equitable and less racist society. Ultimately, I think that's the take-home, and it's a tall, tall order.

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

Anna Maria Barry-Jester: annab@kff.org, @annabarryjester

Listen: California Banks on a Bold Treatment: Pay Drug Users to Stop Using

KFF Health News, October 4, 2021

One addict's story explains how California's unconventional treatment works.

This article was published on Monday, October 4, 2021 in Kaiser Health News.

By April Dembosky, KQED  

This story is from a partnership that includes KQED, NPR and KHN.  

When Billy Lemon was trying to kick his methamphetamine addiction, he went to a drug treatment program at the San Francisco AIDS Foundation three times a week and peed in a cup. If it tested negative for meth, he got paid about $7.

As the pandemic has raged, so has the country's drug epidemic. Health officials have been struggling with methamphetamine and cocaine abuse, in particular, because of a lack of effective treatment for those stimulants.

Listen to Lemon's story and to understand how California's unconventional treatment works.

"For somebody who had not had any legitimate money ― without committing felonies ― that seemed like a cool thing," said Lemon, who was arrested three times for selling meth before starting recovery.

The payments were part of an addiction treatment called contingency management, which gives drug users incentives ― money or gift cards ― to stay off drugs. At the end of 12 weeks, after all his drug tests came back negative for meth, Lemon received $330. For him, it was about more than just the money. It was being told: Good job.

Read the full story here.

This story is from a partnership that includes KQED, NPR and KHN.

April Dembosky, KQED: @adembosky

Youthful Advisers Help Shape a Mental Health Program for Their Peers

KFF Health News, October 4, 2021

Allcove offers standalone health and wellness sites to those ages 12 to 25, often on a walk-in basis, at minimal or no cost.

This article was published on Monday, October 4, 2021 in Kaiser Health News.

By Mark Kreidler  

Phebe Cox grew up in what might seem an unlikely mental health danger zone for a kid: tony Palo Alto, California, in the heart of Silicon Valley. But behind its façade of family success and wealth, she said, is an environment of crushing pressure on students to perform. By 2016, when Cox was in middle school, Palo Alto had a teen suicide rate four times the national average.

Cox's family lived by the railroad tracks where many of the suicides occurred. She got counseling. But that option, she told KHN, is not always easily available to teens in crisis — and she and her peers regarded school mental health services as their last choice because of concerns about either confidentiality or anonymity.

A new program, designed largely by the people who use it, provides an alternative. Called Allcove, it offers standalone health and wellness sites to those ages 12 to 25, often on a walk-in basis, at minimal or no cost. Although Allcove is built to support a wide range of physical, emotional and social needs, its overarching goal is to deal with mental health challenges before they develop into deeper problems.

Allcove is yet in its infancy, with two sites just opened in the Bay Area and five more in the pipeline around California. It's modeled on a 15-year-old program in Australia, Headspace, which has 130 such clinics. Headspace has inspired programs in other countries as well, including Jigsaw in Ireland and Foundry in Canada. All of them, including Allcove, also offer online and phone services.

Allcove's core values resonate with Cox, now 19 and a student at Pitzer College in Claremont, California, and one of dozens of young people who have offered advice on the program's structure and services.

"Right away, I knew it was going to be a big thing," Cox said. "I felt pretty helpless as a young teenager, but Allcove is all about the students and the students' needs."

About half of all lifetime mental illness begins by age 14, and 75% before age 25, according to researchers. Yet access to mental healthcare in the U.S. is lacking. According to the National Alliance on Mental Illness, some 30 million adults and children with mental health conditions go without treatment, and 129 million people live in areas with shortages of mental health professionals. A 2017 survey found that Californians were five times more likely to go outside their private insurance network for mental health office visits than for medical or surgical needs.

Allcove meets some of that head-on by providing fully staffed safe spaces for teens and young adults to discuss and deal with their health, both mental and physical, along with substance misuse issues and educational support. California law allows those 12 and older to get outpatient mental health or counseling services without a guardian's consent.

Allcove's sites in Palo Alto and San Jose are filled with vibrant colors and plenty of open space, the result of input by a youth advisory group that numbers a dozen or more members and changes out about once a year. Inside Allcove, clients can access group or individual care, ask a doctor about a problem, and even get help preparing for college.

Unlike the Australian program, Allcove has no ongoing funding source yet. Allcove is "a really big lift, and we [at the state level] want to say, 'How can we help you?'" said Toby Ewing, executive director of the California Mental Health Services Oversight and Accountability Commission, which administers the fund that seeded the first two sites with $15 million.

Funding eventually may come from a combination of state, private and nonprofit sources, as well as Medi-Cal reimbursements, said Dr. Steven Adelsheim, a psychiatrist who directs Stanford University's Center for Youth Mental Health and Wellbeing.

Adelsheim previously spent nearly 30 years in New Mexico, helping that state build a network of school-based health centers. His experience convinced him that many students were likely to avoid mental health services at school. They were reluctant, he said, to discuss such issues with their own counselors, who might be the same people writing the students' letters of recommendation for college and might unwittingly breach privacy.

That realization led Adelsheim in 2014 to get exploratory funding from the Robert Wood Johnson Foundation to create Allcove. (KHN, which produces California Healthline, also receives funding support from the foundation.) "There is a crying need in the U.S. to reach kids with early intervention and help," Adelsheim said.

The idea struck a chord with Santa Clara County officials, who'd seen Palo Alto lashed by teen suicide clusters during the 2009-10 and 2014-15 school years. "The saddest part of the story is that a teen didn't reach out earlier, didn't have the opportunity to get help when and where they needed it," County Supervisor Joe Simitian said in announcing Allcove's opening in June. "The appeal of the Allcove model is it's designed to engage young people who are struggling, long before they hit a crisis point."

When Cox moved from middle school to Palo Alto's Henry M. Gunn High School, her therapist told her about Adelsheim's project and suggested Cox apply to be part of Allcove's youth council. One of Cox's contributions was to suggest weekday hours extending at least to 7 p.m., "because young adults are doing things and on the move all day. It's the evenings — and even the weekends — when we're dealing with things or feeling more helpless. For a lot of my friends, at night is when things can get overwhelming."

Both Foundry, the Canadian program, and Allcove address physical health as well. Steve Mathias, CEO of Foundry, said his program's emphasis is "on health and wellness, not just mental health, which is a part of wellness." Said Adelsheim, "Sometimes a kid may come in with a physical complaint, and only after a few visits is the mental suffering brought out into the open." When that happens, Allcove can make a "warm handoff" to a mental health specialist on-site.

The most significant difference between Headspace and Allcove may be funding. Headspace is part of the Australian government's mental health initiative, and thus budgeted. Allcove is essentially building on the fly, and its long-term ability to grow will depend on money.

California's Proposition 63, written in 2004 by then-Assembly member Darrell Steinberg (now the mayor of Sacramento), levies a 1% tax on personal incomes over $1 million to fund community mental health services. This year, the tax may yield $2.4 billion, Ewing said. Most of that goes to existing programs, but about 5% each year — more than $100 million in 2021 — feeds an innovation fund to encourage new approaches to mental health.

Santa Clara County got $15 million from that fund to launch Allcove. The state also has helped fund Allcove sites, in Sacramento, San Mateo and Orange counties, and two in Los Angeles County.

"We've made a $30 million-plus investment in this model," Ewing said. "We are assuming that it's going to be successful."

Success, say Adelsheim and Cox, would mean the establishment of hundreds of Allcove centers up and down the state, readily available to young people. The hope is that, if it catches on, Allcove could become a well-known brand for young Californians — and, eventually, others around the country.

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

Mark Kreidler: @MarkKreidler

Mandatory Vaccines for Healthcare Workers Might Upend Nurses' Training

KFF Health News, October 4, 2021

Groups representing the nursing profession say "students should be vaccinated when clinical facilities require it" to complete their clinical training.

This article was published on Monday, October 4, 2021 in Kaiser Health News.

By Michelle Andrews    

Kaitlyn Hevner expects to complete a 15-month accelerated nursing program at the University of North Florida in Jacksonville in December. For her clinical training this fall, she's working 12-hour shifts on weekends with medical-surgical patients at a hospital.

But Hevner and nursing students like her who refuse to get vaccinated against COVID-19 are in an increasingly precarious position. Their stance may put their required clinical training and, eventually, their nursing careers at risk.

In early September, the Biden administration announced that workers at healthcare facilities, including hospitals and ambulatory surgery centers, would be required to receive COVID vaccines. Although details of the federal rule won't be released until October, some experts predict that student nurses doing clinical training at such sites will have to be vaccinated, too.

Groups representing the nursing profession say "students should be vaccinated when clinical facilities require it" to complete their clinical training. In a policy brief released Monday, the National Council of State Boards of Nursing and eight other nurse organizations suggested that students who refuse to be vaccinated and who don't qualify for an exception because of their religious beliefs or medical issues may be disenrolled from their nursing program or be unable to graduate because they cannot fulfill the clinical requirements.

"We can't have students in the workplace that can expose patients to a serious illness," said Maryann Alexander, chief officer for nursing regulation at the national council. "Students can refuse the vaccine, but those who are not exempt maybe should be told that this is not the time to be in a nursing program."

"You're going to go into practice and you're going to be very limited in your jobs if you're not going to get that vaccine," Alexander said.

Hevner, 35, set to finish her clinical training in early October, said she doesn't feel it's acceptable to benefit from a vaccine that was developed using fetal cells obtained through abortion, which she opposes. (Development of the Johnson & Johnson COVID vaccine involved a cell line from an abortion; the Pfizer-BioNTech and Moderna mRNA vaccines were not developed with fetal cell lines, but some testing of the vaccines reportedly involved fetal cells, researchers say. Many religious leaders, however, support vaccination against COVID.)

With vaccines for nursing students still optional in many healthcare settings, nursing educators are scrambling to place unvaccinated students in healthcare facilities that will accept them.

Down the coast from Jacksonville in Fort Pierce, Florida, 329 students are in the two-year associate degree nursing program at Indian River State College, said Roseann Maresca, an assistant professor who teaches third-semester students and coordinates their clinical training. Only 150 of them are vaccinated against COVID, she said.

Not all of the eight medical facilities that have contracts with the school require student nurses to be vaccinated.

"It's been a nightmare trying to move students around this semester" to match them with facilities depending on their vaccination status, Maresca said.

Commonly, healthcare facilities have long required employees to be vaccinated against various illnesses such as influenza and hepatitis B. The pandemic has added new urgency to these requirements. According to a September tally by FierceHealthcare, more than 170 health systems mandate COVID vaccines for their workforces.

In May, the federal Equal Employment Opportunity Commission made it clear that under federal law employers can mandate COVID vaccinations as long as they allow workers to claim religious and medical exemptions.

Under the Biden administration's COVID plan, roughly 50,000 healthcare facilities that receive Medicare or Medicaid payments must require workers to be vaccinated. Until the administration releases its draft rule in October, it is unclear how nursing students assigned to healthcare sites for clinical training will be treated.

But the federal rule published in August that lays out regulations for government hospital payments in 2022 offers clues. It defined healthcare personnel that should be vaccinated as employees, licensed independent contractors and adult students/trainees and volunteers, said Colin Milligan, director of media relations at the American Hospital Association.

In addition to staff members, the Biden plan says mandates will apply to "individuals providing services under arrangements" at healthcare sites.

A spokesperson for the Centers for Medicare & Medicaid Services declined to clarify who would be covered by the Biden plan, noting the agency is still writing the rules.

Nonetheless, vaccination mandates threaten to derail the training of a relatively small proportion of nursing students. A recent survey by the National Student Nurses' Association reported that 86% of nursing students and 85% of new nursing graduates who responded to an online survey said they had been or planned to be vaccinated against COVID.

But the results varied widely by state, from 100% in New Hampshire and Vermont on the high end to 63% in Oklahoma, 74% in Kentucky and 76% in Florida on the low end. The survey had 7,501 respondents.

Students who don't want to be vaccinated are asking schools to offer them alternatives to on-site clinical training. They suggest using life-size computer-controlled mannequins or computer-based simulations using avatars, said Marcia Gardner, dean of the nursing school at Molloy College in Rockville Centre, New York.

Last year, when the pandemic led hospitals to close their doors to students, many nursing programs increased simulated clinical training to give nursing students some sort of clinical experience.

But that's no substitute for working with real patients in a healthcare setting, educators say. State nursing boards permit simulated clinical study to varying degrees, but none allow such instruction to exceed 50% of clinical training, said Alexander. A multisite study found that nursing students could do up to half their clinical training using simulation with no negative impact on competency.

The policy brief by the council of state nursing boards states that nursing education programs "are not obligated to provide substitute or alternate clinical experiences based on a student's request or vaccine preference."

As more nursing students become vaccinated, the issue will grow less acute. And if the Biden plan requires nursing students to be vaccinated to work in hospitals, the number of holdouts is likely to further shrink.

Hevner, the University of North Florida student, said she's not opposed to vaccines in general and would consider getting a COVID vaccine in the future if she could be assured it wasn't created using aborted fetal cells. She filed paperwork with the college to get a religious exemption from vaccine requirements. It turned out she didn't need one because Orange Park Medical Center, where she is doing her clinical training, doesn't require staffers or nursing students to be vaccinated against COVID "at this time," said Carrie Turansky, director of public relations and communications for the medical center, in Orange Park, Florida.

Although Hevner opposes getting the vaccine, "I take protecting my patients and protecting myself very seriously," she said. She gets tested weekly for COVID and always wears an N95 mask in a clinical setting, among other precautions, she said. "But I would ask: Do we give up our own religious rights and our own self-determination just because we work in a healthcare setting?"

She hopes the profession can accommodate people like her.

"I'm concerned because we're in such a divisive place," she said. But she is eager to find a middle ground because, she said, "I think I would make a really great nurse."

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

A Colorado Town Is About as Vaccinated as It Can Get. COVID Still Isn't Over There.

KFF Health News, October 1, 2021

Infectious-disease experts say masks are still necessary to control the spread of the virus.

This article was published on Friday, October 1, 2021 in Kaiser Health News.

By Rae Ellen Bichell  

San Juan County, Colorado, can boast that 99.9% of its eligible population has received at least one dose of COVID-19 vaccine, putting it in the top 10 counties in the nation, according to data from the Centers for Disease Control and Prevention.

If vaccines were the singular armor against COVID's spread, then on paper, San Juan County, with its 730 or so residents on file, would be one of the most bulletproof places in the nation.

Yet the past few months have shown the complexity of this phase of the pandemic. Even in an extremely vaccinated place, the shots alone aren't enough because geographic boundaries are porous, vaccine effectiveness may be waning over time and the delta variant is highly contagious. Infectious-disease experts say masks are still necessary to control the spread of the virus.

The county logged its first hospitalizations of the pandemic in early August — this year, not 2020. Five summer residents were hospitalized. Three ended up on ventilators: Two recovered and the third, a 53-year-old woman, died at the end of August. All were believed to be unvaccinated.

Those cases and even the ones that didn't need hospitalization raised the alarms for the county with a single incorporated town: Silverton. It's a tightknit former mining community nestled in the mountains of southwestern Colorado, where snowstorms and avalanches often block the lone road that passes through.

"The pandemic is just still going on," said DeAnne Gallegos, the county's public information officer and director of the local chamber of commerce. "We kept thinking it was going to end before this summer. Then we were thinking in November. Now we're like, 'No, we don't know when.'"

So the county decided to backtrack: "We went back to the tools that we knew we had," Gallegos said. "Mask mandate indoors and then discouraging indoor events." Outdoor events continued, such as a brass band concert on the courthouse steps, and the area's signature Hardrockers Holidays mining competition, with its pneumatic mucking and spike driving.

On the whole, once the under-12 set is taken into account, 85% of the county's total population is fully vaccinated. But in the summer, the population nearly doubles as seasonal residents roost in second homes and RV parks, some vacationing while others take up seasonal jobs. Then, there's what Gallegos described as "the tsunami of tourism" — the daily influx of people arriving on the historical railroad from Durango and the dusty jeep trails through the mountains. Many of those visitors are of unknown vaccination status.

The county's two-week incidence shot up in August to the highest rate in the state, and stayed there for most of the month. Even though that spike amounted to a grand total of about 40 known cases, it was nearly as many as the county had logged during the entirety of the pandemic — and cases spilled into the vaccinated as well.

Any number of cases would be a big deal in a small place without its own hospital. "We are all one-man bands just trying to make it happen," Gallegos said. The county's public health director, Becky Joyce, for example, does everything from contact tracing and COVID testing to putting shots in arms. And when the county restarted its mask mandate, it was Gallegos who designed the signs and spent her weekend zip-tying them around town.

The biggest concentration of COVID cases happened at an RV park and a music festival driven indoors by rain.

"It makes sense that coming out of three or four weeks of just jamming tourism, people were starting to get sick who work in the restaurants, at the RV parks," Gallegos said. "And then you bring all the locals condensed together for a couple of nights of concerts and it was just the trifecta."

Dana Chambers, who runs the hardware store in Silverton, was vaccinated as soon as possible. She said returning to a mask mandate felt in some ways like "a step back." But, she said, businesses like hers need the summer tourism rush to survive the quiet winter, when just a few hundred tourists come, largely to jump out of helicopters onto ski terrain. "If we have to wear the mask, that's what we'll do."

Julia Raifman, a Boston University School of Public Health epidemiologist who is following state pandemic policies, isn't surprised COVID can attack a place like San Juan County despite high vaccination rates.

Data shows the vaccines protect against death and hospitalization due to COVID. But even effective vaccines are no match for the transmissibility of delta. "Even in the best-case scenario — if vaccines reduce transmission by 80% — you're actually twice as likely to get COVID now than you were in July," Raifman said, due to the virus's recent proliferation. "It's impossible statistically to achieve herd immunity with the delta variant."

Meanwhile, many local and national leaders, including in Colorado, continue to focus on the vaccines almost exclusively as the path forward.

Talia Quandelacy, an epidemiologist with the University of Colorado-Denver and the Colorado School of Public Health, said the concept of herd immunity in this pandemic has been oversimplified and over-relied-on. "It's a useful guide to have some sort of target to aim for," she said. "But usually, if we hit a certain metric, that doesn't mean that transmission or the pandemic is just going to disappear."

Many scientists agree that, especially with most of the world still unvaccinated, COVID is likely here to stay, eventually morphing into something more like the common cold. "It's probably going to be a matter of a couple of years," Quandelacy said. "But that seems to be the trajectory that we are on."

For that reason, the "finish line" language used by many politicians has frustrated Anne Sosin, a policy fellow at the Nelson A. Rockefeller Center for Public Policy at Dartmouth College studying COVID and rural health. The vaccines are doing what they're supposed to do — keeping people from getting really sick, not keeping them from ever getting infected — but that hasn't been communicated well. "The messaging around this has not been very nuanced," she said.

She pointed to the experience of an epidemiologist who wrote in August in The Baltimore Sun that he'd caught COVID at a house party where all 14 guests and the host were vaccinated. The host had infected him and nine others. "As miraculous as they are in keeping people out of the hospital and alive, we can't rely on them alone to prevent infection," Sosin said of the vaccines.

And public health experts said San Juan County shows that measures such as masks, ventilation and distancing are also needed. They are circulating the "Swiss cheese" model of COVID defense, in which each prevention measure (or layer of cheese) has holes in it, but when stacked together they create an effective defense. Sosin said rural places, in particular, may need those layers of defense because residents are often tightly connected, and disease travels quickly within social networks.

Joyce, the public health director, who declined an interview request, wrote on Facebook in August that the county's recent experience proved "the vaccine creates a line of defense but does not make us invincible to this disease or the variants."

Raifman views that realization — paired with San Juan's ensuing indoor mask requirement — as a success at a pivotal moment. The month-long mandate was then lifted Sept. 10, as the county had dropped back to a low COVID transmission rate. At the time, it was the only county in Colorado with such low transmission.

"This is the moment where we kind of define: How are we managing the virus over the longer term?" Raifman said. "So far, we're defining that we don't manage it; we let it manage us."

Even after lifting its mask mandate, the Facebook page of the county's public health department urges residents to wear masks and "pay attention to the COVID-19 situation just as you pay attention to the weather."

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

Hospitals Confront Climate Change as Patients Sick From Floods and Fires Crowd ERs

KFF Health News, October 1, 2021

One recent assessment predicts annual U.S. heat deaths could reach nearly 60,000 by 2050.

This article was published on Friday, October 1, 2021 in Kaiser Health News.

By Miranda Green  

When triple-digit temperatures hit the Pacific Northwest this summer, the emergency room at Seattle's Harborview Medical Center was ill prepared. Doctors raced to treat heat-aggravated illness in homeless people, elderly patients with chronic ailments, and overdosing narcotics users.

"The magnitude of the exposure, this was so far off the charts in terms of our historical experience," said Dr. Jeremy Hess, an emergency medicine physician and professor of environmental and occupational health sciences at the University of Washington.

Doctors, nurses and hospitals increasingly are seeing patients sickened by climate-related problems, from overheating to smoke inhalation from wildfires and even infectious diseases. One recent assessment predicts annual U.S. heat deaths could reach nearly 60,000 by 2050.

For some medical professionals, this growing toll has stimulated a reckoning with the healthcare industry's role in global warming. U.S. hospitals and medical centers consume more energy than any industry except for food service, according to the U.S. Energy Information Administration. Hospitals consume 2.5 times as much energy per square foot as typical office buildings, on average. They also contribute mountains of medical waste and emit atmosphere-damaging gases used in surgery and other procedures.

But the healthcare sector is beginning to respond. The Health and Human Services Department's newly created Office of Climate Change and Health Equity, in addition to focusing on climate-related illness, says it will work "to reduce greenhouse gas emissions and criteria air pollution throughout the healthcare sector." The office could help change regulations that restrict sustainability efforts, climate activists say.

Already, many U.S. hospitals have begun installing solar panels, while others are trying to cut surgical waste and phase out ozone-damaging chemicals. Activists are pressing for the industry to cut back on energy-intensive protocols, such as ventilation requirements that mandate a high level of air circulation, measured as air changes per hour. They say they could be reduced without harming patients.

"I think there is recognition among physicians that climate change is likely to continue and worsen over time," said Hess. "We don't necessarily do as much as we could otherwise to reduce our footprint and advance sustainability, and that's where I'd like to see our health systems go."

But the industry is moving cautiously to avoid harm to patients — and legal liability. They "don't want to make any mistakes. And part of not making mistakes is a resistance to change," said Dr. Matthew Meyer, co-chair of University of Virginia Health's sustainability committee.

The University of Vermont Medical Center was one of the first U.S. hospital systems to focus on sustainability initiatives. It has succeeded in reducing emissions by roughly 9% since 2015 by renovating and building structures to be more energy-efficient and converting off-site medical centers to run 50% on renewable natural gas. One of its hospitals cut waste by more than 60% through reuse and recycling.

Managed-care nonprofit Kaiser Permanente, meanwhile, has focused on greening its energy consumption. By September 2020, all of its 39 hospitals and 727 medical offices had achieved carbon neutrality. At most Kaiser Permanente hospitals, solar panels provide one-quarter to one-third of energy needs.

Kaiser Permanente aims eventually to generate enough electricity through solar technology to eliminate the need for diesel-powered backup generators at its hospitals, which are heavily used in areas with stressed power grids. In 2017 and 2019, power company shut-offs in California forced the health network to evacuate its Santa Rosa Medical Center, and electricity was cut to its Vallejo Medical Center.

"To have those facilities be out for a week or more is just not tolerable," said Seth Baruch, Kaiser Permanente's national director for energy and utilities.

Increased energy sustainability has brought a small financial windfall. Kaiser Permanente saves roughly $500,000 a year in electricity costs through its grids and solar panels, Baruch said. (KHN is not affiliated with Kaiser Permanente.)

Reaching consensus on emission-lowering steps can be difficult. It took seven months for UVA's Meyer, an anesthesiologist, to persuade his hospital to phase out most uses of desflurane, a common anesthetic that damages the ozone layer and is a potent greenhouse gas.

Meyer argued other drugs could replace desflurane. But critics warned that the most common alternatives slowed patients' postoperative recovery, when compared with desflurane. They said there were ways to neutralize excess desflurane in operating room air without discontinuing it entirely.

The "first do no harm" ethos of medicine can also be an obstacle to the reduction of medical waste. The Joint Commission, which accredits more than 22,000 U.S. healthcare organizations, has in recent years pushed for hospitals to use more disposable devices instead of sanitizing reusable devices.

The commission's primary objective is to cut hospital infections, but more disposable items means less sustainability. About 80% of U.S. healthcare sector emissions arise from the manufacturers, and their suppliers and distributors, including the production of single-use disposable medical equipment, according to a study.

Complicating the issue, ethylene oxide — a chemical the Food and Drug Administration requires for sterilization of many devices — has been categorized as a carcinogen by the Environmental Protection Agency. In 2019, health concerns led communities to push for the closure of facilities that use the gas, which threatened to create a shortage of clean medical devices.

Maureen Lyons, a spokesperson for the Joint Commission, said the private accreditor lacks the authority to change regulations. The procurement of disposable versus reusable devices is a supply chain issue, "not one that the Joint Commission is able to evaluate for compliance."

For this reason, healthcare activists are lobbying for sustainability through policy changes. Healthcare Without Harm, an environmental advocacy group, seeks to undo state rules that impose what it sees as excessively energy-intensive ventilation, humidification and sterilization requirements.

In California, the group has sought to change a medical building code adopted statewide in July that will require a higher ventilation standard at healthcare facilities. The group says the new standard is unnecessary. While high rates of circulation are needed in intensive care units, operating rooms and isolation chambers, there is no evidence for maintaining such standards throughout a hospital, said Robyn Rothman, associate director of state policy programs at Healthcare Without Harm. She cited a 2020 study from the American Society for Healthcare Engineering.

Hospital groups have resisted sustainability commitments on the grounds they will bring more red tape and costs to their hospitals, Rothman said.

The American Society for Healthcare Engineering, a professional group allied with the American Hospital Association, has developed sustainability goals for reducing emissions. But existing regulations make it difficult to achieve many of them, said Kara Brooks, the group's sustainability program manager.

For example, the Centers for Medicare & Medicaid Services requires hospitals that treat Medicaid and Medicare patients to have backup diesel generators.

"Hospitals will not be able to eliminate their use of fossil fuels based on the current regulations," Brooks said, but "we encourage hospitals to work toward their goals within the parameters given."

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

Miranda Green: mirandac.green@gmail.com, @mirandacgreen

A COVID Test Costing More Than a Tesla? It Happened in Texas.

KFF Health News, September 30, 2021

A Texas couple each had a COVID diagnostic PCR test at SignatureCare Emergency Center and were charged $56,384  owns across Texas.

This article was published on Thursday, September 30, 2021 in Kaiser Health News.

By Aneri Pattani  

When COVID-19 struck last year, Travis Warner's company became busier than ever. He installs internet and video systems, and with people suddenly working from home, service calls surged.

He and his employees took precautions like wearing masks and physically distancing, but visiting clients' homes daily meant a high risk of COVID exposure.

"It was just like dodging bullets every week," Warner said.

In June 2020, an employee tested positive. That sent Warner and his wife on their own hunt for a test.

Because of limited testing availability at the time, they drove 30 minutes from their home in Dallas to a free-standing emergency room in Lewisville, Texas. They received PCR diagnostic tests and rapid antigen tests.

When all their results came back negative, it was a huge relief, Warner said. He eagerly got back to work.

Then the bill came.

The Patient: Travis Warner, 36, is self-employed and bought coverage from Molina Healthcare off the insurance marketplace.

Medical Service: Two COVID tests: a diagnostic PCR test, which typically takes a few days to process and is quite accurate, and a rapid antigen test, which is less accurate but produces results in minutes.

Total Bill: $56,384, including $54,000 for the PCR test and the balance for the antigen test and an ER facility fee. Molina's negotiated rate for both tests and the facility fee totaled $16,915.20, which the insurer paid in full.

Service Provider: SignatureCare Emergency Center in Lewisville, one of more than a dozen free-standing ERs the company owns across Texas.

What Gives: Throughout the pandemic, stories of shockingly high prices for COVID tests have abounded. A recent report from an insurance trade association noted that "price gouging by certain providers continues to be a widespread problem."

But Warner's PCR bill of $54,000 is nearly eight times the most notable charge previously reported, at $7,000 — and his insurer paid more than double that highest reported charge. Health policy experts KHN interviewed called Warner's bill "astronomical" and "one of the most egregious" they'd seen.

Yet it's perfectly legal. For COVID tests — like much else in American healthcare — there is no cap to what providers can charge, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.

COVID testing has been in a special category, however. When the pandemic hit, lawmakers worried people might avoid necessary testing for fear of the cost. So they passed bills that required insurers to pay for COVID tests without copays or cost sharing for the patient.

For in-network providers, insurers can negotiate prices for the tests, and for out-of-network providers, they're generally required to pay whatever price the providers list publicly on their websites. The free-standing ER was out of network for Warner's plan.

While the policy was intended to help patients, health experts say, it has unintentionally given providers leeway to charge arbitrary, sometimes absurd prices, knowing that insurers are required to pay and that patients, who won't be billed, are unlikely to complain.

"People are going to charge what they think they can get away with," said Niall Brennan, president and CEO of the Healthcare Cost Institute, a nonprofit that studies healthcare prices. "Even a perfectly well-intentioned provision like this can be hijacked by certain unscrupulous providers for nefarious purposes."

A report from KFF published earlier this year found that hospital charges for COVID tests ranged from $20 to $1,419, not including physician or facility fees, which can often be higher than the cost of the tests themselves. About half the test charges were below $200, the report noted, but 1 in 5 were over $300.

"We observed a broad range of COVID-19 testing prices, even within the same hospital system," the authors wrote.

Realistically, the cost of a COVID test should be in the double digits, Brennan said. "Low triple digits if we're being generous."

Medicare pays $100 for a test, and at-home tests are sold for as little as $24 for an antigen test or $119 for a PCR test.

Warner's charges were fully covered by his insurance.

But insurance policy premiums reflect how much is paid to providers. "If the insurance company is paying astronomical sums of money for your care, that means in turn that you are going to be paying higher premiums," Adler said.

Taxpayers, who subsidize marketplace insurance plans, also face a greater burden when premiums increase. Even those with employer-sponsored health coverage feel the pain. Research shows that each increase of $1 in an employer's health costs is associated with a 52-cent cut to an employee's overall compensation.

Even before the pandemic, wide variability in the prices for common procedures like cesarean sections and blood tests had been driving up the cost of healthcare, Brennan said. These discrepancies "happen every single day, millions of times a day."

Resolution: When Warner saw that his insurance company had paid the bill, he first thought: "At least I'm not liable for anything."

But the absurdity of the $54,000 charge gnawed at him. His wife, who'd received the same tests the same day at the same place, was billed $2,000. She has a separate insurance policy, which settled the claim for less than $1,000.

Warner called his insurer to see if someone could explain the charge. After a game of phone tag with the ER and the ER's billing firm, and several months of waiting, Warner received another letter from his insurer. It said they'd audited the claim and taken back the money they had paid the ER.

In a statement to KHN, a spokesperson for Molina Healthcare wrote, "This matter was a provider billing error which Molina identified and corrected."

SignatureCare Emergency Centers, which issued the $54,000 charge, said it would not comment on a specific patient's bill. However, in a statement, it said its billing error rate is less than 2% and that it has a "robust audit process" to flag errors. At the height of the pandemic, SignatureCare ERs faced "unprecedented demands" and processed thousands of records a day, the company said.

SignatureCare's website now lists the charge for COVID tests as $175.

The Takeaway: COVID testing should be free to consumers during the public health emergency (currently extended through mid-October, and likely to be renewed for an additional 90 days). Warner did his insurer a big favor by looking carefully at his bill, even though he didn't owe anything.

Insurers are supposed to have systems that flag billing errors and prevent overpayment. This includes authorization requirements before services are rendered and audits after claims are filed.

But "there's a question of how well they work," Adler said. "In this case, it's lucky [Warner] noticed."

At least one estimate says 3% to 10% of healthcare spending in the U.S. is lost to overpayment, including cases of fraud, waste and abuse.

Unfortunately, that means the onus is often on the patient.

You should always read your bill carefully, experts say. If the cost seems inappropriate, call your insurer and ask them to double-check and explain it to you.

It's not your job, experts agree, but in the long run, fewer overpayments will save money for you and others in the American healthcare system.

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!

Aneri Pattani: apattani@kff.org, @aneripattani

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