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

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

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

Since the pandemic began, about 1 in 434 rural Americans have died of COVID, compared with roughly 1 in 513 urban Americans.

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

By Lauren Weber

Rural Americans are dying of COVID at more than twice the rate of their urban counterparts — a divide that health experts say is likely to widen as access to medical care shrinks for a population that tends to be older, sicker, heavier, poorer and less vaccinated.

While the initial surge of COVID-19 deaths skipped over much of rural America, where roughly 15% of Americans live, nonmetropolitan mortality rates quickly started to outpace those of metropolitan areas as the virus spread nationwide before vaccinations became available, according to data from the Rural Policy Research Institute.

Since the pandemic began, about 1 in 434 rural Americans have died of COVID, compared with roughly 1 in 513 urban Americans, the institute's data shows. And though vaccines have reduced overall COVID death rates since the winter peak, rural mortality rates are now more than double urban rates — and accelerating quickly.

In rural northeastern Texas, Titus Regional Medical Center CEO Terry Scoggin is grappling with a 39% vaccination rate in his community. Eleven patients died of COVID in the first half of September at his hospital in Mount Pleasant, population 16,000. Typically, three or four non-hospice patients die there in a whole month.

"We don't see death like that," Scoggin said. "You usually don't see your friends and neighbors die."

Part of the problem is that COVID incidence rates in September were roughly 54% higher in rural areas than elsewhere, said Fred Ullrich, a University of Iowa College of Public Health research analyst who co-authored the institute's report. He said the analysis compared the rates of nonmetropolitan, or rural, areas and metropolitan, or urban, areas. In 39 states, he added, rural counties had higher rates of COVID than their urban counterparts.

"There is a national disconnect between perception and reality when it comes to COVID in rural America," said Alan Morgan, head of the National Rural Health Association. "We've turned many rural communities into kill boxes. And there's no movement towards addressing what we're seeing in many of these communities, either among the public or among governing officials."

Still, the high incidence of cases and low vaccination rates don't fully capture why mortality rates are so much higher in rural areas than elsewhere. Academics and officials alike describe rural Americans' greater rates of poor health and their limited options for medical care as a deadly combination. The pressures of the pandemic have compounded the problem by deepening staffing shortages at hospitals, creating a cycle of worsening access to care.

It's the latest example of the deadly coronavirus wreaking more havoc in some communities than others. COVID has also killed Native American, Black and Hispanic people at disproportionately high rates.

Vaccinations are the most effective way to prevent COVID infections from turning deadly. Roughly 41% of rural America was vaccinated as of Sept. 23, compared with about 53% of urban America, according to an analysis by The Daily Yonder, a newsroom covering rural America. Limited supplies and low access made shots hard to get in the far-flung regions at first, but officials and academics now blame vaccine hesitancy, misinformation and politics for the low vaccination rates.

In hard-hit southwestern Missouri, for example, 26% of Newton County's residents were fully vaccinated as of Sept. 27. The health department has held raffles and vaccine clinics, advertised in the local newspaper, and even driven the vaccine to those lacking transportation in remote areas, according to department administrator Larry Bergner. But he said interest in the shots typically increases only after someone dies or gets seriously ill within a hesitant person's social circle.

Additionally, the overload of COVID patients in hospitals has undermined a basic tenet of rural health care infrastructure: the capability to transfer patients out of rural hospitals to higher levels of specialty care at regional or urban health centers.

"We literally have email Listservs of rural chief nursing officers or rural CEOs sending up an SOS to the group, saying, 'We've called 60 or 70 hospitals and can't get this heart attack or stroke patient or surgical patient out and they're going to get septic and die if it goes on much longer,'" said John Henderson, president and CEO of the Texas Organization of Rural & Community Hospitals.

Morgan said he can't count how many people have talked to him about the transfer problem.

"It's crazy, just crazy. It's unacceptable," Morgan said. "From what I'm seeing, that mortality gap is accelerating."

Access to medical care has long bedeviled swaths of rural America — since 2005, 181 rural hospitals have closed. A 2020 KHN analysis found that more than half of U.S. counties, many of them largely rural, don't have a hospital with intensive care unit beds.

Pre-pandemic, rural Americans had 20% higher overall death rates than those who live in urban areas, due to their lower rates of insurance, higher rates of poverty and more limited access to health care, according to 2019 data from the Centers for Disease Control and Prevention's National Center for Health Statistics.

In southeastern Missouri's Ripley County, the local hospital closed in 2018. As of Sept. 27, only 24% of residents were fully vaccinated against COVID. Due to a recent crush of cases, COVID patients are getting sent home from emergency rooms in surrounding counties if they're not "severely bad," health department director Tammy Cosgrove said.

The nursing shortage hitting the country is particularly dire in rural areas, which have less money than large hospitals to pay the exorbitant fees travel nursing agencies are demanding. And as nursing temp agencies offer hospital staffers more cash to join their teams, many rural nurses are jumping ship. One of Scoggin's nurses told him she had to take a travel job — she could pay off all her debt in three months with that kind of money.

And then there's the burnout of working over a year and a half through the pandemic. Audrey Snyder, the immediate past president of the Rural Nurse Organization, said she's lost count of how many nurses have told her they're quitting. Those resignations feed into a relentless cycle: As travel nurse companies attract more nurses, the nurses left behind shouldering their work become more burned out — and eventually quit. While this is true at hospitals of all types, the effects in hard-to-staff rural hospitals can be especially dire.

Rural health officials fear the staffing shortages could be exacerbated by health care vaccination mandates promised by President Joe Biden, which they say could cause a wave of resignations the hospitals cannot afford. About half of Scoggin's staff, for example, is unvaccinated.

Snyder warned that nursing shortages and their high associated costs will become unsustainable for rural hospitals operating on razor-thin margins. She predicted a new wave of rural hospital closures will further drive up the dire mortality numbers.

Staffing shortages already limit how many beds hospitals can use, Scoggin said. He estimated most hospitals in Texas, including his own, are operating at roughly two-thirds of their bed capacity. His emergency room is so swamped, he's had to send a few patients home to be monitored daily by an ambulance team.

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP