The U.S. has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015.

This article was published Thursday, September 23, 2021 in Kaiser Health News.

By Michelle Andrews  

It took years for Elle Moxley to get a diagnosis that explained her crippling gastrointestinal pain, digestion problems, fatigue, and hot, red rashes. And after learning in 2016 that she had Crohn's disease, a chronic inflammation of the digestive tract, she spent more than four years trying medications before getting her disease under control with a biologic drug called Remicade.

So Moxley, 33, was dismayed to receive a notice from her insurer in January that Remicade would no longer be covered as a preferred drug on her plan. Another drug, Inflectra, which the Food and Drug Administration says has no meaningful clinical differences from Remicade, is now preferred. It is a "biosimilar" drug.

"I felt very powerless," said Moxley, who recently started a job as a public relations coordinator for Kansas City Public Schools in Missouri. "I have this decision being made for me and my doctor that's not in my best interest, and it might knock me out of remission."

After Moxley's first Inflectra infusion in July, she developed a painful rash. It went away after a few days, but she said she continues to feel extremely fatigued and experiences gastrointestinal pain, constipation, diarrhea and nausea.

Many medical professionals look to biosimilar drugs as a way to increase competition and give consumers cheaper options, much as generic drugs do, and they point to the more robust use of these products in Europe to cut costs.

Yet the U.S. has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015. That's partly because of concerns raised by patients like Moxley and their doctors, but also because brand-name biologics have kept biosimilars from entering the market. The companies behind the brand-name drugs have used legal actions to extend the life of their patents and incentives that make offering the brand biologic more attractive than offering a biosimilar on a formulary, listing which drugs are covered on an insurance plan.

"It distorts the market and makes it so that patients can't get access," said Dr. Jinoos Yazdany, a professor of medicine and chief of the rheumatology division at Zuckerberg San Francisco General Hospital.

The FDA has approved 31 biosimilar medications since 2015, but only about 60% have made it to market, according to an analysis by NORC, a research organization at the University of Chicago.

Remicade's manufacturer, Johnson & Johnson, and Pfizer, which makes the Remicade biosimilar Inflectra, have been embroiled in a long-running lawsuit over Pfizer's claims that Johnson & Johnson tried to choke off competition through exclusionary contracts with insurers and other anti-competitive actions. In July, the companies settled the case on undisclosed terms.

In a statement, Pfizer said it would continue to sell Inflectra in the U.S. but noted ongoing challenges: "Pfizer has begun to see progress in the overall biosimilars marketplace in the U.S. However, changes in policy at a government level and acceptance of biosimilars among key stakeholders are critical to deliver more meaningful uptake so patients and the healthcare system at-large can benefit from the cost savings these medicines may deliver."

Johnson & Johnson said it is committed to making Remicade available to patients who choose it, which "compels us to compete responsibly on both price and value."

Biologic medicines, which are generally grown from living organisms such as animal cells or bacteria, are more complex and expensive to manufacture than drugs made from chemicals. In recent years, biologic drugs have become a mainstay of treatment for autoimmune conditions like Crohn's disease and rheumatoid arthritis, as well as certain cancers and diabetes, among other conditions.

Other drugmakers can't exactly reproduce these biologic drugs by following chemical recipes as they do for generic versions of conventional drugs.

Instead, biosimilar versions of biologic drugs are generally made from the same types of materials as the original biologics and must be "highly similar" to them to be approved by the FDA. They must have no clinically meaningful differences from the biologic drug, and be just as safe, pure and potent. More than a decade after Congress created an approval pathway for biosimilars, they are widely accepted as safe and effective alternatives to brand biologics.

Medical experts hope that as biosimilars become more widely used they will increasingly provide a brake on drug spending.

From 2015 to 2019, drug spending overall grew 6.1%, while spending on biologics grew more than twice as much — 14.6% — according to a report by IQVIA, a healthcare analytics company. In 2019, biologics accounted for 43% of drug spending in the U.S.

Biosimilars provide a roughly 30% discount over brand biologics in the U.S. but have the potential to reduce spending by more than $100 billion in the next five years, the IQVIA analysis found.

In a survey of 602 physicians who prescribe biologic medications, more than three-quarters said they believed biosimilars are just as safe and effective as their biologic counterparts, according to NORC.

But they were less comfortable with switching patients from a brand biologic to a biosimilar. While about half said they were very likely to prescribe a biosimilar to a patient just starting biologic therapy, only 31% said they were very likely to prescribe a biosimilar to a patient already doing well on a brand biologic.

It can be challenging to find a treatment regimen that works for patients with complicated chronic conditions, and physicians and patients often don't want to rock the boat once that is achieved.

In Moxley's case, for example, before her condition stabilized on Remicade, she tried a conventional pill called Lialda, the biologic drug Humira and a lower dose of Remicade.

Some doctors and patients raise concerns that switching between these drugs might cause patients to develop antibodies that cause the drugs to lose effectiveness. They want to see more research about the effects of such switches.

"We haven't seen enough studies about patients going from the biologic to the biosimilar and bouncing back and forth," said Dr. Marcus Snow, chair of the American College of Rheumatology's Committee on Rheumatologic Care. "We don't want our patients to be guinea pigs."

Manufacturers of biologic and biosimilar drugs have participated in advertising, exhibit or sponsorship opportunities with the American College of Rheumatology, according to ACR spokesperson Jocelyn Givens.

But studies show a one-time switch from Remicade to a biosimilar like Inflectra does not cause side effects or the development of antibodies, said Dr. Ross Maltz, a pediatric gastroenterologist at Nationwide Children's Hospital in Columbus, Ohio, and former member of the Crohn's & Colitis Foundation's National Scientific Advisory Committee. Studies may be conducted by researchers with extensive ties to the industry and funded by drugmakers.

Situations like Moxley's are unusual, said Kristine Grow, senior vice president of communications at AHIP, an insurer trade group.

"For patients who have been taking a brand-name biologic for some time, health insurance providers do not typically encourage them to switch to a biosimilar because of a formulary change, and most plans exclude these patients from any changes in cost sharing due to formulary changes," she said.

Drugmakers can seek approval from the FDA of their biosimilar as interchangeable with a biologic drug, allowing pharmacists, subject to state law, to switch a physician's prescription from the brand drug, as they often do with generic drugs.

However, the FDA has approved only one biosimilar (Semglee, a form of insulin) as interchangeable with a biologic (Lantus).

Like Moxley, many other patients using biologics get copay assistance from drug companies, but the money often isn't enough to cover the full cost. In her old job as a radio reporter, Moxley said, she hit the $7,000 maximum annual out-of-pocket spending limit for her plan by May.

In her new job, Moxley has an individual plan with a $4,000 maximum out-of-pocket limit, which she expects to blow past once again within months.

But she received good news recently: Her new plan will cover Remicade.

"I'm still concerned that I will have developed antibodies since my last dose," she said. "But it feels like a step in the direction of good health again."

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

Have letter carriers include in their responsibilities home visits and basic health checks on the growing population of frail and elderly.

This article was published on Thursday, September 23, 2021 in Kaiser Health News.

By Elisabeth Rosenthal

Two of America's toughest problems can be tempered with one solution.

The baby boom generation is graying, creating an ever-larger population of older people, many isolated, whose needs the nation is ill equipped to meet or even monitor.

Meanwhile, the U.S. Postal Service has gone $160 billion into debt, in part as digital communications have replaced snail mail. This year it has requested two rate increases for stamps and other services, bringing the price of a first-class stamp to 58 cents. It is running an aggressive TV ad campaign, presumably to build support for Congress to step in with some kind of rescue.

So here's a potential win-win solution: Have letter carriers spend less time delivering mail, much of which now involves fliers and solicitations. Instead, include in their responsibilities — "the swift completion of their appointed rounds" — home visits and basic health checks on the growing population of frail and elderly.

This may sound out-of-the-box, but it's already done successfully and profitably in other countries, like France and Japan. Indeed, the idea that the USPS could get more involved in home health services — to fill a need and earn money — was suggested by the agency's own Office of Inspector General in March.

So far, other solutions to fill the need for home healthcare have proved elusive. President Joe Biden proposed $400 billion in his initial infrastructure plan to improve services for the homebound elderly, a feature that Congress didn't retain. But Democrats' congressional reconciliation budget resolution, currently under debate, could allot money to the cause.

Meanwhile tens of millions of older Americans — the "old old" — are not so sick that they need a hospital but are unable to live safely at home without help. In Maine, the state with the oldest population, an estimated 10,000 hours of needed and approved home care is not provided every week because of a dearth of workers. That, for example, leaves patients with early dementia fending for themselves at great risk. People who need help preparing medicine or meals can be missing both.

Postal workers are already on virtually every block of America six days a week. They are "people people," as the recent TV ads portray, often beloved by their customers.

Yes, letter carriers are already busy, in part because of the volume of package deliveries, which jumped during the pandemic. But what about scrapping the idea of everyday delivery? That too was suggested by the agency's inspector general, a decade ago. Mail could be delivered just a few times a week, say, every other day. And on the off days, presto — we get a new on-the-ground home health workforce.

They could do home visits, to redress an epidemic of loneliness among older homebound Americans and check on whether a customer has an adequate supply of food and medicines. With a bit of retraining, they could check and record blood pressure, test blood sugar levels in people with diabetes and even administer pills.

Letter carriers already effectively serve as informal watchdogs, noticing if an older client hasn't picked up mail, for example. In some parts of the country, that function is formalized under a voluntary program called Carrier Alert, in which the Postal Service notifies a participating service agency, noted Brian Renfroe, executive vice president of the National Association of Letter Carriers.

But the USPS could be paid, by the government or by individuals, for this and other valuable services.

In France, since 2017, families have been able to pay a small monthly fee to La Poste — about 20 euros or $24 — to have home check-ins for an older relative. The service, called Watch Over My Parents, offers one to six visits per week, and the postal worker reports the resident's condition to the client each time.

Japan launched a similar postal program through a public-private partnership in 2017, to underwrite paid, monthly, half-hour visits (a friendly chat and health check) with members of the aging at-home population.

The post office's essential functions — like delivering the federal government's $1,200 pandemic relief checks, mail-in ballots and prescription medicines — are too important to lose. And USPS finances have improved recently, in part because of package deliveries and a $10 billion loan through the 2020 American Recovery and Reinvestment Act.

But when was the last time you ran to the mailbox to hear from a friend, check the news, or collect a bank statement or bill? It just makes sense financially and socially for the agency to evolve to meet the nation's current needs.

Of course, this alone will not close the USPS' $160 billion budget gap, the bulk of which resulted from a government mandate that it prefund the agency's pension plan and, especially, its retiree health benefits. Without that, the USPS would have been in the black (often just barely) for about half of the years since 2006 — though, overall, it was nearly $10 billion in debt during the period.

Solving that requirement will take congressional intervention; changes will also be needed in a law that currently requires six-day-a-week delivery and generally precludes the USPS from offering "nonpostal" products. Bipartisan legislation introduced in the Senate this year seeks to loosen the latter restriction to help the USPS earn money from services of "enhanced value to the public" (like selling hunting and fishing licenses).

Today, the postal service delivers vast amounts of "junk mail," also called direct mail. Companies spend about $167 annually on direct mail per person, yielding good returns, the industry says. But much of it ends up unread and unopened in the trash or recycling bin, an environmental nightmare.

Why not instead redeploy some of the U.S. Postal Service's vast supply of human resources to deliver a service our aging population — and our country — desperately needs?

Elisabeth Rosenthal: erosenthal@kff.org, @rosenthalhealth

Three physicians in this article are members of the "Disinformation Dozen," a group of top superspreaders of COVID vaccine misinformation on social media.

This article was published on Wednesday, September 22, 2021 in Kaiser Health News.

By Victoria Knight  

Earlier this month, Dr. Rashid Buttar posted on Twitter that COVID-19 "was a planned operation" and shared an article alleging that most people who got the COVID vaccine would be dead by 2025.

His statement is a recent example in what has been a steady stream of spurious claims surrounding the COVID vaccines and treatments that swirl around the public consciousness. Others include testimony in June by Dr. Sherri Jane Tenpenny before Ohio state legislators that the vaccine could cause people to become magnetized. Clips from the hearing went viral on the internet. On April 9, 2020, Dr. Joseph Mercola posted a video titled "Could hydrogen peroxide treat coronavirus?" which was shared more than 4,600 times. In the video, Mercola said inhaling hydrogen peroxide through a nebulizer could prevent or cure COVID.

These physicians are identified as members of the "Disinformation Dozen," a group of top superspreaders of COVID vaccine misinformation on social media, according to a 2021 report by the nonprofit Center for Countering Digital Hate. The report, based on an analysis of anti-vaccine content on social media platforms, found that 12 people were responsible for 65% of it. The group is composed of physicians, anti-vaccine activists and people known for promoting alternative medicine.

The physician voices are of particular concern because their medical credentials lend credence to their unproven, often dangerous pronouncements. All three continue to hold medical licenses and have not faced consequences for their COVID-related statements.

But leaders of professional medical organizations increasingly are calling for that to change and urging medical oversight boards to take more aggressive action.

In July, the Federation of State Medical Boards, the national umbrella organization for the state-based boards, issued a statement making clear that doctors who generate and spread COVID misinformation could be subject to disciplinary action, including the suspension or revocation of their licenses. The American Board of Family Medicine, American Board of Internal Medicine and American Board of Pediatrics issued a joint statement Sept. 9 in support of the state boards' position, warning that "such unethical or unprofessional conduct may prompt their respective Board to take action that could put their certification at risk."

And the superspreaders identified by the center's report are not alone. KHN identified 20 other doctors who have made false or misleading claims about COVID by combing through published fact checks and other news coverage.

For example, at an Indiana school board meeting in August, Dr. Dan Stock claimed the surge in COVID cases this summer was due to "antibody mediated viral enhancement" from people receiving COVID vaccines. PolitiFact rated his claim "Pants on Fire" false.

Dr. Stella Immanuel, a member of a group America's Frontline Doctors, which has consistently made false statements about COVID, said in a video that went viral in July 2020 that masks weren't needed because COVID could be cured by hydroxychloroquine. Immanuel's website currently promotes a set of vitamins, as well as hydroxychloroquine and ivermectin, as COVID treatments.

Two of the doctors mentioned by name in this article responded to requests for comment. Mercola offered documents to rebut criticisms of his hydrogen peroxide COVID treatment and took issue with the center's "Disinformation Dozen" report methodology. Buttar defended his positions, saying via email that "the science is clear and anyone who contests it, has a suspect agenda at best and/or lacks a moral compass." He also pointed to data from the Centers for Disease Control and Prevention's Vaccine Adverse Event Recording System, considered inconclusive by many experts.

Since the onset of the COVID pandemic, misinformation has been widespread on social media platforms. And many experts blame it for undermining efforts to curb the coronavirus's spread. A recent poll showed that more than 50% of Americans who won't get vaccinated cited conspiracy theories as their reasons — for example, saying the vaccines cause infertility or alter DNA.

Some physicians have gained notoriety by embracing COVID-related fringe ideas, quack treatments and falsehoods via social media, conservative talk shows and even in person with patients. Whether promoting the use of ivermectin, an anti-parasitic drug for animals, or a mix of vitamins to treat COVID, doctors' words can be especially powerful. Public opinion polls consistently show that Americans have high trust in doctors.

"There is a sense of credibility that comes with being a doctor," said Rachel Moran, a researcher who studies COVID misinformation at the University of Washington. "There is also a sense they have access to insider info that we don't. This is a very confusing time, and it can seem that if anyone knows what I should be doing in this situation, it's a doctor."

While COVID is a novel and complicated infectious disease, physicians spreading misinformation generally have no particular expertise in infectious diseases. Dr. Scott Atlas, who endorsed former President Donald Trump's unproven statements about the course of the pandemic, is a radiation oncologist.

Traditionally, the responsibility of policing physicians has fallen to state medical boards. Beyond overseeing the licensing process, these panels investigate complaints about doctors and discipline those who engage in unethical, unprofessional or, in extreme cases, criminal activity. Any member of the public can submit a complaint about a physician.

"The boards are relatively slow and weak and it's a long, slow process to pull somebody's license," said Arthur Caplan, founding head of the Department of Medical Ethics at New York University. "In many states, they have their hands full with doctors who have committed felonies, doctors who are molesting their patients. Keeping an eye on misinformation is somewhat down on the priority list."

To date, only two doctors have reportedly faced such sanctions. In Oregon, Dr. Steven LaTulippe had his license suspended in December 2020 for refusing to wear a face mask at his clinic and telling patients that masks were ineffective in curbing the spread of COVID, and even dangerous. Dr. Thomas Cowan, a San Francisco physician who posted a YouTube video that went viral in March 2020 stating that 5G networks cause COVID, voluntarily surrendered his medical license to California's medical board in February 2021.

Dr. Humayun Chaudhry, president of the Federation of State Medical Boards, however, said it's possible some doctors could already be the subject of inquiries and investigations, since these actions are not made public until sanctions are handed down.

KHN reached out to the medical and osteopathic boards of all 50 states and the District of Columbia to see if they had received COVID misinformation complaints. Of the 43 that responded, only a handful shared specifics.

During a one-week period in August, Kansas' medical board received six such complaints. In all, the state has received 35 complaints against 20 licensees about spreading COVID misinformation on social media and in person. Indiana has received about 30 in the past year. South Carolina said it had about 10 since January. Rhode Island didn't share the number of complaints but said it has taken disciplinary action against one doctor for spreading misinformation, though it hasn't moved to suspend his license. (The disciplinary measures include a fine, a reprimand on the doctor's record and a mandate to complete an ethics course.) Five states said they had received only a couple, and 11 states reported receiving no complaints regarding COVID misinformation.

Confidentiality laws in 13 states prevented those boards from sharing information about complaints.

Social media companies have also been slow to take action. Some doctors' accounts — specifically those among the Disinformation Dozen — have been suspended, but others are still active and posting misinformation.

Imran Ahmed, CEO of the Center for Countering Digital Hate, said social media platforms often don't consistently apply their rules against spreading misinformation.

"Even when it's the same companies, Facebook will sometimes take posts down, but Instagram will not," Ahmed said, referring to Facebook's ownership of Instagram. "It goes to show their piecemeal, ineffective approach to enforcing their own rules."

A Facebook spokesperson said the company has removed over 3,000 accounts, pages and groups for repeatedly violating COVID and vaccine misinformation policies since the beginning of the pandemic. Buttar's Facebook and Instagram pages and Tenpenny's Facebook page have been removed, while Mercola's Facebook posts have been demoted, which means fewer people will see them. Tenpenny and Mercola still have Instagram accounts.

Part of the challenge may be that these doctors sometimes present scientific opinions that aren't mainstream but are viewed as potentially valid by some of their colleagues.

"It can be difficult to prove that what is being said is outside the range of scientific and medical consensus," said Caplan. "The doctors who were advising Trump — like Scott Atlas — recommended herd immunity. That was far from the consensus of epidemiologists, but you couldn't get a board to take his license away because it was a fringe opinion."

Even if these physicians don't face consequences, it is likely, experts said, that the public health will.

"Medical misinformation doesn't just result in people making bad personal and community health choices, but it also divides communities and families, leaving an emotional toll," said Moran, the University of Washington researcher. "Misinformation narratives have real sticking power and impact people's ability to make safe health choices."

Victoria Knight: vknight@kff.org, @victoriaregisk

Montana is a national hot spot for COVID infections, recording the highest percentage increase in new cases over the past seven days.

This article was published on Wednesday, September 22, 2021 in Kaiser Health News.

By Nick Ehli

BILLINGS, Mont. — Nurses fill the hospital room to turn a patient from his stomach to his back. The ventilator forcing air into him is most effective when he's on his stomach, so he is in that position most hours of the day, sedated and paralyzed by drugs.

Lying on his stomach all those hours has produced sores on his face, and one nurse dabs at the wounds. The dark lesions are insignificant given his current state, but she continues just the same, gently, soothingly, appearing to whisper to him as she works.

The man has been a patient at Billings Clinic for nearly a month, most of that time in the hospital's intensive care unit. He is among other patients, room after room of them, with the same grim tubes inserted down their throats. They have COVID-19 — the vast majority unvaccinated against the virus, the hospital says. Visitors generally aren't permitted in these rooms, but the man's mother comes most days to gaze through a glass window for the allowed 15 minutes.

This all happened Friday. He was dead, at age 24, by Sunday morning.

The hospital's morgue cart arrived at the ICU — as it frequently has these days — then the room was sterilized, another patient took the man's place, and the cycle began again. In the past week, 14 people have died of COVID here, the state's largest hospital.

"I do feel a little hopeless," said Christy Baxter, the hospital's director of critical care.

The situation has played out in hospitals around the nation since 2020. But now Montana is a national hot spot for COVID infections, recording the highest percentage increase in new cases over the past seven days. The state announced 1,209 new cases on Friday, and Yellowstone County, home to Billings Clinic, is seeing the worst of it. Last week, the county had 2,329 active cases, more than the next two counties combined.

What's different from the early scenes of the pandemic is the public's response. Not so long ago, the cheers of community support could be heard from the hospital parking lot. Now, tensions are so strained that Billings Clinic is printing signs for its hallways, asking that the staff members not be mistreated.

The ICU here has space for 28 patients but last Friday was operating at 160% capacity, Baxter said. To handle the overflow, nurses elsewhere provide care beyond their training as COVID patients fill other parts of the hospital. In the lobby of the emergency department, rooms roughly 6 feet by 6 feet have been fashioned with makeshift plastic walls. Ten members of the Montana Army National Guard arrived last week to help however they can. Hospital staffers volunteer to sit with dying patients. Beds line hallways.

"The problem is," said Brad Von Bergen, the hospital's ER manager, "we are running out of hallways."

The hospital announced it may soon implement "crisis standards of care," which basically means it will ration its equipment, staff and medicine, giving preference to those it can most likely save, regardless of vaccination status. It's an ugly system, abhorred by those who will wield it, with tiebreakers in place to decide who potentially lives and dies. Other hospitals in Montana have taken similar steps.

An overcrowded hospital also means that a person ― say, one injured in a car crash in rural eastern Montana and needing advanced hospitalization ― won't be able to get that care at Billings Clinic.

"We are at the point where we are not confident going forward that we can continue to meet all patients' needs," said Dr. Nathan Allen, the medical ethicist for Billings Clinic and its department chair for emergency medicine. "And that's heartbreaking."

"Nobody wants to be in a position where we may have to ration healthcare and potentially remove a ventilator from one patient who would likely die and give it to another," said Dr. Scott Ellner, the hospital's CEO. "Are we there? I would say we are very close."

To some extent, that rationing is already happening. A patient still hospitalized here with COVID might have benefited from a machine, known as an ECMO machine, needed to keep his heart and lungs functioning. Operating that machine, though, requires at least one nurse, 24 hours a day, usually for two to three weeks. Typically, it would be a last-ditch effort for the most critical of patients. Even with that care, the prognosis for the middle-aged man would be poor. Without it, Baxter said, he will assuredly die.

"The reality is I can't staff that," Baxter said. "Do you give that optimal care to one patient or do you give great care to five?"

Billings Clinic would hire more than 100 additional nurses if it could. The staffing shortage is not unique to this hospital; it's nationwide, meaning the needed help isn't arriving anytime soon. Baxter tells the story of a young nurse who quit, saying he had grown tired of lying to patients he knew would die.

"The patients look at you with that fear in their eyes and say, 'Am I going to make it?'" Baxter said. "You want to encourage them to not give up hope, but you also know the chances of survival are going to be slim."

Recently, a patient's dying wish was to have their preschool-age child come and sit with them, to see them one last time. That typically wouldn't be allowed, but an exception was made, with staffers at the hospital draping the child in oversized protective clothing, goggles and an N95 mask. Afterward, the nurse and doctor sobbed with the patient.

"The moral distress of working in healthcare is for many, many people extremely high right now," said Allen.

Intensifying that, he said, are patients or their loved ones mistreating doctors and nurses. Threats have on occasion required a police response. Screaming, profanity-laden insults are a daily occurrence. One patient threw his own feces at a doctor. Some, even in the face of an intubation tube, question the need to be vaccinated or the effectiveness of the medicine being prescribed.

Dr. Sara Nyquist, an emergency medicine physician, said she has been asked by a patient if she is a Republican or a Democrat.

"I said, 'I am your doctor,'" she recalled. "You do wonder how we got here."

Ellner, the clinic's CEO, said he doesn't understand what happened to civility. "There is a part of the society that wants to pretend that the COVID surge isn't really happening," he said. "But this is our reality every single day."

Jennifer Tafelmeyer, a nurse in the hospital's cardiovascular unit, said the best part of her job before the pandemic was helping patients improve, walking them down hallways, talking about diet and exercise, and eventually escorting them to the front door. That hasn't happened in a long time.

"We just don't get the wins," she said.

As she told the story, she stopped to wipe a tear. Moments before, she had learned that one of the patients on this floor was not expected to survive the night.

Allen predicted Billings Clinic hasn't yet seen the worst of the recent surge in infections.

"We are still seeing growing numbers in community cases," he said. "And we know hospitalizations lag behind new diagnoses. Unfortunately, it can absolutely get worse than where it is at."

In the meantime, he said, he expects the doctors and nurses here will rally as they have, taking comfort from words of thanks from many patients and gestures like a father bringing pizza to the emergency department as a show of appreciation for the care given his child.

"The most difficult things have been the big things," Allen said, "and the most inspiring things have been the little things."