Colorado Lawmakers Wage Multifront Assault on High Drug Costs

KFF Health News, May 25, 2021

State officials estimate the combined impact of the various measures could save Coloradans between 20% and 40% in out-of-pocket costs.

This article was published on Tuesday, May 25, 2021 in Kaiser Health News.

By Markian Hawryluk

DENVER — Tired of waiting for federal action to reduce prescription drug costs, Colorado is acting on its own — even if it must do so with one arm tied behind its back. Unable to set prices or change patent protections, the state is exploring creative legislative and administrative approaches to lower out-of-pocket costs on medications.

While none of the efforts alone would result in broad-based, deep cuts, state officials estimate the combined impact of the various measures could save Coloradans between 20% and 40% in out-of-pocket costs.

"That's why it's so important to have a variety of levers," said Kim Bimestefer, executive director of the Colorado Department of Healthcare Policy & Financing. "You start stacking all these up, and it's remarkable how much we can drive down the cost."

Like many other states, Colorado has been looking to lower drug prices for several years, issuing a report late in 2019 that explained why the state spent more than $1 billion annually on drug purchases. Although the pandemic derailed action last year, the state updated the report in January, and state agencies and the legislature are working to implement some of the proposals.

One bill would create a prescription drug affordability board, which could review prices of medications sold in the state to consumers and set payment limits. The legislation, backed by Democratic Gov. Jared Polis, has already passed the Colorado Senate and is making its way through the House. The board would be charged with ensuring those savings are passed on to consumers.

Drugs would qualify for an affordability review under various triggers, including when prices increase by more than 10% per year, or exceed either $30,000 a year for brand-name drugs or $100 a month for generics per person. Patients or consumer advocates could also nominate drugs for review.

State officials estimate those categories probably cover 100 to 125 medications, but the board would be permitted to set limits for only 12 drugs per year. The board could review affordability of more drugs and make recommendations for other types of administrative or legislative action to lower their costs.

"It is inherently limited," said Isabel Cruz, a policy manager with the Colorado Consumer Health Initiative, a nonprofit that seeks to lower health costs for state residents. "That's the political reality that we had to accept."

The bill is intended to help patients like 18-year-old Koen Lichtenbelt, of Ridgeway, who was diagnosed with a rare autoinflammatory disease in kindergarten. The condition damaged his nerves and, in December, doctors prescribed the drug Hizentra, with an out-of-pocket cost of $10,000 per month. His parents footed the bill for three months before their insurance plan agreed to cover the drug.

His mother, Cat Lichtenbelt, said, that's "$30,000, which is the price of a car, but, you know, this is our son's life."

Once on the medication, Koen, who had been missing half of his school days over the course of his education, was able to graduate this year. He's been accepted to Colorado State University but is taking a gap year to work as a first responder at a local fire department. Had he not had access to the drug, Lichtenbelt said, her son would likely be reliant on state aid now.

"There is a need for pharmaceutical companies to continue to develop medications and drugs to improve people's lives," she said. "However, what is the price point at which there is access to actually being able to use those drugs?"

In addition to opposition from the state's hospital and pharmacy groups, the pharmaceutical industry is throwing its weight against the bill, including threats not to sell in Colorado the drugs facing payment limits.

"Creating a board of unelected bureaucrats with the authority to arbitrarily decide what medicines are worth and what medicines patients can get would be a disaster for patients," said Hannah Loiacono, a spokesperson for the national Pharmaceutical Research and Manufacturers of America industry group.

The Colorado BioScience Association warned that setting payment limits could reduce the funding available for new pharmaceutical discoveries.

"If passed, this bill will create unpredictability for the startups and development-stage companies in Colorado's life sciences ecosystem, making it harder for them to raise funds," said Jennifer Jones Paton, the group's president and CEO. "Investors will look elsewhere for opportunities."

Nonetheless, the bill is expected to pass. Proponents said it's unlikely a manufacturer could carve out specific drugs or states from its supply chain and pointed out that drug companies already sell their highest-cost drugs at lower prices to Medicaid, community health clinics and charity hospitals.

The governor's office is also implementing changes on its own. On July 1, it is formally launching a tool embedded in electronic medical records allowing doctors and other prescribers to see what patients with public or private health plans would pay for a medication. Bimestefer said 80% of prescribers in the state have the tool enabled, and 37% are using it ahead of the official start date.

The state is also pursuing contracts with drug companies that would link prices to the effectiveness of the drugs, measured, for example, by whether they reduce hospitalizations or heart attacks.

The Colorado legislature had previously approved importing drugs from Canada for consumers to purchase at lower costs and, now with federal approval, the state is reviewing bids from contractors to make that happen. The state estimates Canadian imports would reduce costs for 50 common drugs by 63%. But the state found that importing drugs from Australia and France could save 78% to 84%. Colorado would need an adjustment to federal law to expand importation to those countries but could rely on the same infrastructure being built for Canadian imports.

"If we open up other countries, we could increase the supply of the drugs coming in," Bimestefer said. "This will actually help us battle pharma if we can turn on the spigot full, full, full throttle."

Colorado's efforts are part of a national trend by states that started in earnest about five years ago, said Megan Olsen, a principal in the policy practice at Avalere, a healthcare consulting firm in Washington, D.C. The lack of federal action, as well as exploding Medicaid and state employee health plan budgets, encouraged states to tackle the issue.

"Early on the focus was on transparency," she said. "Now what we're seeing is sort of a progression from those transparency bills into more of trying to regulate prices or control prices in different ways."

According to the National Academy for State Health Policy, which provides draft health policy legislation to states, nearly every single state and U.S. territory is considering some sort of prescription drug cost bill this year. There are 14 prescription drug affordability board bills, 24 foreign drug importation bills and 58 bills addressing prescription drug coupons or cost sharing. And, following a December U.S. Supreme Court ruling allowing states to regulate pharmacy benefit managers, the go-between companies that control the drug prices paid by insurance companies, states are considering 97 separate PBM measures. Colorado legislators, for example, are debating a bill that would force those companies to compete to service state health plans.

Trish Riley, executive director for the academy, said states serve as 50 health policy laboratories, experimenting with policies that can set precedent for other states, prove the viability of various approaches and put pressure on the feds to act. Some national policies, such as the Children's Health Insurance Program, started as state measures.

"We're on the front lines," Bimestefer said. "And we can see some of the solutions more readily."

While a patchwork of state regulations can add administrative burdens for drug companies, Riley said it can also spur federal action.

"I would argue chaos theory," Riley said. "The more differentiation between states, the more there's pressure on the federal government to make a more consistent system."

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk

Corporations Encourage Employee Vaccination but Stop Short of Mandates

KFF Health News, May 25, 2021

Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership.

This article was published on Tuesday, May 25, 2021 in Kaiser Health News.

By Anna Almendrala

Many of the companies with the largest number of employees say they'll do almost anything to encourage their employees to get vaccinated. But a survey of some of them found that none would be inclined to mandate shots as a condition for holding a job.

Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership, emphasizing that the shots can both help protect individuals and bring the pandemic to a close.

CVS Health, which administers COVID vaccines as part of the federal pharmacy distribution program, says it strongly encourages the shots for its employees "from a public health standpoint" but won't mandate them. Starbucks is also encouraging the shots "to help mitigate the spread of COVID-19," but also doesn't mandate them.

Some companies are giving employees paid time off to either get shots or stay home if they have side effects, a trend that could increase now that the Biden administration has announced tax credits for smaller companies to offer up to 80 hours of paid sick leave until Sept. 30.

Target is giving hourly employees up to four additional hours of pay if they get the vaccine (two hours per shot). Amazon is offering $40 a shot for hourly workers, and Kroger is giving employees $100 if they receive both doses.

"Vaccination, in our view, is absolutely the only way out of the pandemic, both for us to get to normalcy and also for the country," said Dr. Vin Gupta, a pulmonologist and chief medical officer for Amazon's COVID response.

Amazon, like other large retailers, has experienced COVID outbreaks at its workplaces throughout the pandemic. In October it revealed that nearly 20,000 out of the company's 1.37 million front-line employees had tested positive or were presumed to have been infected with the COVID virus.

The company, which includes Whole Foods Market, distribution warehouses and data centers, has organized vaccination events for employees such as delivery workers in at least 29 states, and is among the giant companies doing the most to bring shots to its workers. But for now, Amazon isn't making vaccines mandatory.

Target, the only company among those surveyed that is offering financial incentives, extra paid time off and vaccinations at the worksite, has no plans to mandate the vaccinations.

However, the pandemic has brought a stream of fast-changing policies and recommendations from federal health authorities, and some companies, while declining mandates for now, indicated that could change.

"I don't have a crystal ball, and I can't predict the future, but that's what our message is now," said Carrie Altieri, vice president of communications for COVID strategy at IBM.

Legal and public health experts caution against any mandates before the Food and Drug Administration fully licenses the shots, which could happen this summer. The vaccines were authorized by the FDA for "emergency use" and as such employers can't require them, some legal experts have argued. Even post-licensure, though, companies could spark a backlash if they require employees to get them, said Joanne Rosen, senior lecturer and associate director at the Center for Law and the Public's Health at Johns Hopkins University.

A mandate could anger certain employees while only marginally increasing the number of vaccinations, Rosen and others say. It would be more prudent to focus on "carrots instead of sticks," she said.

"If the purpose of a mandate is to ensure that the largest number of people get vaccinated, a backlash to a mandate, in which you have more reluctance or opposition to vaccination, is the opposite of the outcome you want to get," she said.

Post-licensure, employers would face fewer legal challenges to vaccine mandates, especially if staff members work with medically vulnerable or at-risk patients, as in nursing homes or prisons. Aside from these special sectors, employee mandates aren't necessarily a good idea from a public health perspective, said Michelle Mello, a professor of law and medicine at Stanford University.

Hard-line vaccine opponents likely wouldn't be swayed by an employment-based vaccine requirement, and it could risk alienating some in the "wait and see" contingent, she said.

About 6% of Americans not yet vaccinated against COVID said they would accept a shot if it was required, according to an April survey from KFF. An additional 15% who hadn't gotten a shot expressed a "wait and see" attitude toward vaccination. And 13% flatly refused to be vaccinated.

Gains in the small group who say they'd get a shot if it's required might not be worth the uproar a mandate could foment, Mello said.

Mandates risk further politicizing COVID vaccines in U.S. society, said Brian Castrucci, CEO of the de Beaumont Foundation, a charity focused on public health.

Polling conducted by de Beaumont and GOP pollster Frank Luntz on April 15 found that 36% of those who voted for Donald Trump in the 2020 presidential election agreed it was important for American businesses to encourage and incentivize the vaccines, versus 54% of Joe Biden voters. The survey also found that 41% of Trump voters believed that businesses should not be involved in COVID vaccinations at all, compared with 18% of Biden voters.

"Mandating vaccination will hit every button there is on the political right," Castrucci said.

Once public health tools and strategies become politicized, local governments can choose to simply take them off the table as an option. A new Florida law bans businesses and government entities from requiring proof of a COVID vaccination. The law builds on Gov. Ron DeSantis' executive order, which he signed April 2.

"Vaccine verification can be a useful tool," Castrucci said. "Now it's no longer available in Florida."

Despite the potential backlash, the financial case for COVID vaccinations is clear, said Aaron Yelowitz, an economics professor at the University of Kentucky, given how effective the shots are.

Taking into account the costs of a shortened life span, mental health conditions and lost income due to illness and shutdowns, the COVID pandemic has cost the average American family of four almost $200,000, according to an analysis by researchers at Harvard.

Some of these costs may be borne by businesses in the form of lost productivity and higher health insurance prices, said Yelowitz. Financial incentives for the shots are thus an extremely tempting trade-off, he said.

Incentives for vaccination — like a $25 gift card or free Uber ride — are "surely worth it in terms of savings," Yelowitz said. In the same vein, he also called Ohio Gov. Mike DeWine's $5 million vaccine lottery "innovative and imaginative."

But for now, employers are sensitive about what they can and can't demand of workers, said Lindsey Leininger, a clinical professor of business administration at Dartmouth College. The tight labor market and the fraught, ongoing negotiations over when and how to bring employees back to the office makes some companies wary of asking too much of their workers, said Leininger, who advises smaller businesses on COVID vaccines and other issues.

"All of the businesses I work with have a general preference for carrot versus stick types of approaches," she said. "How many things do you want to mandate of your employees right now?"

Anna Almendrala: aalmendrala@kff.org, @annaalmendrala

Pandemic Leads Doctors to Rethink Unnecessary Treatment

KFF Health News, May 25, 2021

Numerous studies have shown that overtreatment causes unnecessary suffering and billions of dollars in unnecessary healthcare costs.

This article was published on Tuesday, May 25, 2021 in Kaiser Health News.

By Bruce Alpert

COVID-19 is opening the door for researchers to address a problem that has vexed the medical community for decades: the overtreatment and unnecessary treatment of patients.

On one hand, the pandemic caused major health setbacks for non-COVID patients who were forced to, or chose to, avoid tests and treatments for various illnesses. On the other hand, in cases in which no harm was done by delays or cancellations, medical experts can now reevaluate whether those procedures are truly necessary.

Numerous studies have shown that overtreatment causes unnecessary suffering and billions of dollars in unnecessary healthcare costs.

But never before, said researcher Allison Oakes, has there been such a large database to compare patients who received a particular test or treatment with those who did not.

Oakes was a principal author of an October paper in Health Affairs by the Research Consortium for Healthcare Value Assessment. The paper noted that COVID provided an important new measurement — examining outcomes for patients who received treatment before hospitals canceled care because of COVID and those who had their care canceled.

Areas ripe for study, said Oakes: colonoscopies done on patients older than age 85; hemoglobin blood work for Type 2 diabetes patients; semi-elective surgeries, such as knee arthroscopy for articular cartilage surgery; and yearly dental X-rays. All were done less often because of COVID, she said.

"There are two sides of the pie: low-value care and care that people get in trouble if they don't get," said Oakes, who expects researchers to take advantage of all the data provided from COVID on "both types of care."

One recent study looked at Veterans Affairs patients who had elective surgeries canceled because of COVID. The study found they were no more likely to visit hospital emergency departments than patients who had undergone those surgeries in 2018.

Dr. Heather Lyu of Brigham and Women's Hospital and Harvard Medical School said much testing and care was cut back by patients' fears of contracting COVID in a medical setting and because medical facilities and staffers were fighting just to keep up with COVID cases.

"There are some procedures, tests, and exams that cannot be delayed in any situation," Lyu said in an email. For example, she pointed to the screening, surveillance and treatment of cancer patients.

However, she said other tests and treatments can be delayed or canceled without negative effects. Lyu oversaw a 2017 survey of 2,000 physicians, with half the doctors saying the percentage of unnecessary medical care was higher than 20.6% and half saying it was lower.

Unnecessary treatment or overtreatment can result from several factors, the doctors in Lyu's survey said. Concerns about malpractice lead doctors to test even for unlikely problems to avoid missing something, they said. Sometimes health providers have difficulty assessing patients' prior medical records. Then there is the incentive for the health industry to boost revenue, sometimes to help pay for expensive testing equipment, the doctors said.

Leaps in technology are a major factor.

Dr. Jill Wruble, a radiologist at Johns Hopkins Medicine in Baltimore, said a CT scan that provided 30 or 40 images when she began practicing in the 1990s now provides thousands of high-resolution images.

"We now see things that we would have never seen before, like a lesion that may never become a problem," Wruble said.

Wruble said some patients still opt for aggressive medical treatment for things like that questionable lesion.

"Patients … often resist advice to 'watch and wait' and will demand surgery even when the operation itself comes with potentially dire consequences," Wruble said. The consequences are not only higher costs but potentially years of physical discomfort and pain, along with diminished physical abilities, she said.

Susan Gennaro, dean and professor at the William F. Connell School of Nursing at Boston College, said COVID provides not only opportunities to study unnecessary medical care, but also opportunities to examine areas of insufficient care. She cites a lack of mental health resources for COVID patients suffering through difficult treatment and even facing death without friends or family.

"When we are thinking of new ways to treat, we all need to think about our fascination with surgery and invasive procedures and start thinking more holistically about health," Gennaro said.

COVID's upending of scheduled non-COVID care hit hard in March and April last year, when the pandemic first began to overwhelm hospitals. Cancer surgery scheduled in April for Krista Petruzziello, for example, was postponed due to the focus on COVID care.

Instead of surgery, the 49-year-old real estate agent from Lowell, Massachusetts, received hormonal treatment usually reserved for breast cancer patients with larger tumors.

"It was concerning for sure," said Petruzziello. "Who knew a year ago how long it would be until surgery would be available for patients like me?"

It was only about six or seven weeks later when she had successful surgery to remove a tumor shrunken by the hormonal treatment. A recent follow-up scan found her clear of cancer, she said.

"Maybe there will be cases where the tumor disappears altogether [from hormonal treatment], allowing the surgery to be canceled," Petruzziello said. "Wouldn't that be a good thing?"

Dr. Harold Burstein, an oncologist at Dana-Farber Cancer Institute in Boston who treated Petruzziello, said breast cancer surgery will remain a key component of treatment for the foreseeable future. But he said hormone treatment "before surgery" can shrink the tumor and "hopefully make for less extensive surgery."

COVID, he said, forced healthcare providers to "think outside the box."

Corporations Encourage Employee Vaccination but Stop Short of Mandates

KFF Health News, May 25, 2021

Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership.

This article was published on Tuesday, May 25, 2021 in Kaiser Health News.

By Anna Almendrala

Many of the companies with the largest number of employees say they'll do almost anything to encourage their employees to get vaccinated. But a survey of some of them found that none would be inclined to mandate shots as a condition for holding a job.

Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership, emphasizing that the shots can both help protect individuals and bring the pandemic to a close.

CVS Health, which administers COVID vaccines as part of the federal pharmacy distribution program, says it strongly encourages the shots for its employees "from a public health standpoint" but won't mandate them. Starbucks is also encouraging the shots "to help mitigate the spread of COVID-19," but also doesn't mandate them.

Some companies are giving employees paid time off to either get shots or stay home if they have side effects, a trend that could increase now that the Biden administration has announced tax credits for smaller companies to offer up to 80 hours of paid sick leave until Sept. 30.

Target is giving hourly employees up to four additional hours of pay if they get the vaccine (two hours per shot). Amazon is offering $40 a shot for hourly workers, and Kroger is giving employees $100 if they receive both doses.

"Vaccination, in our view, is absolutely the only way out of the pandemic, both for us to get to normalcy and also for the country," said Dr. Vin Gupta, a pulmonologist and chief medical officer for Amazon's COVID response.

Amazon, like other large retailers, has experienced COVID outbreaks at its workplaces throughout the pandemic. In October it revealed that nearly 20,000 out of the company's 1.37 million front-line employees had tested positive or were presumed to have been infected with the COVID virus.

The company, which includes Whole Foods Market, distribution warehouses and data centers, has organized vaccination events for employees such as delivery workers in at least 29 states, and is among the giant companies doing the most to bring shots to its workers. But for now, Amazon isn't making vaccines mandatory.

Target, the only company among those surveyed that is offering financial incentives, extra paid time off and vaccinations at the worksite, has no plans to mandate the vaccinations.

However, the pandemic has brought a stream of fast-changing policies and recommendations from federal health authorities, and some companies, while declining mandates for now, indicated that could change.

"I don't have a crystal ball, and I can't predict the future, but that's what our message is now," said Carrie Altieri, vice president of communications for COVID strategy at IBM.

Legal and public health experts caution against any mandates before the Food and Drug Administration fully licenses the shots, which could happen this summer. The vaccines were authorized by the FDA for "emergency use" and as such employers can't require them, some legal experts have argued. Even post-licensure, though, companies could spark a backlash if they require employees to get them, said Joanne Rosen, senior lecturer and associate director at the Center for Law and the Public's Health at Johns Hopkins University.

A mandate could anger certain employees while only marginally increasing the number of vaccinations, Rosen and others say. It would be more prudent to focus on "carrots instead of sticks," she said.

"If the purpose of a mandate is to ensure that the largest number of people get vaccinated, a backlash to a mandate, in which you have more reluctance or opposition to vaccination, is the opposite of the outcome you want to get," she said.

Post-licensure, employers would face fewer legal challenges to vaccine mandates, especially if staff members work with medically vulnerable or at-risk patients, as in nursing homes or prisons. Aside from these special sectors, employee mandates aren't necessarily a good idea from a public health perspective, said Michelle Mello, a professor of law and medicine at Stanford University.

Hard-line vaccine opponents likely wouldn't be swayed by an employment-based vaccine requirement, and it could risk alienating some in the "wait and see" contingent, she said.

About 6% of Americans not yet vaccinated against COVID said they would accept a shot if it was required, according to an April survey from KFF. An additional 15% who hadn't gotten a shot expressed a "wait and see" attitude toward vaccination. And 13% flatly refused to be vaccinated.

Gains in the small group who say they'd get a shot if it's required might not be worth the uproar a mandate could foment, Mello said.

Mandates risk further politicizing COVID vaccines in U.S. society, said Brian Castrucci, CEO of the de Beaumont Foundation, a charity focused on public health.

Polling conducted by de Beaumont and GOP pollster Frank Luntz on April 15 found that 36% of those who voted for Donald Trump in the 2020 presidential election agreed it was important for American businesses to encourage and incentivize the vaccines, versus 54% of Joe Biden voters. The survey also found that 41% of Trump voters believed that businesses should not be involved in COVID vaccinations at all, compared with 18% of Biden voters.

"Mandating vaccination will hit every button there is on the political right," Castrucci said.

Once public health tools and strategies become politicized, local governments can choose to simply take them off the table as an option. A new Florida law bans businesses and government entities from requiring proof of a COVID vaccination. The law builds on Gov. Ron DeSantis' executive order, which he signed April 2.

"Vaccine verification can be a useful tool," Castrucci said. "Now it's no longer available in Florida."

Despite the potential backlash, the financial case for COVID vaccinations is clear, said Aaron Yelowitz, an economics professor at the University of Kentucky, given how effective the shots are.

Taking into account the costs of a shortened life span, mental health conditions and lost income due to illness and shutdowns, the COVID pandemic has cost the average American family of four almost $200,000, according to an analysis by researchers at Harvard.

Some of these costs may be borne by businesses in the form of lost productivity and higher health insurance prices, said Yelowitz. Financial incentives for the shots are thus an extremely tempting trade-off, he said.

Incentives for vaccination — like a $25 gift card or free Uber ride — are "surely worth it in terms of savings," Yelowitz said. In the same vein, he also called Ohio Gov. Mike DeWine's $5 million vaccine lottery "innovative and imaginative."

But for now, employers are sensitive about what they can and can't demand of workers, said Lindsey Leininger, a clinical professor of business administration at Dartmouth College. The tight labor market and the fraught, ongoing negotiations over when and how to bring employees back to the office makes some companies wary of asking too much of their workers, said Leininger, who advises smaller businesses on COVID vaccines and other issues.

"All of the businesses I work with have a general preference for carrot versus stick types of approaches," she said. "How many things do you want to mandate of your employees right now?"

Anna Almendrala: aalmendrala@kff.org, @annaalmendrala

Tips for Older Adults to Regain Their Game After Being Cooped Up for More Than a Year

KFF Health News, May 24, 2021

Millions of older Americans are struggling with physical, emotional and cognitive challenges following a year of being cooped up inside.

This article was published on Monday, May 24, 2021 in Kaiser Health News.

By Judith Graham

Alice Herb, 88, an intrepid New Yorker, is used to walking miles around Manhattan. But after this year of being shut inside, trying to avoid COVID-19, she's noticed a big difference in how she feels.

"Physically, I'm out of shape," she told me. "The other day I took the subway for the first time, and I was out of breath climbing two flights of stairs to the street. That's just not me."

Emotionally, Herb, a retired lawyer and journalist, is unusually hesitant about resuming activities even though she's fully vaccinated. "You wonder: What if something happens? Maybe I shouldn't be doing that. Maybe that's dangerous," she said.

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America's 45 million seniors and their families navigate the healthcare system.

Millions of older Americans are similarly struggling with physical, emotional and cognitive challenges following a year of being cooped up inside, stopping usual activities and seeing few, if any, people.

If they don't address issues that have arisen during the pandemic — muscle weakness, poor nutrition, disrupted sleep, anxiety, social isolation and more — these older adults face the prospect of poorer health and increased frailty, experts warn.

What should people do to address challenges of this kind? Several experts shared advice:

Reconnect with your physician. Large numbers of older adults have delayed medical care for fear of COVID. Now that most seniors have been vaccinated, they should schedule visits with primary care physicians and preventive care screenings, such as mammograms, dental cleanings, eye exams and hearing checks, said Dr. Robert MacArthur, chief medical officer of the Commonwealth Care Alliance in Massachusetts.

Have your functioning assessed. Primary care visits should include a basic assessment of how older patients are functioning physically, according to Dr. Jonathan Bean, an expert in geriatric rehabilitation and director of the New England Geriatric Research, Education and Clinical Center at the Veterans Affairs Boston Healthcare System.

At a minimum, doctors should ask, "Are you having difficulty walking a quarter-mile or climbing a flight of stairs? Have you changed the way you perform ordinary tasks such as getting dressed?" Bean suggested.

A little-discussed, long-term toll of the pandemic is that large numbers of older adults have become physically and cognitively debilitated and less able to care for themselves after sheltering in place.

Get a referral to therapy. If you're having trouble moving around or doing things you used to do, get a referral to a physical or occupational therapist.

A physical therapist can work with you on strength, balance, range of motion and stamina. An occupational therapist can help you change the way you perform various tasks, evaluate your home for safety and identify needed improvements, such as installing a second railing on a staircase.

Don't wait for your doctor to take the initiative; too often this doesn't happen. "Speak up and say: Please, can you write me a referral? I think a skilled evaluation would be helpful," said James Nussbaum, clinical and research director at ProHealth & Fitness in New York City, a therapy provider.

Start slow and build steadily. Be realistic about your current abilities. "From my experience, older adults are eager to get out of the house and do what they did a year ago. And guess what. After being inactive for more than a year, they can't," said Dr. John Batsis, associate professor of geriatrics at the University of North Carolina-Chapel Hill.

"I'm a fan of start low, go slow," Batsis continued. "Be honest with yourself as to what you feel capable of doing and what you are afraid of doing. Identify your limitations. It's probably going to take some time and adjustments along the way."

Nina DePaola, vice president of post-acute services for Northwell Health, the largest healthcare system in New York, cautioned that getting back in shape may take time. "Pace yourself. Listen to your body. Don't do anything that causes discomfort or pain. Introduce yourself to new environments in a thoughtful and a measured fashion," she said.

Be physically active. Engaging regularly in physical activity of some kind — a walk in the park, chair exercises at home, video fitness programs — is the experts' top recommendation. The Go4Life program, sponsored by the National Institute on Aging, is a valuable resource for those getting started and you can find videos of some sample exercise routines on YouTube. The YMCA has put exercise classes online, as have many senior centers. For veterans, the VA has Gerofit, a virtual group exercise program that's worth checking out.

Bienvenido Manzano, 70, of Boston, who retired from the Coast Guard after 24 years and has significant lower back pain, attends Gerofit classes three times a week. "This program, it strengthens your muscles and involves every part of your body, and it's a big help," he told me.

Have realistic expectations. If you're afraid of getting started, try a bit of activity and see how you feel. Then try a little bit more and see if that's OK. "This kind of repeated exposure is a good way to deal with residual fear and hesitation," said Rachel Botkin, a physical therapist in Columbus, Ohio.

"Understand that this has been a time of psychological trauma for many people and it's impacted the way we behave," said Dr. Thomas Cudjoe, a geriatrician and assistant professor at Johns Hopkins Medicine in Baltimore. "We're not going to go back to pre-pandemic activity and engagement like turning on a light switch. We need to respect what people's limits are."

Eat well. Make sure you're eating a well-balanced diet that includes a good amount of protein. Adequate protein consumption is even more important for older adults during times of stress or when they're sedentary and not getting much activity, noted a recent study on health aging during COVID-19. For more information, see my column about how much protein older adults should consume.

Reestablish routines. "Having a structure to the day that involves social interactions, whether virtual or in person, and various activities, including some time outside when the weather is good, is important to older adults," said Dr. Lauren Beth Gerlach, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.

Routines are especially true for older adults with cognitive impairment, who tend to do best when their days have a dependable structure and they know what to expect, she noted.

End-of-day routines are also useful in addressing sleep problems, which have become more common during the pandemic. According to a University of Michigan poll, administered in January, 19% of adults ages 50 to 80 report sleeping worse than they did before the pandemic.

Reconnect socially. Mental health problems have also worsened for a segment of older adults, according to the University of Michigan poll: 19% reported experiencing more sadness or depression while 28% reported being more anxious or worried.

Social isolation and loneliness may be contributing and it's a good idea to start "shoring up social support" and seeing other people in person if seniors are vaccinated, Gerlach said.

Families have an important role to play in re-engaging loved ones with the world around them, Batsis suggested. "You've had 15 months or so of only a few face-to-face interactions: Make it up now by visiting more often. Make the effort."

Laura Collins, 58, has been spending a lot of time this past month with her mother, Jane Collins, 92, since restrictions on visitation at Jane's nursing home in Black Mountain, North Carolina, eased and both women were vaccinated. Over the past year, Jane's dementia progressed rapidly and she became depressed, sobbing often to Laura on the phone.

"She loves getting outside and that has been wonderful," Laura said. "Her mood immediately shifts when she gets out of the building: She's just happy, almost childlike, like a kid going out for ice cream. And, in fact, that's what we do — go out for ice cream."

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the healthcare system. Visit khn.org/columnists to submit your requests or tips.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

Is Your Living Room the Future of Hospital Care?

KFF Health News, May 24, 2021

Hospital-level care at home — some of it provided over the internet — is poised to grow after more than a decade as a niche offering.

This article was published on Monday, May 24, 2021 in Kaiser Health News.

By Julie Appleby

Major hospital systems are betting big money that the future of hospital care looks a lot like the inside of patients' homes.

Hospital-level care at home — some of it provided over the internet — is poised to grow after more than a decade as a niche offering, boosted both by hospitals eager to ease overcrowding during the pandemic and growing interest by insurers who want to slow healthcare spending. But a host of challenges remain, from deciding how much to pay for such services to which kinds of patients can safely benefit.

Under the model, patients with certain medical conditions, such as pneumonia or heart failure — even moderate COVID — are offered high-acuity care in their homes, with 24/7 remote monitoring and daily visits by medical providers.

In the latest sign that the idea is catching on, two big players — Kaiser Permanente and the Mayo Clinic — announced plans this month to collectively invest $100 million into Medically Home, a Boston-based company that provides such services to scale up and expand their programs. The two organizations estimate that 30% of patients currently admitted to hospitals nationally have conditions eligible for in-home care. (KHN is not affiliated with Kaiser Permanente.)

Several other well-known hospital systems launched programs last summer. They join about two dozen already offering the service, including Johns Hopkins Medicine in Baltimore, Presbyterian Healthcare Services in New Mexico and Massachusetts General Hospital.

But hospitals have other financial considerations that are also part of the calculation. Systems that have built sparkling new in-patient facilities in the past decade, floating bonds and taking out loans to finance them, need patients filling costly inpatient beds to repay lenders and recoup investments.

And "hospitals that have surplus capacity, whether because they have newly built beds or shrinking populations or are losing business to competitors, are not going to be eager about this," said Dr. Jeff Levin-Scherz, co-leader of the North American Health Management practice at consultancy Willis Towers Watson.

Medicare gave the idea a boost in November when it agreed to pay for such care, to help keep non-COVID patients out of the hospital during the pandemic. Since then, more than 100 hospitals have been approved by Medicare to participate, although not all are in place yet.

Tasting opportunity, Amazon and a coalition of industry groups in March announced plans to lobby for changes in federal and state rules to allow broader access to a wide range of in-home medical services.

"We're seeing tremendous momentum," said Dr. Bruce Leff, a Johns Hopkins Medical School geriatrician who has studied and advocated for the hospital-at-home approach since he helped establish one of the nation's first programs in the mid-1990s.

Leff and other proponents say various studies show in-home care is just as safe and may produce better outcomes than being in the hospital, and it saves money by limiting the need to expand hospitals, reducing hospital readmissions and helping patients avoid nursing home stays. Some estimates put the projected savings at 30% over traditional hospital care. But ongoing programs are a long way from making a dent in the nation's $1.2 trillion hospital tab.

While the goal is to shift 10% or more of hospital patients to home settings, existing programs handle far fewer cases, sometimes serving only a handful of patients.

"In a lot of ways, this remains aspirational; this is the early innings," said Dean Ungar, who follows the insurance and hospital industries as a vice president and senior credit officer at Moody's Investors Service. Still, he predicted that "hospitals will increasingly be reserved for acute care [such as surgeries and ICUs]."

Challenges to scaling up include maintaining the current good safety profile in the face of rapid growth and finding enough medical staff — especially nurses, paramedics and technicians — who travel to patients' homes.

The attraction for insurers is clear: If they can pay for care in a lower-cost setting than the hospital, with good outcomes, they save money.

For hospitals, "the financials of it are, frankly, a little tough," said Levin-Scherz.

Those most attracted to hospital-at-home programs run at or near capacity and want to free up beds.

Even so, Gerard Anderson, a health policy professor at Johns Hopkins University Bloomberg School of Public Health, said hospitals likely see the potential, long term, for "huge profit margins" through "saving a lot of capital and personnel expense by having the work done at home."

But Anderson worries that broad expansion of hospital-at-home efforts could exacerbate healthcare inequities.

"It's realistic in middle- and upper-middle-class households," Anderson said. "My concern is in impoverished areas. They may not have the infrastructure to handle it."

Suburban and rural areas — and even some lower-income urban areas — can have spotty or nonexistent internet access. How will that affect the ability of those areas to participate, to communicate with physicians and other hospital staff members miles away? Proponents outline solutions, from providing patients with "hot spot" devices that provide internet service, along with backup power and instant communication via walkie-talkie-type handsets and computer tablets.

Social factors play a big part, too. Those who live alone may find it harder to qualify if they need a lot of help, while those in crowded households may not have enough room or privacy.

Another possible wrinkle: Not all patients have the necessary human support, such as someone to help an ill patient with the bathroom, meals or even answering the door.

That's why both patients and their caregivers should get a detailed explanation of the day-to-day responsibilities before agreeing to participate, said Alexandra Drane, CEO of Archangels, a for-profit group that works with employers and provides resources for unpaid caregivers.

"I love the concept for a resourced household where someone can take this job on," said Drane. "But there's a lot of situations where that's not possible. What If I have a full-time job and two children, when am I supposed to do this?"

The programs all say they aim to reduce the burden on families. Some provide aides to help with bathing or other home care issues and provide food. None expects family members to perform medical procedures. The programs supply monitoring and communication equipment and a hospital bed, if needed.

"We see the patient in their home setting," said Morre Dean, president of Adventist Health's hospital at home program, which serves a broad area of California and part of Oregon. "What is in their refrigerator? What is their living situation? Can we impact that? We aren't reliant on the family to deliver care."

Patients are typically visited in their homes daily by various health workers. Physicians make home visits in some programs, but most employ doctors to oversee care from remote "command centers," talking with patients via various electronic gadgets.

All of that was delivered to James Clifford's home in Bakersfield, California, after he opted to participate in the Adventist program so he could leave the hospital and finish treatment for an infection at home. It required coordination — his wife had to be at their house for the set-up team even as she was scheduled to pick him up — but "once it was set up, it worked well."

At home, he needed treatment with antibiotics every eight hours for several days and "one nurse came at 2 a.m.," said Clifford, 70. "It woke up my wife, but that's OK. We had peace of mind by my being at home."

Adventist launched its program a year ago, but it hasn't achieved the scale needed to save money yet, said Dean. Ultimately, he envisions the hospital-at-home option as "our biggest hospital in Adventist Health," with 500 to 1,500 patients in the program at a time.

Medicare's payment decision gave momentum to such goals. But the natural experiment it created with its funding ends when the pandemic is declared over. Because of the emergency, Medicare paid the same as it would for in-hospital care, based on each patient's diagnosis. Will hospitals be as enthusiastic if that is not the case in the future? Commercial insurers are unlikely to pay unless they see lower rates, since there are already concerns about overuse.

"From a societal perspective, it's great if these programs replace expensive inpatient care," said Levin-Scherz at Towers. But, he said, it would be a negative if the programs sought to grow by admitting patients who otherwise would not have gone into the hospital at all and could have been treated with lower-cost outpatient services.

Julie Appleby: jappleby@kff.org, @Julie_Appleby

No-Cancel Culture: How Telehealth Is Making It Easier to Keep That Therapy Session

KFF Health News, May 24, 2021

Virtual visits can also save patients money, because they might not need to travel, take time off work or pay for child care.

This article was published on Monday, May 24, 2021 in Kaiser Health News.

By Eric Berger

When the COVID-19 pandemic forced behavioral health providers to stop seeing patients in person and instead hold therapy sessions remotely, the switch produced an unintended, positive consequence: Fewer patients skipped appointments.

That had long been a problem in mental healthcare. Some outpatient programs previously had no-show rates as high as 60%, according to several studies.

Only 9% of psychiatrists reported that all patients kept their appointments before the pandemic, according to an American Psychiatric Association report. Once providers switched to telepsychiatry, that number increased to 32%.

Not only that, but providers and patients say teletherapy has largely been an effective lifeline for people struggling with anxiety, depression and other psychological issues during an extraordinarily difficult time, even though it created a new set of challenges.

Many providers say they plan to continue offering teletherapy after the pandemic. Some states are making permanent the temporary pandemic rules that allow providers to be reimbursed at the same rates as for in-person visits, which is welcome news to practitioners who take patients' insurance.

"We are in a mental health crisis right now, so more people are struggling and may be more open to accessing services," said psychologist Allison Dempsey, associate professor at University of Colorado School of Medicine in Aurora. "It's much easier to connect from your living room."

The problem for patients who didn't show up was often as simple as a canceled ride, said Jody Long, a clinical social worker who studied the 60% rate of no-shows or late cancellations at the University of Tennessee Health Science Center psychiatric clinic.

But sometimes it was the health problem itself. Long remembers seeing a first-time patient drive around the parking lot and then exit. The patient later called and told Long, "I just could not get out of the car; please forgive me and reschedule me."

Long, now an assistant professor at Jacksonville State University in Alabama, said that incident changed his perspective. "I realized when you're having panic attacks or anxiety attacks or suffering from major depressive disorder, it's hard," he said. "It's like you have built up these walls for protection and then all of a sudden you're having to let these walls down."

Absences strain providers whose bosses set billing and productivity expectations and those in private practice who lose billable hours, said Dempsey, who directs a program to provide mental healthcare for families of babies with serious medical complications. Psychotherapists often overbooked patients with the expectation that some would not show up, she said.

Now Dempsey and her colleagues no longer need to overbook. When patients don't show up, staffers can sometimes contact a patient right away and hold the session. Other times, they can reschedule them for later that day or a different day.

And telepsychiatry performs as well as, if not better than, face-to-face delivery of mental health services, according to a World Journal of Psychiatry review of 452 studies.

Virtual visits can also save patients money, because they might not need to travel, take time off work or pay for child care, said Dr. Jay Shore, chairperson of the American Psychiatric Association's telepsychiatry committee and a psychiatrist at the University of Colorado medical school.

Shore started examining the potential of video conferencing to reach rural patients in the late '90s and concluded that patients and providers can virtually build rapport, which he said is fundamental for effective therapy and medicine management.

But before the pandemic, almost 64% of psychiatrists had never used telehealth, according to the psychiatric association. Amid widespread skepticism, providers then had to do "10 years of implementations in 10 days," said Shore, who has consulted with Dempsey and other providers.

Dempsey and her colleagues faced a steep learning curve. She said she recently held a video therapy session with a mother who "seemed very out of it" before disappearing from the screen while her baby was crying.

She wondered if the patient's exit was related to the stress of new motherhood or "something more concerning," like addiction, she said. She thinks she might have better understood the woman's condition had they been in the same room. The patient called Dempsey's team that night and told them she had relapsed into drug use and been taken to the emergency room. The mental health providers directed her to a treatment program, Dempsey said.

"We spent a lot of time reviewing what happened with that case and thinking about what we need to do differently," Dempsey said.

Providers now routinely ask for the name of someone to call if they lose a connection and can no longer reach the patient.

In another session, Dempsey noticed that a patient seemed guarded and saw her partner hovering in the background. She said she worried about the possibility of domestic violence or "some other form of controlling behavior."

In such cases, Dempsey called after the appointments or sent the patients secure messages to their online health portal. She asked if they felt safe and suggested they talk in person.

Such inability to maintain privacy remains a concern.

In a Walmart parking lot recently, Western Illinois University psychologist Kristy Keefe heard a patient talking with her therapist from her car. Keefe said she wondered if the patient "had no other safe place to go to."

To avoid that scenario, Keefe does 30-minute consultations with patients before their first telehealth appointment. She asks if they have space to talk where no one can overhear them and makes sure they have sufficient internet access and know how to use video conferencing.

To ensure that she, too, was prepared, Keefe upgraded her Wi-Fi router, purchased two white noise machines to drown out her conversations and placed a stop sign on her door during appointments so her 5-year-old son knew she was seeing patients.

Keefe concluded that audio alone sometimes works better than video, which often lags. Over the phone, she and her psychology students "got really sensitive to tone fluctuations" in a patient's voice and were better able to "pick up the emotion" than with video conferencing, she said.

With those telehealth visits, her 20% no-show rate evaporated.

Kate Barnes, a 29-year-old middle school teacher in Fayetteville, Arkansas, who struggles with anxiety and depression, also has found visits easier by phone than by Zoom, because she doesn't feel like a spotlight is on her.

"I can focus more on what I want to say," she said.

In one of Keefe's video sessions, though, a patient reached out, touched the camera and started to cry as she said how appreciative she was that someone was there, Keefe recalled.

"I am so very thankful that they had something in this terrible time of loss and trauma and isolation," said Keefe.

Demand for mental health services will likely continue even after the lifting of all COVID restrictions. About 41% of adults were suffering from anxiety or depression in January, compared with about 11% two years before, according to data from the U.S. Census Bureau and the National Health Interview Survey.

"That is not going to go away with snapping our fingers," Dempsey said.

After the pandemic, Shore said, providers should review data from the past year and determine when virtual care or in-person care is more effective. He also said the healthcare industry needs to work to bridge the digital divide that exists because of lack of access to devices and broadband internet.

Even though Barnes, the teacher, said she did not see teletherapy as less effective than in-person therapy, she would like to return to seeing her therapist in person.

"When you are in person with someone, you can pick up on their body language better," she said. "It's a lot harder over a video call to do that."

If You Are Vaccinated, You Can Dance the Night Away

KFF Health News, May 23, 2021

For Ibiza Nightclub in southeastern North Carolina — a political battleground state — the vaccine card requirement is proving to be a lightning rod.

This article was published on Friday, May 21, 2021 in Kaiser Health News.

By Aneri Pattani

Marissa Castrigno was walking through downtown Wilmington, North Carolina, when she spotted the sign in the window of one of her favorite dance clubs. After months of being shuttered by the pandemic, Ibiza Nightclub was reopening April 30, it announced.

This story also ran on Raleigh News & Observer. It can be republished for free.

Thrilled, Castrigno immediately made plans with friends to be there.

About 50 miles north in Jacksonville, Kennedy Swift learned of Ibiza’s reopening on social media. He, too, decided to attend with friends.

But on the night of April 30, the two groups were in for a surprise — one they would react to in starkly different ways.

In addition to IDs, they learned, they’d need to show covid-19 vaccination cards for entry. The club was letting in only people who had had at least one shot.

“I was shocked,” said Swift, 21. He learned of the policy a few hours before the reopening, when the club posted it on its Facebook page.

He and his friends had to cancel their plans, since none of them was vaccinated.

“I’m not against [Ibiza] exercising their rights as a business,” Swift said. “I just think it’s foolish. … This will discourage a lot of former patrons from returning to the club.”

On the other hand, Castrigno and her friends, most of whom had been fully vaccinated since early April, felt the policy made their return to nightlife even better.

“There was raw excitement about going out to a place and feeling safe,” said Castrigno, 28.

Similar conversations are playing out across the country as vaccination rates increase and bars, clubs and other businesses navigate how to reopen. The concept of vaccine passports — which allow people who have been inoculated against covid and are at lower risk of contracting or spreading the disease to participate in certain activities — has been floated for clubs, cruise ships and other spaces where large groups gather in close quarters. The Centers for Disease Control and Prevention’s recent announcement that vaccinated people can safely gather indoors and outdoors without masks has reignited the idea. Yet these passports remain highly controversial and their implementation is largely piecemeal. Many private businesses are making their own decisions, and governments in different parts of the country are adopting varying stances.

In New York, for instance, Gov. Andrew Cuomo announced in early May that places where proof of vaccination or a negative covid test are required can operate at a greater capacity. Some nightclubs there have implemented policies similar to Ibiza’s. In Florida, however, Gov. Ron DeSantis recently signed a law prohibiting businesses, schools and government offices from requiring proof of vaccination, with fines of up to $5,000 per incident.

For Ibiza Nightclub in southeastern North Carolina — a political battleground state — the vaccine card requirement is proving to be a lightning rod. The club’s Facebook post announcing the policy had sparked 70 comments as of mid-May, and posts across other platforms echoed different sides of the issue.

“I am thrilled to see a personal business putting the health and safety forward in order to keep their business running,” one comment read.

Others took a markedly different tone: “This is pretty dumb!”

“Discrimination, expect lawsuits,” read another.

The Honor Code

Last week, after the CDC said vaccinated adults could largely live their lives mask-free, Raleigh restaurant owner Hisine McNeill felt a troubling pang of déjà vu. He owns Alpha Dawgs, a sandwich shop in southeast Raleigh, and said small businesses like his carried the burden of mask enforcement for much of the pandemic. Now, he said, they’re tasked with trusting adults who say they’ve been vaccinated. He isn’t ready to do that.

“I don’t have the luxury of taking chances on an honor code,” McNeill said. “If I have an outbreak because someone didn’t wear a mask and have to close down, who’s going to help keep me open?”

McNeill opened Alpha Dawgs in 2018 and, like most restaurateurs, he said, struggled through the pandemic, professionally and personally. He said he has lost friends and family members and doesn’t believe the pandemic is over.

“I know people personally in the ICU still recovering from [covid],” McNeill said. “I don’t need any more examples about how serious this is.”

So McNeill posted a new requirement on the restaurant’s Facebook page. He asked everyone to continue wearing masks unless they were prepared to show him a vaccine card.

“To whom it may concern,” McNeill wrote. “If you decide to come into my establishment claiming that you are fully vaccinated, I WILL ASK TO SEE YOUR CARD. If you don’t want to provide it then you will have to wear a mask in my store. And if you still don’t want to comply with either then I have the right to deny service. Thank you for your cooperation.”

The day after he posted that statement, North Carolina Gov. Roy Cooper eased most covid-related restrictions in the state, including its mask mandate. The Alpha Dawgs post stirred some online debate over masks and vaccinations and led to a few responses, including one from the Raleigh Republican Club.

“Should you be in the area…,” it read. “Eat somewhere else….”

McNeill felt the Raleigh Republican Club was calling for a boycott. Afterward, he noticed multiple one-star reviews pop up on Google, not from people who had been to the restaurant, but people accusing McNeill of discrimination.

“This is not political for me, this is a personal belief,” McNeill said. “I have an 85-year-old grandmother I see every other week. I’m going to make sure she’s protected.”

Raleigh Republican Club board member Guy Smith said the group’s post was written collectively, but he didn’t see it as a call for a boycott.

“Our philosophical position is it’s his business, the owner can choose to do what they choose to do within the confines of the individual business,” Smith said. “Our philosophical position is, to demand someone to demonstrate they’re vaccinated with a card, we think that’s out of bounds.”

Smith said the group also condemns writing bogus reviews of a business.

McNeill said Alpha Dawgs’ business has not suffered from the online dust-up.

“I haven’t had any problems,” McNeill said. “Only the online harassment.”

The Nightclub Expected Opposition

Charles Smith, general manager of the club, said he knew the policy would garner backlash, but “we’ve always put the health and safety of both staff and our patrons, and their families, first.”

Since opening as a gay bar in 2001, Ibiza has been a pillar of the LGBTQ community in Wilmington. Although its clientele has expanded over time, it’s still known for drag shows on Friday nights.

Last year, the club shut down March 12, about a week before Gov. Cooper ordered all North Carolina bars and restaurants to stop dine-in service. Ibiza remained shuttered for 14 months, using the time to renovate, Smith said, and leaning on federal and state assistance for small businesses.

When it came to reopening, he said, “the question was: How do we provide the absolute safest experience alongside the nightlife experience we’ve been known for?”

It wouldn’t be easy. Nightclubs are a perfect cocktail of covid risks: lots of people socializing and dancing in close quarters. Alcohol lowering inhibitions. Music forcing people to speak louder, releasing more droplets into the air.

“The concept of social distancing in a nightclub is an oxymoron,” Smith said. And the club’s staff didn’t want to be “the police of nightlife,” trying to separate people on the dance floor, he added.

The safest option, it seemed, was to require people to be vaccinated.

The club waited till all adults in the state were eligible for vaccines before reopening. 

Now Ibiza requires patrons to present their vaccine cards or photos of the cards for entry. On reopening night, the club asked customers to wear masks and limited its capacity to 50%, per an executive order from the governor. But as of May 14, the state lifted its capacity restrictions and masking requirements.

Castrigno, who’d been looking forward to that night for weeks since she saw the sign in the club’s window, said it was “the most jubilant I’d ever seen Ibiza.” Several performers put on a drag show. Customers took turns dancing on poles. Some people wore masks with rhinestones to match their outfits, she said.

She wasn’t surprised that many people took the vaccine requirement in stride. “Queer people are well versed in the risks of public health crisis and protecting the community,” she said, referring to the AIDS crisis, which devastated the community in the ’80s and ’90s.

For James Colucci, who has been a customer since 2016, supporting Ibiza’s vaccine policy is about protecting the club’s employees. Some of them have “spearheaded the [LGBTQ] movement, so we can get together and have events like this,” he said.

But others say the policy is discriminatory and injects the nightclub into people’s personal health care decisions.

Joey Askew, a 37-year-old from Greenville, wrote on Ibiza’s Facebook page, “I’ll never go back to this club until they lift this mandate!!”

In an interview with KHN, Askew said he’s not ready to get the vaccine because there haven’t been lifetime studies of recipients to determine long-term side effects. He’s willing to wear a mask and maintain physical distance, but a vaccine requirement goes too far.

“A mask is something I can buy from anywhere and take off whenever I choose,” he said. “But I can’t take a vaccine out. It’s a permanent choice that [the club] is involving themselves in, and it’s not their place.”

In between the people condemning the club’s policy and those applauding it are many who are conflicted.

Mark Russell, 29, is a nurse in Washington, D.C., who cares for covid patients and contracted covid last year. He plans on visiting Ibiza Nightclub in late May while attending a small wedding in North Carolina where everyone will be vaccinated.

The club’s policy makes him feel safer, Russell said. But he also worries about its effect on people of color, who in many places have faced barriers to vaccination.

“It’s a battle in my own brain, thinking those two things,” Russell said.

For Heidi Martek, 55, the policy raised a personal question. “What about those who can’t get the vaccine?” she wrote on Ibiza’s Facebook page.

She has an autoimmune disease, making her body hypersensitive to any vaccine, Martek said, even the flu shot.

But when commenters on Facebook suggested she sue the club, Martek pushed back. The club is facing difficult choices, she told KHN, and there’s no right answer.

“Whether I can go in or not, I support them,” said Martek, who’s been a patron at Ibiza for six years.

She wants the club to survive the pandemic, unlike other establishments that have closed in the past year.

“It’s not like Wilmington is overwhelmed with LGBTQ clubs,” Martek said. “Ibiza is really important.”

News & Observer reporter Drew Jackson contributed to this story.

As Pandemic Eases, Many Seniors Have Lost Strength, May Need Rehabilitative Services

KFF Health News, May 21, 2021

Large numbers of older adults have become physically and cognitively debilitated and less able to care for themselves during 15 months of sheltering in place.

This article was published on Friday, May 21, 2021 in Kaiser Health News.

By Judith Graham

Ronald Lindquist, 87, has been active all his life. So, he wasn't prepared for what happened when he stopped going out during the coronavirus pandemic and spent most of his time, inactive, at home.

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America's 45 million seniors and their families navigate the healthcare system.
 
"I found it hard to get up and get out of bed," said Lindquist, who lives with his wife of 67 years in Palm Springs, California. "I just wanted to lay around. I lost my desire to do things."

Physically, Lindquist noticed that getting up out of a chair was difficult, as was getting into and out of his car. "I was praying 'Lord, give me some strength.' I kind of felt, I'm on my way out — I'm not going to make it," he admitted.

One little-discussed, long-term toll of the pandemic: Large numbers of older adults have become physically and cognitively debilitated and less able to care for themselves during 15 months of sheltering in place.

No large-scale studies have documented the extent of this phenomenon. But physicians, physical therapists and health plan leaders said the prospect of increased impairment and frailty in the older population is a growing concern.

"Anyone who cares for older adults has seen a significant decline in functioning as people have been less active," said Dr. Jonathan Bean, an expert in geriatric rehabilitation and director of the New England Geriatric Research, Education and Clinical Center at the Veterans Affairs Boston Healthcare System.

Bean's 90-year-old mother, who lives in an assisted living facility, is a case in point. Before the pandemic, she could walk with a walker, engage in conversation and manage going to the bathroom. Now, she depends on a wheelchair and "her dementia has rapidly accelerated — she can't really care for herself," the doctor said.

Bean said his mother is no longer able to benefit from rehabilitative therapies. But many older adults might be able to realize improvements if given proper attention.

"Immobility and debility are outcomes to this horrific pandemic that people aren't even talking about yet," said Linda Teodosio, a physical therapist and division rehabilitation manager in Bayada Home Healthcare's Towson, Maryland, office. "What I'd love to see is a national effort, maybe by the CDC [U.S. Centers for Disease Control and Prevention], focused on helping older people overcome these kinds of impairments."

The extent of the need is substantial, by many accounts. Teodosio said she and her staff have seen a "tremendous increase" in falls and in the exacerbation of chronic illnesses such as diabetes, congestive heart failure and chronic obstructive pulmonary disease.

"Older adults got off schedule during the pandemic," she explained, and "they didn't eat well, they didn't hydrate properly, they didn't move, they got weaker."

Dr. Lauren Jan Gleason, a geriatrician and assistant professor of medicine at the University of Chicago, said many older patients have lost muscle mass and strength this past year and are having difficulties with mobility and balance they didn't have previously.

"I'm seeing weight gain and weight loss, and a lot more depression," she noted.

Mary Louise Amilicia, 67, of East Meadow, New York, put on more than 100 pounds while staying at home round-the-clock and taking care of her husband Frank, 69, who was hospitalized with a severe case of COVID-19 in early December. While Amilicia also tested positive for the virus, she had a mild case.

"We were in the house every day 24/7, except when we had to go to the doctor, and when he got sick I had to do all the stuff he used to do," Amilicia told me. "It was a lot of stress. I just began eating everything in sight and not taking care of myself."

The extra weight made it hard to move around, and Amilicia fell several times after Christmas, fortunately without sustaining serious injuries.

After coming home from the hospital, Frank couldn't get out of a chair, walk 10 feet to the bathroom or climb the stairs in his house. Instead, he spent most of the day in a recliner, relying on his wife for help.

Now, the couple is getting physical therapy from Northwell Health, New York state's largest healthcare system. Just before the pandemic, Northwell launched a "rehabilitation at home" program for patients who otherwise would have seen therapists in outpatient facilities. (Medicare Part B pays for the treatments.)

The program is serving more than 100 patients on Long Island, in Westchester County and in parts of New York City. "The demand is very strong and we're in the process of hiring another 20 therapists," said Nina DePaola, Northwell's vice president of post-acute services.

Sabaa Mundia, a physical therapist working with the Amilicias, said Mary Louise can walk up to 400 feet without a walker, after doing strengthening exercises twice a week over the course of three weeks. Frank had been using a wheelchair and is now regularly walking 150 feet with a walker after more than a month of therapy.

"Older adults can lose about 20% of their muscle mass if they don't walk for up to five days," Mundia said. "And their endurance decreases, their stamina decreases, and their range of motion decreases."

Recognizing that risk, some health plans have been reaching out to older members to assess how they're faring. In Massachusetts, Commonwealth Care Alliance serves more than 10,000 older adults who are poor and eligible for both Medicare and Medicaid, the federal-state program for people with low incomes. On average, they tend to have more medical needs than similarly aged seniors.

Between March and September last year, the plan's staffers conducted "wellness outreach assessments" by phone every two weeks, asking about ongoing medical care, new physical and emotional challenges, and the adequacy of available help, among other concerns. Today, calls are made monthly and staffers have resumed seeing members in person.

An increase in physical deconditioning is one of the big issues that have emerged. "We've had physical therapists digitally engage with members to coach them through strength and balance training," said Dr. Robert MacArthur, a geriatrician and Commonwealth Care's chief medical officer. "And when that didn't work, we sent therapists into people's homes."

In California, SCAN Health Plan serves a similarly vulnerable population of nearly 15,000 older adults dually eligible for Medicare and Medicaid through its Medicare Advantage plans. Care navigators are calling these members frequently and telling them "now that you're vaccinated, it's safe to go see your doctor in person," said Eve Gelb, SCAN's senior vice president of healthcare services. Doctors can then evaluate unmet health needs and make referrals to physical and occupational therapists, if necessary.

Another SCAN program, Member2Member, pairs older adult "peer health advocates" with members who have noted physical or emotional difficulties on health risk assessments. That's how Lindquist in Palm Springs connected with Jerry Payne, 79, a peer advocate who calls him regularly and helped him come up with a plan to emerge from his pandemic-induced funk.

"First, he said, 'Ron, you should try getting up every hour and taking a few steps' — that was the start of it," Lindquist told me. "Then, he'd suggest walking another block when I would take my dog out. It was painful. Walking was not pleasant. But he was very encouraging."

A month ago, Payne had a Fitbit sent to Lindquist. At first, Lindquist walked about 1,500 steps a day; now, he's up to more than 5,000 steps a day and has a goal of reaching 10,000 steps. "I'm sleeping better and I feel so much better all around," Lindquist said. "My whole attitude and physicality has changed. I tell you, this has been an answer to my prayers."

Coming Monday: Tips for Older Adults to Regain Their Game

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the healthcare system. Visit khn.org/columnists to submit your requests or tips.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

Colorado Will Pay Hospitals to Close Expensive Free-Standing ERs

KFF Health News, May 21, 2021

The state wants hospitals to convert them to other purposes, such as providing primary care or mental health services.

This article was published on Friday, May 21, 2021 in Kaiser Health News.

By Phil Galewitz

Colorado health officials so abhor the high costs associated with free-standing emergency rooms they're offering to pay hospitals to shut the facilities down.

The state wants hospitals to convert them to other purposes, such as providing primary care or mental health services.

At least 500 free-standing ERs have set up in more than 20 states in the past decade. Colorado has 44, 34 owned by hospitals.

The trend began a decade ago with hopes these stand-alone facilities would fill a need for ER care when no hospital was nearby and reduce congestion at hospital ERs.

But that rarely happened.

Instead, these emergency rooms — not physically connected to hospitals — generally set up in affluent suburban communities, often near hospitals that compete with the free-standing ERs' owners. And they largely treated patients who did not need emergency care, but still billed them and their insurers at expensive ER rates, several studies have found.

"We don't want hospitals to have stand-alone ERs, so we are willing to pay to shut them down," said Kim Bimestefer, executive director of Colorado's Department of Healthcare Policy & Financing, which oversees the state's Medicaid program. She said using these facilities to treat common injuries and illnesses leads to higher costs for Medicaid, which the state partly finances, and other insurers.

Colorado's move is part of a new initiative that requires hospitals to improve their quality of care to qualify for millions of dollars in Medicaid payments. Hospitals can choose among goals provided by the state such as lowering readmission rates or screening patients for social needs such as housing. Converting free-standing ERs to meet other needs is one of those goals.

"Money talks," Bimestefer said in explaining why the state is offering the financial incentives.

Money has been a major driver of the boom in free-standing emergency centers. Hospitals used them to attract patients who could be referred to the main hospital for inpatient care. They are also seen as a way to compete with rivals. For instance, in Palm Beach County, Florida, for-profit hospital chain HCA Healthcare has opened free-standing ERs near competing hospitals in Palm Beach Gardens and Boynton Beach.

In addition, the massive amounts of private equity funds flowing into healthcare have further fueled the growth of independently owned stand-alone ERs.

The Denver-based Center for Improving Value in Healthcare found that most conditions treated in these facilities are more appropriate for lower-acuity, lower-cost urgent care centers. Patients can pay 10 times more in a free-standing ER than in an urgent care center for treatment of the same condition, the organization's studies show.

Adam Fox, deputy director of the Colorado Consumer Health Initiative, said free-standing ERs have not been placed where healthcare services are scarce. Instead, they've opened in middle- and upper-income neighborhoods where most people have health insurance and access to care. "This push from the state will help" as hospitals rethink whether these facilities still make sense financially, he said.

In the past few years, Colorado has moved to make owning these facilities less attractive with laws preventing them from sticking patients with surprise bills for high fees because the ER was out of their insurer networks. It also has required that patients without true emergencies be told they can get treatment for a lower price at an urgent care facility.

The law requires a free-standing ER to post a sign informing patients it is an emergency room that treats emergency conditions. It must also specify the prices of the 25 most common services it provides.

Even before the new policy begins to roll out later this year, some Colorado hospitals started converting these facilities. UCHealth has turned nine in the past two years into primary or urgent care centers and one into a specialty center. It still has nine others in operation across the state.

The conversions were not prompted by state actions, according to Dan Weaver, a spokesperson for UCHealth, part of the University of Colorado. "Neither surprise billing legislation nor price transparency played a role in these decisions — we converted them because we felt patients in these communities needed urgent care, primary care and/or specialty care services close to home," Weaver said.

He added that the hospital system always stressed that people should use lower-cost services, including urgent care, primary care or virtual urgent care, in nonemergencies.

Ryan Westrom, senior director of finance at the Colorado Hospital Association, said hospitals have converted some of these centers to services such as urgent care in response to changes in insurance reimbursement and other factors. He said he wasn't sure whether many hospitals will accept the state payments to close their free-standing ERs.

HealthONE, which has eight free-standing ERs in the Denver area, said it has no plans to close any despite the state incentive payment.

Vivian Ho, a health economist at Rice University in Houston who has tracked the growth of these stand-alone emergency rooms, applauded Colorado's effort.

But she worries hospitals may decide it's not worth closing a free-standing emergency department and forfeiting the profits: "You have to attack free-standing EDs from multiple angles to get people to stop going to them and to get hospitals from using them as a way to generate extra revenues for care that can be delivered at lower-cost sites."

Ho said the COVID pandemic, which dampened demand for emergency care, and recent federal surprise billing legislation may hurt the growth of free-standing ERs.

They are already facing headwinds. Adeptus Health, the Texas company that's been leading the trend there and started dozens of the free-standing emergency rooms, often in conjunction with hospitals, filed for bankruptcy this year. And numerous stand-alone facilities closed at least temporarily during the pandemic as demand for care fell dramatically.

Advisers to Medicare are also pushing back on the growth. A recent proposal from the Medicare Payment Advisory Commission, which reports to Congress, would cut Medicare payment rates 30% on some services at stand-alone facilities within 6 miles of an emergency room in a hospital.

According to a MedPAC analysis of five markets — Charlotte, North Carolina; Cincinnati; Dallas; Denver; and Jacksonville, Florida — 75% of free-standing facilities were within 6 miles of a hospital with an emergency department. The average drive time to the nearest such hospital was 10 minutes.

Markian Hawryluk, KHN's senior Colorado correspondent, contributed to this article.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

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