Physicians Premier ER charged Dr. Zachary Sussman's insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.
This article was published on Saturday, September 5, 2020 in ProPublica.
When Dr. Zachary Sussman went to Physicians Premier ER in Austin for a COVID-19 antibody test, he assumed he would get a freebie because he was a doctor for the chain. Instead, the free-standing emergency room charged his insurance company an astonishing $10,984 for the visit — and got paid every penny, with no pushback.
The bill left him so dismayed he quit his job. And now, after ProPublica’s questions, the parent company of his insurer said the case is being investigated and could lead to repayment or a referral to law enforcement.
The case is the latest to show how providers have sometimes charged exorbitant prices for visits for simple and inexpensive COVID-19 tests. ProPublica recently reported how a $175 COVID-19 test resulted in charges of $2,479 at a different free-standing ER in Texas. In that situation, the health plan said the payment for the visit would be reduced and the facility said the family would not receive a bill. In Sussman’s case, the insurer paid it all. But those dollars come from people who pay insurance premiums, and health experts say high prices are a major reason why Americans pay so much for health care.
Sussman, a 44-year-old pathologist, was working under contract as a part-time medical director at four of Physicians Premier’s other locations. He said he made $4,000 a month to oversee the antibody tests, which can detect signs of a previous COVID-19 infection. It was a temporary position holding him over between hospital gigs in Austin and New Mexico, where he now lives and works.
In May, before visiting his family in Scottsdale, Arizona, Sussman wanted the test because he had recently had a headache, which can be a symptom of COVID-19. He decided to go to one of his own company’s locations because he was curious to see how the process played out from a patient’s point of view. He knew the materials for each antibody test only amounted to about $8, and it gets read on the spot — similar to an at-home pregnancy test.
He could even do the reading himself. So he assumed Physicians Premier would comp him and administer it on the house. But the staff went ahead and took down his insurance details, while promising him he would not be responsible for any portion of the bill. He had a short-term plan through Golden Rule Insurance Company, which is owned by UnitedHealthcare, the largest insurer in the country. (The insurance was not provided through his work.)
During the brief visit, Sussman said he chatted with the emergency room doctor, whom he didn’t know. He said there was no physical examination. “Never laid a hand on me,” he said. His vitals were checked and his blood was drawn. He tested negative. He said the whole encounter took about 30 minutes.
About a month later, Golden Rule sent Sussman his explanation of benefits for the physician portion of the bill. The charges came to $2,100. Sussman was surprised by the expense but he said he was familiar with the Physicians Premier high-dollar business model, in which the convenience of a free-standing ER with no wait comes at a cost.
“It may as well say Gucci on the outside,” he said of the facility. Physicians Premier says on its website that it bills private insurance plans, but that it is out-of-network with them, meaning it does not have agreed-upon prices. That often leads to higher charges, which then get negotiated down by the insurers, or result in medical bills getting passed on to patients.
Sussman felt more puzzled to see the insurance document say, “Payable at: 100%.” So apparently Golden Rule hadn’t fought for a better deal and had paid more than two grand for a quick, walk-in visit for a test. He was happy not to get hit with a bill, but it also didn’t feel right.
He said he let the issue slide until a few weeks later when a second explanation of benefits arrived from Golden Rule, for the Physicians Premier facility charges. This time, an entity listed as USA Emergency sought $8,884.16. Again, the insurer said, “Payable at: 100%.”
USA Emergency Centers says on its website that it licenses the Physicians Premier ER name for some of its locations.
Now Sussman said he felt spooked. He knew Physicians Premier provided top-notch care and testing on the medical side of things. But somehow his employer had charged his health plan $10,984.16 for a quick visit for a COVID-19 test. And even more troubling to Sussman: Golden Rule paid the whole thing.
Sussman was so shaken he resigned. “I have decided I can no longer ethically provide Medical directorship services to the company,” he wrote in his July 13 resignation email. “If not outright fraudulent, these charges are at least exorbitant and seek to take advantage of payers in the midst of the COVID19 pandemic.”
Sussman agreed to waive his patient privacy so officials from the company could speak to ProPublica. USA Emergency Centers declined interview requests and provided a statement, saying “the allegations are false,” though it did not say which ones.
The statement also said the company “takes all complaints seriously and will continue to work directly with patients to resolve issues pertaining to their emergency room care or bill. …The allegations received pertain to a former contracted employee, and we cannot provide details or further comment at this time.”
Physicians Premier advertises itself as a COVID-19 testing facility on its website, with “results in an hour.” According to the claims submitted by Physicians Premier to Golden Rule, obtained by Sussman, the physician fee and facility fees were coded as emergency room visits of moderate complexity. That would mean his visit included an expanded, problem-focused history and examination. But Sussman said the staff only took down a cursory medical history that took a few minutes related to his possible exposure to COVID-19. And he said no one examined him.
The claims also included codes for a nasal swab coronavirus test. But that test was not performed, Sussman said. The physician’s orders documented in the facility’s medical record also do not mention the nasal swab test. Those charges came to $4,989.
The claims show two charges totaling $1,600 for the antibody test Sussman received. In a spreadsheet available on its website on Friday, Physicians Premier lists a price of $75 for the antibody test.
For comparison, Medicare lists its payment at $42.13 for COVID-19 antibody tests. That’s because Medicare, the government’s insurance plan for the disabled and people over 65, sets prices.
Complicating matters, Texas is the nation’s epicenter for free-standing emergency rooms that are not connected to hospitals. Vivian Ho, an economist at Rice University who studies the facilities, said their business model is based on “trying to mislead the consumer.” They set up in locations where a high proportion of people have health insurance, but they don’t have contracted rates with the insurers, Ho said. They are designed to look like lower-priced urgent care centers or walk-in clinics, Ho said, but charge much higher emergency room rates. (The centers have defended their practices, saying that they clearly identify as emergency rooms and are equipped to handle serious emergencies, and that patients value the convenience.)
The day after he resigned, Sussman texted an acquaintance who works as a doctor at Physicians Premier. The acquaintance said the facility typically only collects a small percentage of what gets billed. “I just don’t want to be part of the game,” Sussman texted to him.
Shelley Safian, a Florida health care coding expert who has written four books on medical coding, reviewed Sussman’s medical records and claims at ProPublica’s request. The records do not document a case of a complex patient that would justify the bills used to code the patient visit, she said. For example, the chief complaint is listed as: “A generic problem (COVID TESTING).” Under “final acuity,” the medical record says, “less urgent.” Under the medical history it says, “NO SYMPTOMS.”
Safian described the charges as “obscene” and said she was shocked the insurer paid them in full. “This is the exact opposite of an employee discount,” she said. “Obviously nobody is minding the store.”
Congress opened the door to profiteering during the pandemic when it passed the CARES Act. The legislation, signed into law in March, says health insurers must pay for out-of-network testing at the cash price a facility posts on its website, or less. But there may be other charges associated with the tests, and insurers generally have tried to avoid making patients pay any portion of costs related to COVID-19 testing or treatment.
The charges for Sussman’s COVID-19 test visit are “ridiculous,” said Niall Brennan, president and CEO of the Health Care Cost Institute, a nonprofit organization that studies health care prices. Brennan wondered whether the CARES Act has made insurers feel legally obligated to cover COVID-19 costs. He called it “well intentioned” public policy that allows for “unscrupulous behavior” by some providers. “Insurance companies and patients are reliant on the good will and honesty of providers,” Brennan said. “But this whole pandemic, combined with the CARES Act provision, seems designed for unscrupulous medical providers to exploit.”
It’s illegal for medical providers to charge for services they did not provide. But ProPublica has previously reported how little insurers, including UnitedHealthcare, do to prevent fraud in their commercial health plans, even though experts estimate it consumes about 10% of all health care costs. For-profit insurance companies don’t want to spend the time and money it takes to hold fraudulent medical providers accountable, former fraud investigators have told ProPublica. Also, the insurance companies want to keep providers in their networks, so they easily cave.
In mid-July, Sussman used the messenger system on Golden Rule’s website to report his concerns about the case. Short-term health plans are typically less expensive because they offer less comprehensive coverage. Sussman said he appreciated that his plan covered the charges, and felt compelled to tell the company what had happened.
That led to a phone conversation with a fraud investigator. They went line by line through the charges and Sussman told him many of the services had not been provided. “His attitude was kind of passive,” Sussman said of the fraud investigator. “There was no indignation. He took in stride, like, ‘Yep, that’s what happens.’” The investigator said he would escalate the case and see if the facility had submitted any other suspect claims. But Sussman never heard back.
Maria Gordon-Shydlo, a spokeswoman for UnitedHealthcare, which owns Golden Rule, would not provide anyone to be interviewed. She said in an emailed statement that the company’s first priority during the pandemic “has been to ensure our members get the care they need and are not billed for COVID testing and treatment. Unfortunately, there are some providers who are trying to take advantage of this and are inappropriately or even fraudulently billing.”
“Golden Rule has put processes in place to address excessive COVID-related billing,” the statement said. “We are currently investigating this matter and, if appropriate, will seek to recoup any overpayment and potentially refer this case to law enforcement.”
Golden Rule’s 100% payment of the charges may simply come down to “incompetence,” said Dr. Eric Bricker, a Texas internist who spent years running a company that advised employers who self-fund their insurance. Insurance companies auto-adjudicate millions of claims on software that may be decades old, said Bricker, who produces videos to help consumers and employers understand health care. If bills are under a certain threshold, like $15,000, they may sail through and get paid without a second look, he said.
UnitedHealth Group reported net earnings of $6.6 billion in the second quarter of 2020. Bricker said the company may be paying bills without questioning them because it doesn’t “want to create any noise” by saying no at a time its own earnings are so high, Bricker said.
Texas has a consumer protection law that’s designed to prevent businesses from exploiting the public during a disaster. The attorney general’s office has received and processed 52 complaints about health care businesses and billing or price gouging related to the pandemic, a spokeswoman from the office said in an email. The agency does not comment on the existence of any investigations, but has not filed any cases related to overpriced COVID-19 tests.
Sussman said he got one voicemail from a billing person at Physicians Premier, saying she wanted to explain the charges, but he did not call back. He said he spoke out about it to ProPublica because he opposes Medicare-for-all health care reform proposals. Bad actors in the profession could cause doctors to lose their privilege to bill and be reimbursed independently, he said. Most physicians are fair with their billing, or even conservative, he said. “If instances like these go unchecked it will provide more ammo for advocates of a single-payer system.”
The government overpaid by hundreds of millions for Philips ventilators, says a House investigation spurred by ProPublica reporting. Now that deal is off and Congress is scrutinizing other coronavirus deals made by trade adviser Peter Navarro.
This article was published on Tuesday, September 1, 2020 in ProPublica.
The federal government is backing out of a controversial $646.7 million deal to buy ventilators from Royal Philips N.V., acting before the company had delivered a third of the order.
The deal has been the focus of several ProPublica stories since March. That reporting prompted a congressional investigation that last month found “evidence of fraud, waste and abuse” in the acquisition of the Philips ventilators.
This week, the House Committee on Oversight and Reform’s Subcommittee on Economic and Consumer Policy announced it is expanding its probe to look at other coronavirus-related deals negotiated by Peter Navarro, the president’s trade adviser, who served as the point man on the Philips deal.
In addition, the U.S. Department of Health and Human Services, which oversaw the Philips contract, confirmed that the deal is the subject of an internal investigation and legal review.
“It was ProPublica’s reporting that got my subcommittee interested in this contract,” Rep. Raja Krishnamoorthi, the Illinois Democrat who chairs the subcommittee, said in a statement. “It prompted our investigation where we uncovered unfathomably inept dealmaking by top Administration officials like Peter Navarro.”
Navarro did not respond to a request for comment. But Sarah Matthews, a White House spokeswoman, defended Navarro on Tuesday, saying he has “played a vital role in our response” to the pandemic, helping to oversee the use of a federal act that compelled production of critical supplies and created “thousands of jobs in the process.”
“While the Trump Administration has been focused on saving lives, House Democrats continue to focus on pointless investigations,” she wrote.
Philips, a Dutch company, announced Monday that its U.S. factories had stopped making the ventilators covered by the contract after receiving an early termination notice from HHS. Philips has delivered 12,300 ventilators, less than a third of the 43,000 the federal government had originally sought.
The congressional investigation determined that the deal would have resulted in the U.S. overpaying for the ventilators by as much as $500 million, thanks to “inept contract management and incompetent negotiating by the Trump Administration.”
ProPublica first wrote about the U.S. government’s relationship with Philips in March, detailing how a decade ago government planners had paid Philips millions of dollars to develop a low-cost ventilator that could be stockpiled and deployed if ever there were a pandemic. The U.S. ordered 10,000 once the company received clearance from the Food and Drug Administration.
But when COVID-19 cases overwhelmed hospitals in New York in the spring, Philips hadn’t delivered any. Instead, ProPublica found, Philips was selling a commercial version of that ventilator — manufactured at its Pennsylvania factory — overseas at far higher prices.
Rather than force production of low-cost ventilators, a White House team led by Navarro cut a new deal for more ventilators, agreeing to pay more than four times the price.
ProPublica in April revealed that this new deal boosted the price of what appeared to be similar ventilators from $3,280 each under the Obama administration deal to $15,000 under the Trump administration. Neither Philips nor HHS would explain how the two models were different.
In its investigation of the deal, the House subcommittee asked Philips to turn over a trove of records and discovered that the more expensive ventilators were “functionally identical” to the cheaper ones.
Navarro and his team “appeared gullible” and there was no evidence that they even tried to negotiate a lower price, the House investigators found.
The U.S. government paid the highest price for the ventilators among American buyers, the investigators found. The company’s records show that Philips had sold more than 5,000 of that model at far lower prices before May 27.
Philips CEO Frans van Houten said earlier this summer that his company did not raise prices to cash in on the coronavirus crisis and did not agree with the conclusions of the congressional investigators.
This week a Philips spokesman said that the list price of the ventilator was $21,000 and that the negotiated price of $15,000 reflected the “higher costs for the expedited delivery schedule.”
“While we are disappointed in light of these vast efforts, we will adjust our plans and work with HHS to effectuate the partial termination of this contract,” van Houten said in a written statement Monday.
It’s not clear how much the deal will ultimately cost taxpayers. Philips, HHS and the White House all declined to say whether the company would be paid an early termination fee.
Stephanie Bialek, a spokeswoman for the HHS office in charge of the Strategic National Stockpile, said in a statement that the government has 120,000 ventilators available and didn’t face any shortages. She said her agency had also terminated two other smaller ventilator deals early as it balanced “federal stockpile requirements with commercial market demand for ventilators.”
“As a result, HHS is saving the U.S. taxpayer millions of dollars by halting delivery of additional ventilators that are no longer required,” Bialek wrote.
Separately, the HHS Office of Inspector General announced in July that it was auditing the five largest ventilator contracts to determine whether the awarding and monitoring of the contracts complied with federal requirements and HHS policies.
As for the 10,000 low-cost ventilators the U.S. ordered for the stockpile years ago, they will arrive eventually. Philips spokesman Steve Klink said the company still planned to deliver them by September 2022, when they are due.
In New Orleans, hospitals sent patients infected with the coronavirus into hospice facilities or back to their families to die at home, in some cases discontinuing treatment even as relatives begged them to keep trying.
This article was published on Wednesday, September 2, 2020 in ProPublica.
Sarah Johnson spent her entire life taking care of people — the six children she raised, mostly alone, and the hospital patients she served in her 25 years as a nurse. But at 86, she was the one who needed care. She was thin and frail and had COVID-19.
Her son Rodney Lavalais anguished over the fact that she was all by herself; he'd moved in with her four years ago after he saw her struggling to open a jar. But when the ambulance took her to Ochsner West Bank, a hospital in the New Orleans suburbs, he couldn't come with her.
He couldn't see how stretched the hospital was in mid-April, as the coronavirus surged through the city and flooded its intensive care unit to capacity. Nor could he speak up for his mother when a doctor asked her questions she couldn't answer.
When he and his siblings received a call from the hospital only 23 hours after she was admitted, informing them there was nothing more doctors could do, they were devastated. Their mother was breathing on her own, but her kidneys were failing. "They told us we couldn't see her, and that maybe contributed to our decision to bring her home," he said. "They said hospice will be there to make sure she's comfortable."
In that moment, Ochsner made a decision in stark contrast to those made by other hospitals in COVID-19 hot spots across the country: At a time when relatives were being kept away from their sick loved ones to prevent the spread of a contagious and deadly virus, Ochsner sent infected patients back into communities to die at home, and be cared for by untrained family members without the proper protective equipment.
Under normal conditions, hospice workers make frequent face-to-face visits, especially in a patient's final days. But during the pandemic, when hospice companies were limiting in-person visits, Johnson's family was left to spend her last days alone with her, watching her moan, convinced she was in pain.
The city's death statistics reveal an aberration, ProPublica found. Nationally, coronavirus patients aged 85 and older died at home only 4% of the time, according to data from the Centers for Disease Control and Prevention; local coroner records show that in New Orleans, it was 17%. Reporters attempted to contact the families of everyone who died at home there.
The interviews revealed a striking pattern: Before they died, about two dozen patients first sought care at a hospital, which then discharged them, in many cases sending them home to die with hospice care. All were Black. The vast majority came from Ochsner Health, the largest hospital network in Louisiana, which treated 60% of the region's critically ill coronavirus patients.
The families of eight patients, as young as 69, told ProPublica that Ochsner staff pressured them into accepting hospice care for their loved ones who had COVID-19, even as some questioned or pushed back against the suggestion. Three families said they were told that there wasn't enough space to continue treating the patient in the hospital, or that the hospital needed the bed for another patient.
Some family members felt that their loved ones suffered without hospice workers at their side to manage their pain and navigate their complex symptoms. At least two relatives got sick, after being denied the proper protective gear.
It hurt enough for Johnson's children to lose her, but then, there was what her medical records revealed: That the decision to recommend hospice was influenced by a doctor's questionable speculation on her mental capacity; that on the day she was discharged home, her kidneys had improved to the point that she was no longer in renal failure; that with additional treatment, according to one expert who reviewed her case for ProPublica, she probably could have survived.
Even though Johnson's son signed a waiver permitting Ochsner to discuss her treatment with ProPublica, officials did not respond to questions about her care, stating they do "not believe that, ethically or legally, a waiver by a family member of these protections on behalf of a deceased patient equate to our ability to speak freely to the general public about the patient's care."
Ochsner did not answer ProPublica's questions about families feeling pressured into hospice. These are always difficult discussions, a spokesperson said, and with the rapid deterioration of COVID-19 patients, relatives often had to make end-of-life decisions more quickly than with other illnesses. In an email, the spokesperson said the pandemic's strains on staffing and supply levels had no influence on care: "We do not and did not cut corners on our patient's care at any time during or after COVID-19."
Prior to the pandemic, an increasing number of people were choosing to die at home, bolstered by a growing hospice movement. But data reveals that during the pandemic, the trend has flipped, with most COVID-19 deaths occurring in the hospital due to the "acuity of the illness, the rapid decline and the severity of illness," said Dr. Sadiya Khan, an assistant professor of cardiology and preventive medicine at Northwestern University's Feinberg School of Medicine, whose recent research has analyzed the locations of COVID deaths. In areas where many home deaths occurred, Khan said that it's "a signal that there was potentially an overwhelmed healthcare system."
Hospitals in Seattle, Chicago and New York City, three other early hotspots, told ProPublica they did not send patients home for hospice care, in part because of the threat of infection to vulnerable caretakers, and in part because of the harrowing deaths that families might have to navigate mostly alone.
"You have to be very aggressive in terms of getting ahead of symptoms, because with COVID, once that shortness of breath starts, it's very hard to control," said Dr. Darrell Owens, a doctor of nursing practice who runs palliative and supportive care at the University of Washington Medical Center-Northwest in Seattle. He said he would be "very worried about trying to manage that" in home hospice, and that dying patients at his hospital were provided palliative support through an inpatient program.
"We sent nobody — zero — home on hospice to die of COVID."
In mid-March, two weeks after more than a million people descended on New Orleans for Mardi Gras, the virus spread uncontrollably and exponentially across the city, marking it as an early hotspot for COVID-19.
Sarah Johnson knew what that meant for someone her age. Her phone conversations with friends, about the intrigues of "The Young and the Restless," started to drift toward the new threat. "We talked about it and how we had to be careful," said her cousin Lois Smith. "I was a little more conscious about visitors, but she still had them."
Grandchildren stopped by; two of her sons saw her almost daily. Johnson's daughter would drive her around town, letting her tour her old neighborhoods from the safety of the car.
Despite the physical limitations that came with aging — she could no longer bear to sit in church pews with her bad back — she remained the independent woman who had put herself through nursing school and bought a home with cash, so adamant about avoiding debt that she sometimes paid bills up to a year in advance. She still balanced her checkbook, and spent her days doing crossword puzzles and poring over her Bible.
So when she grew too weak to get out of bed, her children knew something was wrong. After several days, her family called an ambulance. Emergency medical technicians concluded her blood oxygen saturation was low enough that she required hospital care. On the afternoon of April 16, they dropped her off at Ochsner West Bank.
The hospital was slammed. To accommodate the influx of patients, Ochsner was converting operating rooms into makeshift intensive care units. But even so, earlier that week, Ochsner West Bank's ICU reached 100% capacity, according to state data obtained by the Documenting COVID-19 project at the Brown Institute for Media Innovation. Nurses at West Bank told ProPublica that there was a period during the surge when every ventilator was in use, with critically ill patients waiting in line.
One nurse said that her middle-aged patient died while waiting for a ventilator. "That was the hardest one," the nurse told ProPublica. "I fought to get them a vent all day."
Ochsner denies this. "We did not triage or ration the utilization of ventilators," a spokesperson said. "All patients who required ventilation received that care in a timely fashion."
As capacity shrunk, Ochsner employees adopted an unusual method to withhold life-sustaining care from patients with poor prognoses, several told ProPublica. In some cases, doctors gave patients do-not-resuscitate orders without family or patient consent, sometimes overruling families that wanted everything done for their loved one, three nurses said.
In 2016, a top Ochsner attorney published an articlein Ochsner's medical journal that asked what doctors should do when they believe "any clinical treatment other than comfort care will be ineffective or harmful to a patient" but the patient's family is "in support of 'doing everything.'" The lawyer wrote that it would be "prudent" to have two doctors sign off before implementing a do-not-resuscitate order unilaterally.
During the pandemic, three nurses across the hospital system told ProPublica they'd seen cases where two doctors signed off to give COVID-19 patients a do-not-resuscitate status without the patient or family's agreement. For the sickest ones, they said, this effectively meant the hospital was withdrawing care, since a patient sick enough to need a ventilator was unlikely to survive without one and they generally wouldn't intubate someone with a DNR.
"You get the family that says absolutely not — we want you to do everything," one nurse at Ochsner West Bank told ProPublica. "When there's enough vents," the nurse said, doctors will respect the family's wishes even if they disagree with them. "But when your decision is impacting other people, we can't keep doing care."
Ochsner denies that its employees issued any do-not-resuscitate orders unilaterally. "DNRs are not issued without the consent of or over the objection of a patient or legally authorized representative," an Ochsner spokesperson said. "Given these challenging and unusual times, it comes as no surprise that a member of the care team, including nursing, had a different perception of those end of life conversations, especially where they were not involved in all of the discussions and interactions."
The last time New Orleans healthcare workers faced a crisis like this was Hurricane Katrina, when floodwaters knocked out the power at several hospitals, leaving patients and staff marooned. At Memorial Hospital, which was owned by a different company at the time, several DNR patients died after doctors injected them with high doses of morphine. In the aftermath, Memorial's parent company sold Memorial and two other hospitals, including what is now known as West Bank, to Ochsner, which began a period of expansion in which it would become the largest hospital network in the state.
During the spring surge of the virus, staffingwas among the Ochsner system's most pressing concerns. As early as March 25, about 60 Ochsner employees had tested positive and hundreds more were out on quarantine. The system repurposed staff from its closed outpatient clinics, and recruited an additional 140 nurses from other locations. "We adapted our staffing plans as needed to avoid little to no disruption to the quality of patient care," the spokesperson said.
ProPublica spoke with more than two dozen doctors, nurses, and other healthcare workers at Ochsner about their experiences during the pandemic. All asked that their names be withheld, to not jeopardize their employment. Many described how limited time and resources prevented them from giving the level of care they were accustomed to, and in some cases forced them to ration treatment.
"If I could've doubled myself, I could've saved some people," a nurse at Ochsner Baptist told ProPublica. With critically ill dialysis patients, the nurse would normally carefully monitor their machines, tweaking their levels before anything could cause a problem. "But I can't be everywhere. My other patient is coding. So I'm just going from code to code to code."
Despite the chaos, Johnson was evaluated within minutes, tested for the virus and hooked up to intravenous fluids. Dr. Charlane Liles noted that she was "markedly dehydrated" and her heart rhythm was fast and irregular — a problem likely caused by the virus, an Ochsner cardiologist later determined. She was alert and oriented, though, and her breathing was normal. And thanks to a breathing tube in her nose, the mildest option for treating lung problems, her oxygen levels had improved to almost 100%.
But her labs revealed another problem: Johnson — who already had modest chronic kidney disease — was now in acute renal failure, a common consequence of COVID-19, which can severely damage kidneys. Doctors agreed that they needed to treat Johnson's dehydration. Liles admitted Johnson to the hospital so she could continue getting oxygen, fluids and heart medication and receive "close monitoring."
Overnight, a nurse turned off her oxygen, letting her breathe on her own, because Johnson no longer needed the help.
As the sun rose, a new series of medical experts began to evaluate her.
First was Zannah Richard, a dietitian, who had been asked to determine if Johnson was malnourished; at 106 pounds, she was thin, and her labs revealed depleted levels of albumin, a liver protein for which low levels can be a sign of malnutrition but is also associated with kidney diseaseand other illnesses.
While Johnson could be at risk of being underweight, Richard determined, she was not malnourished. The dietitian left her recommendations for Johnson on sticky notes and filed them electronically.
Three hours later, without physically examining Johnson, citing coronavirus protocols, nephrologist Dr. Miguel Molina reviewed her records and determined she was not a dialysis candidate. Experts told ProPublica this was likely because she was not sick enough for dialysis. Molina then decided to take her off of fluids.
Shortly thereafter, around 10:30 a.m., Dr. Amanda Cruz-Cruz entered Johnson's room for a more general evaluation. Johnson was asleep when she came in, but the physician awoke her easily. Johnson asked for some water, and while she appeared attentive, her speech was delayed, her memory impaired and she was unable to "hold a meaningful conversation," the doctor noted. When another doctor had tried to take her medical history the night before, Johnson was too confused to provide it.
Cruz-Cruz then proceeded to make a series of judgments that several experts told ProPublica confused them and, in some instances, appeared inappropriate.
"Based on physical appearance and presentation, patient likely has advanced [or] end stage dementia," Cruz-Cruz wrote, suggesting that her dementia was likely so bad that even before she contracted the coronavirus, she had been bed bound and incapacitated. At this point, according to the medical notes, no one at the hospital had spoken to her children about her mental state.
ProPublica interviewed seven relatives and friends who saw or spoke with her regularly; while she sometimes misplaced keys or repeated childhood stories — indicating to her family that she might be in the early stages of dementia — they all said she was still sharp, and not at all incapacitated until she contracted COVID-19.
The assessment also went against what seven geriatricians described as well-established best practices in geriatric medicine. "You shouldn't be diagnosing dementia in the acute setting," said Dr. Louise Aronson, a professor of medicine at the University of California, San Francisco Division of Geriatrics and author of "Elderhood," a finalist for the Pulitzer Prize. The prevalence of delirium is highwith acutely ill elderly patients, particularly those with COVID-19, and Aronson said that dementia should not be diagnosed in a "hospital setting because it's delirium until proven otherwise."
Cruz-Cruz also noted that Johnson was "severely malnourished." The doctor did not explain her reasoning, and it is unclear if she was aware that the dietitian asked to evaluate Johnson for malnutrition had determined the opposite just hours earlier.
Cruz-Cruz concluded: Since she "is not candidate for dialysis if needed, is severely malnourished, [is of] advanced age, appears to have advanced dementia and functional status [is] currently poor," Johnson would benefit from a do-not-resuscitate order and potentially should receive hospice care going forward. Cruz-Cruz did not respond to ProPublica's questions.
Shortly thereafter, a nurse noted that palliative care specialists had been consulted to determine if Johnson's family would consent to a DNR, "which in turn will determine plan of care."
At 2 p.m., Crystal Burke, a nurse practitioner specialized in palliative care, called Lavalais and his siblings. According to her notes, she told the family Johnson's prognosis was "poor" and they discussed what would be best for her in light of her "dementia, renal failure, respiratory failure, and malnutrition." Burke explained how hospice can "help [a] patient live with the best quality of life possible," and the family agreed to go along with the plan.
Lavalais does not remember anyone mentioning advanced dementia or malnutrition, and was surprised by Burke's record of the conversation. Burke did not respond to ProPublica's questions about Johnson's care. According to the family, they were told that their mother had COVID-19, her kidneys were failing and she was going to die, and that there was nothing the hospital could do to save her.
With the children's approval, at 4:18 p.m., a social worker faxed a referral to Compassus, a national, for-profit company that provides hospice care and has an office in the New Orleans suburbs. It was late on a Friday afternoon, and Johnson stayed at the hospital over the weekend.
By Monday morning, a new set of labs returned. Two experts who reviewed Johnson's medical records for ProPublica said that the tests showed her kidney function had improved remarkably, not close to normal levels but enough so that she was no longer in kidney failure. Additionally, her electrocardiogram showed that her heartbeat had gone back to normal, beating healthily throughout the day. But a new problem had arisen: her sodium levels were rising precipitously. Generally caused by dehydration, high sodium can make people confused and erratic, and if untreated, can result in coma or death.
None of the doctors at Ochsner noted that Johnson's chief medical problems were improving, or her concerning sodium increase, in more than 650 pages of detailed medical records from her stay. In a discharge summary hours later, Dr. Diane Van Gerwen, who did not respond to ProPublica's questions, even wrote that Johnson's heartbeat was still fast and irregular and that her "renal failure [was] not improving but not worsening."
Then, as required under Medicare, Van Gerwen documented the reasons Johnson needed hospice care, citing her kidney problems as the main reason, along with dementia and a general "failure to thrive." At 6 p.m., Johnson was discharged.
"If she stayed in a few more days and got more IV fluid, I think she would've done fine," said Dr. Brobson Lutz, an infectious disease doctor on staff at Ochsner, who served as the New Orleans Director of Health for 13 years and reviewed the case for ProPublica. "She was only mildly symptomatic for COVID. She was certainly getting better and responding."
Lutz thinks the decision to move to hospice rather than monitor her probably worsened Johnson's chances significantly. "She didn't meet hospice criteria, renal failure not needing dialysis," he said. "When she went home, she probably got more dehydrated. That sodium of 150 was pretty high."
Dr. David Goldfarb, clinical director of the nephrology division at NYU Langone Health in New York City, said her kidney injury wasn't severe enough to necessitate hospice. "She has pretty bad kidney function, but she's not going to die of kidney failure," he told ProPublica. "The acute kidney injury wasn't bad enough to really make sense as a hospice diagnosis."
In keeping with national criteria, Ochsner's spokesperson said, "hospice was determined and recommended by the care team if the patient had a life-limiting illness in which death is anticipated in the next six months."
As an 86-year old with COVID-19 and kidney problems, Johnson's long-term life expectancy was not good, Goldfarb said. "Would you be surprised if this patient died in six months? Probably most doctors would say no," he told ProPublica. "On the other hand, could she live for another year? I wouldn't be surprised by that, either."
For that reason, it was not unreasonable for Ochsner to suggest hospice, Goldfarb said. But that was not the only option, and he said the family should have had a choice.
To understand why so many people died outside of hospitals in New Orleans, ProPublica analyzed local coroner records of the city's more than 460 deaths through early May. An overwhelming majority, 384, died in a hospital; an additional 21, in nursing homes or an assisted living facility.
ProPublica focused on those who remained — the 55 people who died outside of any acute care setting, in categories the coroner labeled "decedent residence," "hospice" and "other care center," which often included hospice deaths. Reporters attempted to reach every one of their families, and spoke with 35 of them.
Experiences seemed divided along racial lines.
While Black people died from the virus at a disproportionate rate in New Orleans, white people died outside of hospitals at a higher rate than Black people. In the cases ProPublica examined, this was by choice. Reporters spoke with three families of white people who died with home or hospice care; their families said they chose to avoid the hospital and made arrangements to stay home instead. Some Black patients also stayed home, and did not seek care at the hospital.
Twenty-five families told ProPublica the deaths of their loved ones occurred after the patient sought care at a hospital. All 25 patients were Black.
A few were told they were not sick enough to be admitted, and then died at home. But 18 of the 25 Black patients were sent by a hospital to die under hospice care, according to their families. The vast majority came from Ochsner facilities.
The families of eight Black patients said they felt pressured by Ochsner staff into accepting hospice care for their loved ones.
Erma Winston's children remain convinced that Ochsner pushed their 83-year old mother into hospice because resources were limited and she had no family at her bedside to advocate for her. Her adult granddaughter Chantell, who was involved in conversations around her care, believes she could've gotten better treatment. "Do I think this would have happened if COVID wasn't going on? No, because we would have been right by her side."
In early April, her grandmother was taken in an ambulance to Ochsner's main campus with coronavirus symptoms. When a nurse helped Winston video chat with her family about five days later, she appeared transformed. The former postal worker, who lived independently at home, now could hardly speak. But she responded to her daughter's voice and nodded along as she prayed.
A day later, Winston's family got a call from a member of the palliative care team, recommending she move to hospice, they said. They pushed back. The family had already consented to forgo chest compressions if Winston's heart stopped, but they were not ready to discontinue her care.
However, the hospital was adamant, her family told ProPublica, and her children came to believe that the decision to discharge their mother had already been made. According to one of her daughters, the hospital told her that Winston needed to either transfer to a hospice facility or be discharged home within the next day.
Her family agonized over the decision. They knew nothing about the pop-up hospice unit, which a private company had set up in a matter of days to care for COVID-19 patients in vacant space at another hospital. At the same time, if their mom came home, the whole family could get sick. They begged a social worker for more time to think. But the family said their requests seemed to fall on deaf ears. "They were definitely rushed," Chantell said. "They could have kept her there a couple more days until we made a decision."
The next day, Winston was transferred to the hospice unit, where about 10 days later, she died.
"It was poor management," Chantell told ProPublica. "And sometimes with poor management, African Americans suffer."
Ochsner Health declined to comment on Winston's care, citing privacy restrictions. A spokesperson said that Black patients had "disproportionate rates of infection, hospitalization and deaths," and that they seemed to be sicker when they arrived in the emergency room, with "a higher rate of kidney and liver function abnormalities."
The spokesperson did not respond to ProPublica's questions about racial disparities and hospice referrals, but said that "the disparities in health that we see among the Black population are something we've known for decades and COVID-19 has opened the door for more people to become infected, but also an opportunity to address disparities head on and initiate change."
Researchhas shown that Black families have disproportionately negative experiences with end-of-life care. Dr. Michael C. Francis, a community physician on staff at Ochsner, told ProPublica he's seen discrimination firsthand when his patients navigate these difficult decisions with medical teams.
"They assume that Black folks don't know anything," he said, "and that if the doctors do something they don't agree with, they're not going to do anything about it."
Under normal circumstances, hospice care can be a blessing for dying patients, allowing them to transition surrounded by loved ones in the comfort of their own home. Through Medicare, if a patient is terminally ill and has a life expectancy of six months or less, they can access on-call nursing assistance, medical equipment and prescriptions, as well as continuous care in crisis moments when symptoms flare. About half of Medicare beneficiaries die receivinghospice services.
But due to the coronavirus's infectious and unpredictable nature, the use of home hospice for these patients has become contentious.
At the UW Medical Center—Northwest in Seattle, one of the earliest hotspots of the virus, patients dying of COVID-19 were kept in the hospital and provided palliative support through an inpatient program. SUNY Downstate Medical Center in New York City did the same, entirely avoiding home hospice for coronavirus patients, said Dr. Bonnie Arquilla, the hospital's director of emergency preparedness. And Rush University Medical Center in Chicago likewise handled palliative cases in the hospital instead of sending coronavirus patients home for hospice, and allowed families to visit if a patient's death was imminent.
The public health risk of expecting relatives to care for dying loved ones at home would have been too high, said Dr. Paul Casey, Rush's acting chief medical officer and an emergency room physician. "A young healthy patient that we saw and diagnosed with COVID, we'd be able to send home and say, 'You need to quarantine yourself away from family members and others to make sure you're not potentially impacting them,'" Casey said. "That's very different than sending someone home to be cared for by the family where you know there will be contact in the effort of needing to take care of them."
Some hospitals were able to continue to offer home hospice care to dying patients with COVID-19, but took measures to make sure families were prepared.
In New York City, hospices were limited in what they could do because "there just wasn't enough personal protective equipment and, without enough PPE, they couldn't go into homes," said Dr. Diane E. Meier, the head of the Center to Advance Palliative Care at Mount Sinai. So Meier helped set up a 24/7 telemedicine practice with palliative doctors, nurses and physician assistants always on call for people who wanted to avoid hospital care and instead take their chances at home.
The palliative care service was available to patients from hospitals across New York City. But in a place where over 20,000 people died with COVID-19, Meier said, the palliative service had about 30 home care cases in the first couple of months of the surge.
End-of-life care is a distinctly subtle form of medicine, dependent on sensitive communication and trust between patients, families and medical staff. Even in normal times, communication does not always live up to that ideal.
Dr. William LaCorte, a New Orleans physician who works with nursing homes and hospitals, said he is often given a stack of documents outlining patients' end-of-life goals and asked to sign them to make them official. "And I won't," he told ProPublica. "I say I want to talk to the family first, or to the patient — and half the time, they disagree with whatever plan of care they supposedly just said they wanted."
The coronavirus has created new, immense barriers. Hospital visitor restrictions leave patients isolated from family members, who often lack vital information to help make complex decisions.
Touro Infirmary, another hospital in New Orleans, allowed family members to visit their loved ones in the hospital before making end-of-life decisions, said Melissa Pennebaker, a nurse practitioner on its palliative care team. "It became clear early on in this pandemic that families really needed to see their family members when making these difficult decisions," Pennebaker told ProPublica.
At Ochsner facilities, by contrast, families generally had to make these decisions over the phone, several nurses and physicians told ProPublica. Ochsner allowed families to visit, but only after they'd decided on comfort care or when the patient was actively dying, they said.
An Ochsner spokesperson did not say whether families were permitted to visit to discuss hospice and other options, but said, "Ochsner, like many health systems and hospitals across the country and as required by [the Louisiana Department of Health] instituted a zero-visitor policy. This policy did have an exception for essential visitors that included limited visitors for end-of-life patients."
In late March, 66-year-old Army veteran Lionel Ferdinand spent roughly a week at Ochsner Medical Center's main campus battling COVID-19, growing increasingly delirious. Eventually, he refused the dialysis treatment he needed to survive.
"He wasn't in his right mind," said his wife, Connie, who said she was told by the hospital that his organs were shutting down and nothing more could be done. Unlike other families, Connie asked if her husband could be discharged, hoping that he'd be more comfortable at home. The hospital arranged for hospice care.
The hospice and home health company AmeraCare provided the family with a hospital bed, oxygen tanks and medicine, but neither it nor Ochsner provided PPE, which was hard to come by at the beginning of the pandemic. Ferdinand's family was worried about caring for him without protection, an AmeraCare nurse noted in his hospice records. She told them to "contact any and all resources to try to attain proper PPE." Connie's daughter-in-law and niece were able to track down cloth masks; another family member gave her gloves.
"They should have had everyone prepared," said his daughter Kelly.
At home, Ferdinand declined swiftly, delirious and unable to sleep. "He looked like he was smothering himself," said his daughter Tina. "His head was popping up. We didn't know how to treat him or how to deal with this."
They tried to soothe him, but because he appeared to be suffering, they called the hospice company in the middle of the night and begged for a nurse to come help. No one showed.
Alone, Tina and her mother tended to Ferdinand, trying not to think about the virus particles each cough sent flying. "I was afraid," Tina said. "But I knew my daddy needed good care."
About 5 p.m. the next day, a hospice nurse finally came. From the hallway, without entering his bedroom, she inspected Ferdinand and told the family he was getting ready to transition, Connie said. The visit lasted 20 minutes, according to hospice records.
For seven hours after the nurse left, Ferdinand's family cared for him as he lay dying, sweating profusely, struggling to breathe and unresponsive. They tried to make him comfortable by opening the window, turning on a fan and continuing anti-anxiety medication, but his chest heaved in distress. Then, just after midnight, Ferdinand passed away. His family feels they weathered his death alone, unprepared to relieve his suffering.
Then, some of them fell ill.
"It felt like I was breathing water … like I was catching a heart attack" said Tina, who first showed symptoms of what she believes was COVID-19. She decided not to go to the hospital, instead isolating herself until she recovered. Ferdinand's granddaughter also fell ill.
In moments like Ferdinand's first night at home, when family caretakers struggle to control severe symptoms, face-to-face visits from hospice workers become crucial, said Dr. Joan Teno, a medical professor at Oregon Health & Science University and a leading researcher on hospice quality, having studied palliative and end-of-life care for more than two decades. Stepping in when families are unable to keep a patient comfortable isn't just a gold standard, she said. Failure to do so can constitute "really poor quality hospice care." If symptoms are too difficult to control, continuous in-person nursing care or admission to an inpatient unit could be necessary, she said. Death is "the one big sentinel event in that family and when it goes wrong, it's really traumatic to them."
AmeraCare declined to respond to specific questions about Ferdinand's care.
During the first couple of months of the pandemic in New Orleans, hospice companies faced many of the same pressures as hospitals, workers told ProPublica. A hospice employee from AmeraCare, who spoke on the condition of anonymity, said that in-person visits were reduced to one per week, unless death was imminent. "If we could prevent going out and doing telehealth instead, like a patient not knowing the type of medication, the side effects, what it does, we could direct it on the phone," they said. In Ferdinand's hospice records, an AmeraCare staff member noted that the company was limiting skilled nursing visits and that they'd halted certified nursing assistant visits.
Taking the pandemic pressures into account, in late March, the Centers for Medicare and Medicaid Services scaledback hospice regulatory requirements, allowing telehealth to replace face-to-face visits, if feasible and appropriate. CMS also dropped the requirement of having a nurse conduct an on-site hospice visit at least once every two weeks, allowing less qualified aides to provide care instead.
A nurse who worked at Compassus, the company that took care of Sarah Johnson, also said that their company limited visits. "We had decreased the amount of time that we go to the homes to once every two weeks unless they needed a nurse," said the worker, who requested anonymity. "The patients had to really need a nurse. … None of us wanted to go in a house with a COVID patient since there is no control over how clean the surroundings would be. ... But we had to if we had to."
Dana Coleman, a spokesperson for Compassus, told ProPublica that they equipped their workers with PPE, trained them on safety protocols and utilized virtual visits as permitted by CMS. She also said that additional staff members were deployed to New Orleans to maintain visit frequencies during the pandemic, and that nurse visits were not limited to once every two weeks.
Dr. Kai Romero, an emergency medicine doctor and the chief medical officer of Hospice by the Bay in Northern California, told ProPublica that they wouldn't take on a COVID-19 hospice case unless there were adequate safety and infection control measures in place for family caretakers.
"In March and April, there wasn't enough [PPE] for our own staff," she said, adding that they ultimately needed to rely on the University of California, San Francisco, to help track down protective gear, such as masks for staff and family caretakers. "The considerations around who was going home on hospice, what supplies they're given or can get access to, how that's determined, is an extremely thoughtful process and if those don't line up, at least here in San Francisco, we don't admit them to home-based hospice."
Ochsner did not respond to ProPublica's questions about how it vetted hospice companies to see how prepared they were to handle the infectious disease, nor did they comment on the family caretakers who subsequently contracted the virus.
Before Johnson came home from the hospital, Compassus delivered a bed, oxygen tanks and morphine, and trained the family on how to administer the painkiller. "They tried to explain how to take care of her," Lavalais said, "but it was hard to remember."
Like the Ferdinands, Johnson's family received no PPE. Lavalais, who is high risk with diabetes and hypertension, was deeply concerned. When he asked the company for masks, he received a box of gloves. Though difficult to find, the family tracked down a few surgical masks from a store, which was selling them for $5 apiece.
"Consistent with industry practices, we do not provide family caregivers with PPE as a matter of course," said Coleman. "Given that many caregivers, friends, family, clergy, church members, neighbors, etc., may enter the home of a patient at any point during their time in hospice care, it is not possible for any provider to supply PPE for all possible visitors/exposures."
Coleman pointed to CMS's guidancefor hospice agencies during the pandemic, which says they should not be penalized for not providing PPE "if they are having difficulty obtaining these supplies for reasons outside of their control."
The guidance also says "we do expect providers/suppliers to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible."
When Johnson arrived, she seemed to have improved. She was alert, conversing with her children and even eating a little food. She told her son that when she regained her health, she wanted to visit her childhood home, a small shotgun house in the Seventh Ward. She wasn't in pain, so he decided to not give her morphine and hoped that she might even recover before he would have to.
A hospice nurse checked in on Johnson the first two days she was home, said Lavalais and his brother, Michael. They assumed the daily visits would continue. But over the next 11 days, hospice workers came only two more times, they said. In contrast, a recent study analyzed data from a national, for-profit hospice company and found that, in normal times, home hospice patients receive an average of about 7 visits per week from hospice workers, totaling about 9 hours of care time. Even in the pandemic, Teno said that in-person visits are important. "You should have PPE and you should be able to go in there and see the patient," she said.
In Chicago, 70 of the city's 100 first recorded victims of COVID-19 were black. Their lives were rich, and their deaths cannot be dismissed as inevitable. Immediate factors could — and should — have been addressed.
Coleman said that Compassus employees are available 24/7 for "emergent" calls or visits if a sudden need arises. While Compassus did not answer ProPublica's questions about how many face-to-face visits were made to patients, Coleman said that if you include "virtual visits," its patients were contacted four to fives times per week on average during the pandemic.
Johnson remained isolated in her bedroom, the door cracked open so her sons could check on her. She grew weaker. A little over a week into her stay at home, Lavalais watched her struggle to swallow as she tried to drink. It sounded "like a piece of steel was stuck in her throat," he said, "and the water couldn't go through."
When she'd shown signs of this problem at West Bank, a speech therapist evaluated her and gave careful recommendations on how to handle it in the hospital, like thickening liquids to make them easier for Johnson to drink. No one told the family about the issue.
Lavalais called the hospice company; he says he was told to stop giving his mother food and water, which is not an unusual practice for hospice patients close to death. He was also told to increase the morphine. Lavalais asked if she should be readmitted to the hospital. "The hospice nurse said, 'They won't be able to do anything for her, but I can't tell you what to do,'" he said.
When Johnson asked her son for water, saying she was thirsty, Lavalais didn't know what to do. "I couldn't give her anything," he said. "I felt terrible." He and his brother said that as Johnson worsened during her final three days, no hospice nurse visited.
Coleman said patients always have the right to revoke hospice care and seek more aggressive or curative care at a hospital; under Medicare, hospice patients can also go to the hospital if they have "uncontrolled pain that cannot be managed at home." Compassus declined to answer specific questions about Johnson, despite having a waiver from her son permitting them to speak about her care.
"When someone is in the dying process, they develop a constellation of more symptoms," said Teno, adding that when death is imminent, symptoms can be hard to control. "We know that when visits don't occur in the last few days of life, it's very stressful for the family." These visits are so critical that the federal government uses them to evaluate hospice quality.
When Johnson's children moved her, "she would moan and groan in pain," Lavalais said. "I was overwhelmed. I didn't feel comfortable."
On the morning of May 3, Lavalais walked into his mother's room to check in on her and saw that she wasn't breathing. Thirteen days after coming home from the hospital, she had passed. "I thought she'd be in good hands," her son said. "I know she suffered."
Dr. Sara Cody, health officer of Santa Clara County, California, was tired of seeing the same thing over and over again. Her contact tracers were telling people exposed to COVID-19 that they needed to get tested, but when some went to testing sites, healthcare providers turned them away because they didn't have any symptoms.
This posed a problem for Cody's work. Knowing if a contact was infected would help her department keep an accurate count of her county's coronavirus infection rate; also, if a contact tested positive, it'd spur a new round of contact tracing from her staff, to help stop any further transmission from that asymptomatic carrier.
Cody decided to issue a countywide health officer order in June requiring certain healthcare facilities to provide testing for all close contacts, and also all front-line workers, such as mass transit drivers and retail workers, whether or not they had symptoms.
Then last week, the U.S. Centers for Disease Control and Prevention quietly changed guidelineson its website to say that people without symptoms did not necessarily need to be tested, even if they had been in contact with someone who had COVID-19. Cody was confused. "Was it because there isn't enough testing capacity?" she initially wondered. But there was no such explanation from the agency.
The CDC was met with a degree of pushback that was notable in its intensity; several states flat-out said they would not follow the guidelines, including California, where Gov. Gavin Newsom said, "I don't agree with the new CDC guidance. Period. Full stop."
The controversy surrounding the CDC guideline change is all just a symptom of a deeper issue that has plagued America's coronavirus response: Even though we have spent more than half a year battling a virus whose insidious hallmark is its ability to spread through those with no symptoms, the country has not yet articulated a coherent strategy to test these silent carriers.
"The fact that we're this far into the pandemic and we're still talking about how to do asymptomatic testing and going back and forth on this is a major part of the reason why we're struggling to open schools and colleges, and why people are still dying in prisons," said Dr. Ashish Jha, dean of the Brown University School of Public Health.
The lack of consistent asymptomatic testing guidelines means that from state to state, county to county, a hodgepodge of strategies are being used with varying standards, testing methods and levels of access. Decisions are being made sometimes by people who have been thrust into the role of public-health officer with no training — school principals and college deans, leaders of companies and daycares and churches, who are just trying to do right by the people they are responsible for.
It's unfair to ask them to have to come up with their own testing strategies, or to have to navigate the maze of their local health authority's often shifting recommendations. There may be pros and cons to various strategies experts have proposed, with variables to consider like testing technologies, supply chains and federal funding, but perhaps the more urgent need at this point is picking a plan and actually seeing it through.
To understand why, we need to start with a clearer understanding of the pivotal role asymptomatic testing plays in containing this virus, particularly in the absence of a vaccine.
Why Asymptomatic Testing Is Important
Let's start with the most basic question: Why do we bother testing in the first place? There are, broadly speaking, two reasons to use a test. The first is as a clinical diagnostic; the other is as a public health tool. Both are important, but for different reasons.
Doctors use a clinical diagnostic like a strep test to tell whether a patient is sick with a disease that can be treated with particular medicines. "The purpose of the test is based around doing one thing when it's negative and doing another thing when it's positive," said Dr. Patrick O'Carroll, head of health systems strengthening at the Task Force for Global Health, who previously worked at the CDC for 18 years.
From this perspective, it seems pointless for an asymptomatic person who might have COVID-19 to take a test, because there's not going to be any difference in how they will be treated — there are no symptoms to medicate. You might have even heard your doctor say, "Don't bother taking a test if you only have mild symptoms, because I'm not going to tell you do anything different besides drinking fluids, taking Tylenol and resting."
But from a public health standpoint, testing asymptomatic people can yield actionable information. COVID-19 is unlike many other diseases, in which a patient's peak contagiousness coincides with the height of their symptoms. With COVID-19, about 40% of patients do not show any symptoms or have such mild ones that it would never have occurred to them that they had been infected. In a recent study of 192 young people with suspected COVID-19 in Boston, only half who tested positive had a fever.
Furthermore, studies have shown that among patients who do develop symptoms, viral load, which correlates with a patient's contagiousness, is highestright before or at the time when symptoms start appearing. Put together, these features have explained why the coronavirus has been able to spread so perniciously across the globe. It's one sneaky virus.
If an asymptomatic person tests positive, public health officials can ask them to isolate from others and begin the process of contact tracing in order to break chains of transmission. In the bigger picture, it also helps them keep tabs on where the virus is spreading in their city. (This is what's known as "surveillance" in public health parlance: They're not spying on you. They're tracking the virus.)
"Since the beginning, testing has been the foundation of our response, because it tells us who is positive, where they are, in which demographic, and what the patterns are," said Dr. Umair Shah, executive director for Harris County Public Health in Texas.
Understanding population prevalence also helps guide public health actions. For example, said O'Carroll, "if testing shows that only 2% of the population is positive, I'm going to call all of those people, interview them, put all of the contacts in quarantine and really try to stamp it out. But if I find that 30% are positive, then I really don't have the resources to interview and chase down thousands and thousands of people — that's when spread is too high for contact tracing to be useful."
When testing is restricted to symptomatic patients, health officials will only have limited signals about the extent of the virus's spread, leaving them to operate partially blind.
Standards Vary From State to State
There are two categories of asymptomatic people to consider: The first includes those who had close contact with someone who has already tested positive for the virus. The second includes people who don't have any reason to believe they have been exposed. The first group is a higher testing priority, because there's a far greater chance that they have been infected and can be spreading the virus.
In an ideal world, if testing were abundant and cheap and results were fast, we would test everyone daily and catch all of the asymptomatic carriers. But when there aren't enough tests to go around, public health officials need to triage.
In the earliest stages of the pandemic, when there were hardly any tests available across the country, public health officials had to limit tests to the most urgent need — people with severe symptoms in hospitals. As tests became more available, they started to widen the criteria, first to people with symptoms, then to asymptomatic people with known exposure. Finally, in some areas of the country, anyone who wanted a test could get one, whether or not they had symptoms.
But to this day, the decisions have been made piecemeal. I reached out to health departments around the country, and found that testing criteria still vary depending on where you live.
In Delaware, close contacts are asked to get tested once, at the end of their 14-day quarantine period. The state lets anyone get tested, whether or not they were exposed or have symptoms. Maryland recommends that people who suspect they've been exposed to the virus get a test, whether they are symptomatic or not. Arkansas says it works to facilitate testing for all close contacts of positive cases, and also tries to provide testing for anyone in the state who wants a test, asymptomatic or not.
But Oregon and Wisconsin don't recommend testing for asymptomatic people who have not had close contact with a confirmed case. (Oregon makes an exception for people in a high-risk category, such as agricultural workers.)
Some states have more nuance to their recommendations. New Jersey said testing is available to all, but noted that if you are asymptomatic, testing is recommended if you are a front-line worker, if you were in a large crowd with difficulty social distancing, if you are a member of a vulnerable population or if you recently traveled somewhere with a high COVID-19 infection rate.
Effective Contact Tracing Can't Happen Without Efficient Testing
Within each state, however, guidelines aren't always followed consistently by test providers. Cody, the health officer in California, isn't the only one whose contact tracers are unable to get asymptomatic people tested.
Rebecca Fischer, an assistant professor at Texas A&M University School of Public Health, said she's seen the same thing happen in Brazos County. "We call them and say, 'How did the test go? And they'll say, 'They sent me away because I don't have symptoms.' and we'll say, 'You need to go back and say the health department sent you,' and often they get turned away again." Sometimes, Fischer said, the health department would have to give the person a letter to verify that they needed a test.
"We get on the local news station and plead with test providers to help us facilitate widespread testing," Fischer said.
It's unclear why providers are turning down asymptomatic patients. It may be, in part, due to the perceived purpose of the test. Dr. Michael Hochman, a primary care doctor and director of the Gehr Family Center for Health Systems Science and Innovation
at the University of Southern California, said he thinks the value of testing contacts without symptoms is "modest" and would rather make them stay home for 14 days instead of come into a clinic for a test, "which is bringing them together with other people, the opposite of what you want."
He worries that a false negative could give patients a misguided sense of security and prompt contacts to leave quarantine before they're supposed to. Hochman says he sometimes has patients calling who say they have potential exposure and want a test, but when he explains to them that regardless of the result, they still will need to quarantine, the patients often then decide they won't bother with a test.
Cody countered that many people don't always adhere to the 14-day guidelines. "We're not doing legal orders, so there's not going to be perfect compliance," she said. Given the opportunity to test and find out that an asymptomatic contact is positive is always preferable, she said, because people are more likely to take precautions and isolate properly, particularly around family members.
Without a Clear National Strategy, Confusion Abounds
Into this already chaotic environment came the CDC's guidance change on Aug. 24.
Normally, when the agency updates its guidances, it gives a heads-up to state and local health departments, so they can decide how to adjust their own recommendations or how to communicate to the public, said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents large metropolitan health departments.
"Usually at minimum, there's a big tent call … and normally at the top of the call, they say, we're going to update this."
But this time, it didn't happen. "It was buried in an email," she said. "If you hadn't clicked on it, you wouldn't have known."
Previously, the CDC recommended testing for all close contacts of people with known COVID-19 infection, specifically noting that "because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts … be quickly identified and tested." The new guidance, however, said, "If you have been in close contact … you do not necessarily need a test unless you are a vulnerable individual or your healthcare provider or state or local public health officials recommend you take one."
The new guidance for asymptomatic people who had no known exposure conveyed a number of different messages, depending on which part of the website you read. On one hand, it said, "If you do not have COVID-19 symptoms and have not been in close contact with an infected person: You do not need a test."
But farther down the page, the site also said, "If there is significant spread of the virus in your community, state or local public health officials may request to test more asymptomatic 'healthy people.'"
In the absence of explanation or context, confusion ensued.
Calling the new guidelines "vexing and hard to interpret," Dr. Jeff Duchin, health officer for public health for Seattle & King County said in a statement that "testing asymptomatic close contacts of COVID-19 cases is important to identify cases and interrupt transmission and we intend to continue to do that pending additional information that would lead us to reconsider."
When I asked the CDC to explain the change in guidance, it didn't respond, instead pointing me toward the Department of Health and Human Services.
HHS sent me a statement from Adm. Brett Giroir, the federal testing czar, saying that the updated guidance "places an emphasis on testing individuals with symptomatic illness, those with a significant exposure or for vulnerable populations, including residents and staff in nursing homes or long term care facilities, critical infrastructure workers, healthcare workers and first responders, and those individuals (who may be asymptomatic) when prioritized by public health officials."
The revised guidance did not appear to be generated internally by the CDC. Giroir later told reporters that the recommendations were approved by members of the White House coronavirus task force, saying, "We all worked together to make sure that there was absolute consensus that reflected the best possible evidence." Dr. Anthony Fauci, however, saidhe was undergoing surgery and was not part of the discussion.
A few days later, CDC director Dr. Robert Redfield verbally softened the changes, saying that testing "may be considered" for asymptomatic contacts, though the guidelines online were not changed.
"Ultimately, it may not actually be a huge change," said Juliano, but in practice it means that the federal government "is really pushing the decision down to states and local."
"It means when public health says you should get tested, someone could say, 'well, the CDC says it's not necessary.' It leads to public confusion, and you're really putting state and local in a line of fire that's not necessary."
Use the Right Test for the Right Situation
Now that we've talked about the reasons it's important to do asymptomatic testing, it's time to think about resources. In recent months, many experts have been advocating that different types of tests be used for different purposes, in order to optimize available supplies and avoid testing delays.
The idea goes like this: We should save the most sensitive tests — known as PCR tests — for diagnostic purposes, when we need to be absolutely sure that a patient has COVID-19, because we're going to be treating them or asking them to isolate, based on the results. So these tests should be used for people with COVID-19 symptoms and people who were known to be exposed to the virus.
But for public health purposes, when it comes to keeping tabs on how broadly the virus is spreading, we could instead be using slightly less sensitive — though not poor quality — rapid tests, known as antigen tests, which typically can provide results in minutes to hours. Such tests should be used for screening people en masse in settings like nursing homes, essential workplaces, and communities that have limited testing resources, proposesa team at Duke University's Margolis Center for Health Policy. Any positives that turn up could then be confirmed with a PCR test.
The goal is to avoid the long testing turnaround times that the country was plagued with this summer. PCR tests, while highly accurate, usually require at least a day or two to return results even under optimal conditions, and require more specialized equipment, labs and staff. This summer, when the majority of tests were being shoved into the PCR queue, turnaround times stretched out, with some people waiting more than two weeks for test results.
This is not just an annoyance for individuals. It's a massive public health problem, because a test that takes more than two days to come back is pretty much useless.
"Patients don't know what to do in those two weeks, and guess what, we can't do our contact tracing, so we can't fight the pandemic — all of that gums up the system." said Shah, of Harris County. Such long turnaround times are "shameful. It makes no sense."
Dr. Mark McClellan, one of the authors of the Duke paper, said the government must set aside funding to pay for antigen tests in at-risk populations, including low-income, minority and immigrant communities, and public schools and colleges.
The University of Illinois is requiring all faculty, staff and students to participate in screening testing twice a week, using a rapid saliva-based test. Not every college has the resources to perform these routine tests, but advocates for this kind of testing point to the university to show that it isn't a fantasy.
"It is feasible," said Carl Bergstrom, a computational biologist at the University of Washington. "It's just a matter of will."
McClellan and his co-authors estimate that about 14 million people are in high-risk settings that need regular screening testing, requiring an average of two tests per week. "There needs to be a lot more financial support to get that capacity up, something like Operation Warp Speed, with the government going in jointly with manufacturers," he said.
What We Need to Do: Pick a Plan, and See It Through
For now, though, the federal government doesn't appear to embrace this vision. Testing czar Giroir told reporters in a call on Aug. 13, "I'm really tired of hearing, by people who are not involved in the system, that we need millions of tests every day. … You don't need this degree of testing. You need strategic testing combined with smart policies."
Giroir explained that the administration's focus was testing symptomatic patients as well as vulnerable populations, such as nursing home residents, coupled with policies including mask wearing, social distancing and hand washing. "That plan is being implemented and that plan is working," he told reporters.
Some public health experts say that approach won't be enough to curb the pandemic.
"Masks are a very powerful tool for virus control, and they're not completely off the table, but a lot of our population has not been able to adhere to them because it's become politicized," said Dr. Michael Mina, assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health.
And while social distancing is important, said Jha, he doesn't think that alone will work in places where people are regularly congregating, like schools. "It's not the real world," he said. "Do we really think kids will never get close to each other?"
Mina argues for an audacious plan that calls for far more testing than the U.S. has been capable of to date. His testing strategy, particularly when it comes to how it approaches asymptomatics, seems directly at odds with Giroir's.
Mina envisions tests so cheap ($1 apiece) and so widely available (over the counter) that every American can test themselves at least twice a week. The tests we'd use are paper strips that require only a saliva sample. They would certainly be less sensitive than PCR tests, but sensitive enough to catch people when their viral load is highest, which is exactly when they are most infectious.
The technology for a cheap, rapid antigen test certainly exists: Abbott Laboratories' $5 test, authorizedby the U.S. Food and Drug Administration last week, goes a long way to prove this point. But Abbott's test is intended to be used on symptomatic patients, and needs to be performed by a doctor. Mina wants people to be able to test themselves.
Mina's vision has gained broad support in recent weeks by numerous public health experts, but would need buy-in from the federal government, particularly the FDA, to become reality.
Many otherplans have been proposed, but at this point, more time has been spent talking about what we should be doing and debating the various options, rather than mustering the necessary regulatory, financial and political power to get any one of the plans fully executed.
"Choosing not to test those who are asymptomatic is like saying we won't fight the fire until it reaches the second floor," said Brian Castrucci, chief executive officer of health philanthropy the de Beaumont Foundation.
The pandemic has been raging across America for more than half a year. It's past time we had a coherent national plan to put out the fire. Bottom of Form
Caroline Chen covers healthcare for ProPublica. She is currently reporting on the coronavirus pandemic.
The richest man in South Dakota, T. Denny Sanford, was investigated for possible possession of child pornography. Sanford is a major donor to children's charities and Republican politicians.
This article was published on Friday, August 31, 2020 in ProPublica.
T. Denny Sanford, the richest man in South Dakota and a major donor to children's charities, was being investigated for possible possession of child pornography, according to four people familiar with the probe.
Investigators with the South Dakota attorney general's Division of Criminal Investigation obtained a search warrant as part of the probe, according to two of the people, who spoke on the condition of anonymity. They said the case was referred to the U.S. Department of Justice for further investigation.
Sanford has not been charged with any crime. It's not clear what evidence, if any, investigators used to obtain the search warrant or what they collected from the search. It's also not clear how the investigation may have progressed since federal authorities received the referral or if it is still ongoing.
Sanford's lawyer did not respond to requests for comment, but on Friday night he told the Argus Leader, a South Dakota newspaper, "Although we know very little about any state or federal inquiry relating to Mr. Sanford, we do know those authorities responsible for investigating allegations obviously did not find information or evidence that supported or resulted in any criminal charges."
Sanford controls First Premier Bank, a major issuer of high-interest credit cards for people who have poor credit. Worth an estimated $1.6 billion, he is a major donor to the state's political figures, including its U.S. senators and state-level officials, and a prolific supporter of children's organizations and other charitable causes, including a major hospital system based in South Dakota that bears his name.
Sanford has close ties to top state and federal political figures, including Sen. John Thune, whose wife has worked for a Sanford-affiliated organization, and the state's former attorney general and senate majority leader, both of whom now work for Sanford.
He was recently named one of the country's top 10 philanthropists in 2019, clocking in just behind Bill and Melinda Gates. He also donates the Children's Home Society of South Dakota, which serves young victims of violence and abuse, and children's hospitals. Academic and research institutions across the country are named after him.
The South Dakota attorney general's chief of staff, Timothy Bormann, said the office's policy is to neither confirm nor deny the existence or details of any criminal investigation.
A Justice Department spokesman did not immediately respond to questions from ProPublica.
Sanford is being represented by Marty Jackley, a former attorney general and U.S. attorney in South Dakota. As part of an unsuccessful primary campaign for governor, Jackley highlighted his role as U.S. attorney in creating a stand-alone Internet Crimes Against Children Task Force in the state. As attorney general, he co-chaired a national campaign to rescue children from sexual exploitation.
Sanford is a towering presence in South Dakota's largest city, Sioux Falls, sometimes jokingly called Sanford Falls. The 12,000-seat indoors sports and events arena bears his name, as do several of the largest buildings in town. Outside the castle-like Sanford Children's Hospital, a statue named "For the Love of Children" depicts Sanford kneeling beside two small boys and a girl. Another statue, "Chasing Dreams," at the Sanford Sports Complex portrays children running toward him with basketballs.
"My primary bent, in terms of philanthropy, is directed at small children, to give them the opportunity to realize a full life," he told the Argus Leader in 2004.
Websitesfor Sanford organizations show the billionaire frequently interacting with kids involved in his charitable programs, visiting a small girl in a hospital bed, smilingat drawings with a schoolchild sitting in his lap and passing out candy canes to a group of kids. A newsletter for the Children's Home Society of South Dakota, which received a record $55 million from Sanford in 2019, featured an illustration of him drawn by a child in appreciation of his support.
According to his foundation biography, Sanford has given almost $1 billion to Sanford Health, the nation's largest rural nonprofit healthcare system, including a $400 million gift in 2007 that was called the largest contribution ever to an American healthcare organization. After a $12.5 million gift this month from Sanford, the University of South Dakota's law school named itself after Sanford's friend and lawyer, David Knudson, the former state Senate majority leader.
Sanford has close ties to state and federal elected officials. He has spent more than $425,000 on political contributions, according to databases that track election spending, mostly to Republican causes and candidates including small sums to Donald Trump.
Affiliates of the health system have employed Kimberley Thune, the wife of the second-ranking Republican in the Senate, according to John Thune's financial disclosures. Thune's office didn't respond to requests for comment, and a woman who picked up Kimberley Thune's cellphone hung up on a ProPublica reporter.
Thune also lobbied for the health system, then called Sioux Valley Hospitals, after an unsuccessful Senate bid in 2002, according to disclosure records. Thune, whose campaigns have received at least $8,000 in donationsfrom Sanford, has laudedthe billionaire from the Senate floor, calling him "a giving man with a passion for making a difference in the lives around him."
Sanford splits his time between homes in Sioux Falls, San Diego, Scottsdale, Arizona, and Vail, Colorado. In a 2007 Forbesprofile that Sanford cooperated with, executives described him as a colorful boss, gathering his employees in his Phoenix winter home, cooking them breakfast in his underwear, and taking them out for bike rides and nights out dancing. His golf shoes are inscribed with his nickname, WOLT, which stands for World's Oldest Living Teenager.
In March, a southern Illinois man who was under isolation orders for showing COVID-19 symptoms entered a busy gas station. An employee recognized him from Facebook. Prosecutors charged him with reckless conduct. Now, the case has been dismissed.
This article was published on Friday, August 28, 2020 in ProPublica.
Prosecutors have dismissed a criminal charge against a southern Illinois man whom they accused of endangering public safety when he entered a busy gas station store after he was ordered to self-isolate because of coronavirus-like symptoms.
Jason Liddle, 36, of Olney, was charged in late March, as Illinois was under a shelter-in-place order because of the accelerating number of COVID-19 cases. Liddle had stopped at The Gas Station convenience store in Sainte Marie, in Jasper County, so his then 4-year-old son could use the bathroom. A store employee who attended high school with Liddle recalled a Facebook post that Liddle shared that showed a note from medical professionals instructing him to stay at home for 14 days because of “possible COVID 19 illness.”
Once Liddle left the store, the employee informed her supervisor, who, in turn, called authorities. The Jasper County state’s attorney’s office charged Liddle with reckless conduct, a misdemeanor.
The charge was dropped Thursday, according to the Jasper County Circuit Clerk’s Office.
State’s Attorney Chad Miller couldn’t be reached for comment. He had said Liddle’s actions “showed a willful and wanton disregard for the safety of others.” Liddle also could not be reached for comment. Edward Deters, Liddle’s attorney, declined to comment on the case.
In March, Liddle told ProPublica Illinois he had experienced chest pains, a symptom consistent with the novel coronavirus, which prompted him to go to a respiratory clinic. Though he was not tested for the virus, the satellite TV installer was told he could not work and that he must self-isolate.
Three days after Liddle’s mandatory isolation orders, he and his family drove to his in-laws’ home. At some point during the roughly 30-minute drive, he stopped at The Gas Station. The trip was the only time he had left his house, Liddle told ProPublica Illinois.
By the end of March, there were no reported coronavirus cases or deaths in Jasper County or in neighboring Richland County, where Liddle lives. As of Aug. 27, Jasper County has reported 104 positive COVID-19 cases and seven deaths, while Richland County has reported 58 cases and one death.
At the time Liddle was cited, the case was thought to be the first of its kind. At least one more case has emerged since then. This month, Richland County prosecutors charged a woman with reckless conduct after she reportedly tested positive for the coronavirus and allegedly violated a stay-at-home order, according to news reports.
The American Diabetes Association is creating an initiative to fight unnecessary amputations, which a ProPublica investigation found disproportionately affect Black diabetics.
This article was published on Thursday, August 27, 2020 in ProPublica.
Prompted bya ProPublica story that detailed how Black Americans with diabetes lose limbs at a rate triple that of others, the American Diabetes Association has included an initiative to prevent unnecessary amputations as part of an unprecedented campaign to reduce racial disparities in diabetes care.
"The ProPublica article raised the consciousness of what the problem is," said Tracey Brown, the CEO of the ADA. "Every four minutes, someone is losing a limb from diabetic complications. That's ridiculous. We have got to find a way to drive change."
The story highlighted obstacles to equitable care for diabetic patients at risk of amputation, from the government's decision not to endorse screening at-risk patients for vascular disease in the legs, to the inadequate incentives for certain specialists to move to underserved areas, to the health system's failure to consider limb-saving options before permitting surgeons to apply a blade.
In the weeks that followed publication, several congressional and state legislative offices reached out to the association to ask for guidance on drafting policy to reduce disparities in diabetic amputations. In response, the organization decided to build an agenda around the issue.
The ADA's Health Equity Now campaign, which addresses the cost of diabetes care, nutrition, discrimination and more, was motivated by the racial health disparities that have been exposed by COVID-19, which has hit Black Americans with diabetes particularly hard. As part of the project, the association has built a Health Equity Bill of Rights, asserting that all diabetes patients are entitled to affordable drugs, healthy food, the latest medical advances and other protections.
The right to avoid preventable amputations is the only complication of uncontrolled diabetes that is included in the list. The organization is sharing the document with policymakers, practitioners and patients as it begins to look toward policy change. It is also encouraging members of the public to ask their governors to support the project.
Dr. Ronald Dalman, the president of the Society for Vascular Surgery, said: "I commend the ADA for doubling down on this particular complication of poorly managed diabetes. It's a long overdue prioritization." He added that it's a "moment in time where we can leverage this concern about healthcare disparities to call out a very specific problem: the prevalence of amputation in certain subsets of the population."
Dr. Gary Puckrein, the head of the National Minority Quality Forum, a nonprofit focused on reducing healthcare disparities, said that the ADA's efforts are just a step. "The American healthcare system was organized during an era when inequality was acceptable and mainstream in American society," he said. "It's not that African Americans are sicker, it's that the healthcare delivered is unequal."
He hopes that the national conversation on health disparities will mirror the conversation about police violence against Black Americans. "You, in effect, have your knees on their neck in the healthcare system as well when you don't provide them with the care that they need."
Black patients were losing limbs at triple the rate of others. The doctor put up billboards in the Mississippi Delta. Amputation Prevention Institute, they read. He could save their limbs, if it wasn't too late.
Two weeks after publication of the story, Rep. Bennie Thompson, a Democrat from Mississippi, honored Dr. Foluso Fakorede, the main subject of the ProPublica article, for his work in reducing unnecessary amputations in Bolivar County, Mississippi. The acknowledgement, made in the House of Representatives, referenced ProPublica's findings.
The co-chairs of the Congressional Peripheral Artery Disease Caucus — Rep. Donald M. Payne Jr., a Democrat from New Jersey, and Rep. Gus Bilirakis, a Republican from Florida — have also begun work on a bill to address disparities in amputations, particularly for people with peripheral artery disease, a condition in which clogged arteries in the legs limit the flow of blood.
"The ProPublica article has brought strong awareness and real interest from a variety of parties — from the medical field and from patients and from potentially future patients," said a spokesman for Payne. "We have been working with Bilirakis and other members to move this forward, with the ultimate goal of introducing legislation."
Summer Blevins, deputy chief of staff for Bilirakis, added that their legislative ambition "is based on the basic principle that prevention, education and early intervention is best for the patient and also saves money."
It remains unclear just how many newborns were separated from their mothers as a result of the policies. Lovelace Women’s Hospital did not admit to any wrongdoing but reported that the practice has been halted.
This article was first published on Saturday, August 22, 2020 in ProPublica.
ALBUQUERQUE, N.M. — A prominent women’s hospital here violated patients’ rights by singling out pregnant Native American women for COVID-19 testing and separating them from their newborns without adequate consent until test results became available, according to a federal investigation disclosed to New Mexico In Depth and ProPublica.
Lovelace Women’s Hospital did not admit to any wrongdoing but reported that the practice has been halted. Hospital officials submitted a plan to fix problems identified by investigators, including a promise to conduct internal audits to ensure compliance with state and federal regulations and COVID-19 screening guidance.
“The Department of Health will assure that the plan of correction is fully and effectively enacted,” said New Mexico Secretary of Health Kathyleen Kunkel, the state’s highest-ranking public health official. “The Division of Health Improvement will be conducting an unannounced onsite survey to verify compliance.”
Investigators with the state Health Department, who are contracted to conduct site surveys for the U.S. Centers for Medicare and Medicaid Services, or CMS, launched their inquiry after an article by New Mexico In Depth and ProPublica reported that the hospital had targeted Native American mothers for COVID-19 testing based on their tribal-area ZIP codes, then separated them from their newborns while awaiting test results.
All patients were screened upon arrival at the hospital with forehead temperature checks and standard questionnaires. But starting in late April, according to the report, patients with home ZIP codes on the hospital’s list were treated as “persons under investigation” and tested for COVID-19.
That practice stopped May 28, investigators were told — one week after New Mexico In Depth and ProPublica first approached a hospital official about newborns being separated from Native American mothers.
The practice, while meant to stop the spread of COVID-19, was described by clinicians and health care ethicists as racial profiling. Isolating expectant mothers as though they had the virus created a stressful birth experience, a clinician noted. Separating newborns from mothers awaiting lab test results denied them early skin-to-skin contact and breastfeeding, which studies have shown can affect bonding.
Investigators concluded that the hospital failed to protect patients’ rights by implementing an “informal policy to target patients that live on Native American reservations for COVID testing, and [to] separate mother and baby while test results were pending, and did not provide clear options for these patients to request or refuse COVID testing and separation from their babies.”
Lovelace “inconsistently implemented the ZIP code list, which was limited to patients that lived on Native American lands,” investigators concluded. The “deficient practices” may have resulted in “confusion in the provision of care by hospital staff and unnecessary stress for the patients.”
It remains unclear just how many newborns were separated from their mothers as a result of the policies. Lovelace has repeatedly declined over recent months to publicly reveal that information. Investigators might not have interviewed all affected mothers, Kunkel acknowledged.
One mother told investigators that the experience was “traumatic.”
Lovelace officials defended their actions, noting test shortages and conflicting advice during the coronavirus crisis.
“At no time during the pandemic has any mother been separated from their baby without her consent or approval,” Lovelace spokeswoman Whitney Marquez said. “Those who chose to be separated while their COVID results were pending were then roomed-in with their mother once the COVID test results were returned.”
But some Native American mothers told investigators they felt pressured or misled by the hospital when it came to ZIP code-based COVID-19 testing and newborn separations pending test results.
Native American patients and family members contacted by New Mexico In Depth and ProPublica were not comfortable speaking on the record about their birth experiences at Lovelace, but the report contains statements from several women.
One Native American mother was tested for COVID-19 upon admission despite having no symptoms or known exposures. She was placed in an isolation room to begin her labor in quarantine but her test results came back negative before she gave birth, so she was not separated from her baby. She told investigators she overheard a nurse say she’d been quarantined because of her home ZIP code.
Another Native American mother, who had not been screened as high risk but whose home ZIP code was on the hospital’s list, said she was not given the option to decline the COVID-19 test and signed no consent form.
She was separated from her baby for a day pending test results.
“They told me that I could keep her with me, but it would be better to send her to the NICU to keep her safe, because they didn’t know if I had COVID or not,” that mother reported.
Another mother said she signed a consent form to send her baby to the NICU, but because she was groggy from pain medication, she could not recall whether she consented to be tested. She and her baby were separated for 18 hours.
Yet another Native American mother was tested for COVID-19 without being told she had the option of declining the test. She was told that because of her ZIP code, she was a high-risk patient and was moved to a quarantine room to deliver her baby. Only once labor had been induced with medication did a nurse-midwife explain her newborn would be separated from her until her test results were available.
She was told there were only two options, she reported to investigators: She could stop the contraction-inducing medication and sleep to await test results, or she could continue with the birth process and the newborn would be taken away “because that’s the policy.” But because labor had already been induced, there was no guarantee that ceasing medication would stop the birth process.
“I told her, ‘You are not going to do that, and you are not going to take my baby,’” she told investigators. “I was already in active labor. She then offered the waiver.”
She was only offered the waiver form allowing her to stay with her newborn after she objected to the separation policy, she said.
“It was very traumatic,” she told investigators.
Her husband was by her side but was not tested, the mother noted.
“They specifically referenced my ZIP code,” she told investigators. “I argued and said it was unfair and that I was being discriminated against ... because of my ZIP code.”
CMS referred the findings to the U.S. Department of Health and Human Services’ Office for Civil Rights. CMS and the state Health Department did not immediately respond Friday to questions about the status of the Office for Civil Rights inquiry.
Investigators found the ZIP code protocol was also on the books at Lovelace’s emergency department, in addition to its labor and delivery and perinatal care units.
The hospital’s chief nursing officer told investigators that there had been no formal meetings to implement the ZIP code list with staff and that no formal policy was developed regarding its use. That conflicts with clinicians, who in interviews said that the policy was read aloud at the beginning of shifts. Clinicians reported that binders containing those scripts and other COVID-19 related records were removed from nursing stations during the early days of the investigation.
Lovelace’s plan appears to leave it largely to the hospital itself to determine whether or not the proposed improvements are met. For example, 10 Lovelace employees will be audited weekly to verify they are not utilizing ZIP codes or geographic locations to screen or test patients. If no violations of the new prohibition are identified after three weeks, then “the audits will stop with the approval of the senior leadership team.”
“The people responsible for the action plan are the same people that put the policies into place,” noted a Lovelace clinician who asked not to be identified for fear of retribution, after reading the hospital’s plan.
“Lovelace owes the Native community an apology,” that clinician said. “Regardless of their intentions, the investigation confirms Native patients were treated differently under the informal ZIP code policy and I am disappointed that Lovelace hasn’t reached out to the community to assure them they are committed to repairing trust.”
Bryant Furlow is a reporter for New Mexico In Depth.
The deaths of 18 residents of a New York nursing home highlight the continuing controversy over the Cuomo administration's decision not to count deaths in hospitals as nursing home deaths. The home denies the allegations.
This article was published on Tuesday, August 11, 2020 in ProPublica
The nurse with the Columbia County Health Department recorded the COVID-19 deaths at nearby hospitals — two at Albany Medical Center on May 4, another at the same hospital two days later; one at Columbia Memorial Hospital on May 17, and another there two days later — and, along with her boss, concluded there was a pattern.
The people dying at the hospitals had been residents of a local nursing home, the Grand Rehabilitation and Nursing at Barnwell in the tiny town of Valatie, New York. In all, the nurse counted 18 deaths of residents over five weeks. She didn't have detailed medical records for the patients, but she noted that all had arrived at the hospital with orders saying no extraordinary measures were to be taken to keep them alive. As a result, she and the Columbia County health director developed a theory: "For me," said Jack Mabb, the health director, "it appeared they were sending people to the hospital so they wouldn't die in the facility."
A change in the way New York tabulated nursing home deaths could have incentivized such behavior, he said, making homes' records on COVID-19 containment appear better than they were.
In the early weeks of the pandemic, the state had counted these deaths by attributing them to the nursing home regardless of where they physically occurred. But in April — as the death toll related to nursing homes mushroomed, hitting as many as 250 deaths a day — that changed: The administration of Gov. Andrew Cuomo decided not to count residents who died of COVID-19 in hospitals as nursing home deaths, saying it feared that their deaths would be double-counted if they were recorded that way.
The administration insisted the move wasn't meant to suppress the numbers at nursing homes, facilities Cuomo had reassured the public were his top priority for protecting from the pandemic. In public testimony this month, Howard Zucker, the state's health commissioner, defended the decision and argued that New York had been as transparent about nursing home casualties as any state in the nation.
Today, more than 6,500 nursing home residents are known to have perished in New York facilities, some 6% of the state's nursing home population. The state declined to say how many additional residents died in hospitals after being sickened in nursing homes.
Mabb said that his department's nurse had sent reports about the deaths of Barnwell residents at local hospitals to state authorities, and that he had asked for an investigation. Some of the residents died soon after arriving at the hospitals, Mabb said, while others took longer to pass away. But the fact that all 18 had do-not-resuscitate orders or similar directives suggested to him that they had been sent to the hospitals with little hope of ever returning to the home. The department, Mabb said, shared its documenting of the deaths with the state.
"There are very few legitimate reasons for a nursing home to send seriously ill residents with do-not-resuscitate orders to a hospital unless there is a real chance that their conditions could be improved," Mabb said. "We flagged it for the state. We told the Department of Health we thought something big was going on."
Mabb said the state Health Department, which regulates nursing homes, has yet to tell him if it's investigating what happened to the Barnwell residents.
Bruce Gendron, a vice president of the company that operates the Barnwell nursing home and 15 others, rejected Mabb's claims that the home had sought to dump dying residents at local hospitals. He said that residents only would have been sent if they needed care beyond what the home could provide, and that those residents deserved every chance to survive.
Gendron said any scheme to inappropriately send residents to die elsewhere would have involved the home's medical director and several of its nurses, all of whom are licensed by the state and would have been putting their careers at risk.
Twice in May, state Health Department investigators conducted "complaint surveys" at the Barnwell home after scores of staff members and residents at the home tested positive for COVID-19.
The Department of Health website shows that inspectors found problems with the facility's ability to contain the virus: Uninfected residents were living alongside infected residents; residents suspected of having COVID-19 also were not separated. Some Barnwell staffers told the Health Department that they were confused about when they were supposed to wear masks and gloves or change out of old equipment and under what circumstances. The inspectors cited the facility and ordered a halt to additional admissions. Dozens of residents were eventually relocated.
Gendron first told ProPublica that the allegations of dumping dying residents at hospitals had been investigated by the state Health Department and found to be unsubstantiated. Asked to produce such a finding, Gendron referred to the inspections done in May, saying the absence of any findings related to hospital transfers proved the home had been cleared. Barnwell's quality of care related to COVID-19 had become a public controversy in May, prompting coverage in the local media, and Gendron said he assumed the state would have been alert to any other problems at the home, including signs of dumping residents.
The state's inspection reports make no mention of investigating hospital transfers. The Health Department did not respond to questions from ProPublica about whether it had investigated Mabb's allegations. ProPublica shared Gendron's version of events with the state, but again, the Health Department did not respond. Jill Montag, a department spokeswoman, appeared to be unaware of the allegations involving the home's dying residents, asking ProPublica to send along a record of them.
There is little doubt that Barnwell, a 236-bed facility in the Hudson Valley, was overwhelmed by the virus this spring. From March 30 through the first week of June, according to county statistics, scores of staff members and residents tested positive for the virus.
But trying to unpack what exactly unfolded at Barnwell lays bare the confusing and often conflicting available information about COVID-19's deadly path through the state's elderly population.
The county Health Department is responsible for identifying cases of COVID-19, and nursing homes are obligated to report such cases to it. But nursing homes are regulated by the state, and the county has a limited ability to make sure such facilities are responsibly reporting and managing outbreaks.
Mabb said he had only received notifications from the Barnwell home on two deaths inside the facility. The state Health Department says online that the death toll from the home is 12. Mabb said he thought the first infection at Barnwell had involved a staff member; the state has said the first case of COVID-19 at the facility involved a resident, but it can't say with certainty what role if any the resident played in the eventual outbreak.
Mabb said he has ultimately come to mistrust any information coming from either the state or officials with Barnwell. He said he counts the 18 deaths of Barnwell residents at the hospitals as nursing home deaths.
ProPublica contacted the three hospitals where Barnwell residents died, but none would talk about the deaths or the county's allegation that residents had been sent to them to avoid being recorded as nursing home fatalities.
As Gendron pointed out, decisions to send nursing home residents to the hospital for additional care are supposed to be approved by a home's medical director. He would not provide copies of such approvals involving the 18 residents who later died at hospitals, however, saying he didn't have the staff to do such work, and noted that some of the residents had been taken to the hospital after 911 calls, when a medical director's approval would not have been required.
Sorting out the events at Barnwell, it turns out, also involves another disputed state policy: the order from the Health Department that nursing homes accept medically stable COVID-19 patients being discharged from hospitals. The policy also barred patients from being tested to see if they were still positive for the virus.
The policy, enacted March 25, alarmed and angered many — nursing home operators, families of residents, elected officials worried about an already vulnerable population being subjected to additional possible harm. The state, after a blizzard of criticism, abandoned the order some seven weeks after implementing it.
Last month, the Health Department issued a report asserting that the policy had not significantly contributed to deaths of nursing home residents.
The report was met with open skepticism among nursing home personnel, epidemiologists, and Republican and Democratic officials in New York and Washington. Those lawmakers repeated their calls for a truly independent investigation of the state's handling of the COVID-19 crisis at its more than 600 nursing homes.
In the Health Department's report, which said more than 6,400 COVID-19 patients had been sent from hospitals to nursing homes under the policy, the state said the vast majority of the roughly 310 homes that accepted those patients had already had a case of COVID-19 among their staff members or residents. The report said the spread of the virus in the homes had been driven by infected staff members.
But the report made clear that dozens of homes had experienced no cases of COVID-19 before receiving a coronavirus patient from a nearby hospital. ProPublica asked the state to produce the data involving 58 homes that had not been affected prior to taking in a COVID-19 patient.
Days later, the state Health Department said the data in its report had been inaccurate. And several days after that, the department said updated information indicated that just six homes, not 58, had been free of COVID-19 prior to the arrival of a patient from a hospital.
The department would not answer an array of questions about how and why it had changed the data in its report, one it had used to defend its controversial policy. It would not say how what it had called a peer-reviewed study had relied on erroneous or incomplete data; it would not say how the new information had come to light.
It did say, though, that the Barnwell home was one of the facilities that did not have a case of COVID-19 among its staff or residents prior to the first arrival of a COVID-19 patient from a hospital. The state, however, would not say when that transfer occurred or if it had studied what role, if any, it had played in the eventual outbreak that overran the facility. The county recorded Barnwell's first COVID-19 case on March 30, two weeks before the surge in cases among both staff and residents.
Ron Kim, a Democratic state legislator from Queens, said he has no faith that the state has been honest about what happened as a result of its policy.
Kim, a member of the State Assembly's Health Committee, said he had taken an intense interest in the state's efforts to protect nursing home residents. One ZIP code in his Queens district had more nursing home deaths than any other in the state, he said. One of those deaths was a member of his family. Kim said he had filed Freedom of Information requests seeking all administration communications about nursing homes during the pandemic.
"The theme of the report was to shift the blame and scapegoat the workers and the families over the decision that the executive office had made," Kim said of the Health Department report made public last month. "It's clear that the executive office is directing and ordering up the report and data collection in a way that will give them what they want out of the report.
"They are trying their best to use government resources and the Department of Health to exonerate the executive office of any wrongdoing," Kim added.
Kim said given the state's lack of transparency, it was impossible to say whether what's alleged to have happened at the Barnwell facility may have been more widespread.
Kim and other lawmakers have said they know of no other state that counts nursing home deaths the way New York currently does.
Informed of Kim's specific claims, the state Health Department referred ProPublica to public statements made by Zucker, the department's commissioner.
On Aug. 3, Zucker testified before a joint hearing held by state legislators. He was grilled repeatedly about the state's seeming inability or unwillingness to answer basic questions about how many nursing home residents might have died to date in the pandemic.
The policy of not counting deaths in hospitals was revisited again and again.
Addressing Zucker in one exchange, State Senate Investigations Committee Chair James Skoufis, a Democrat from the Hudson Valley where Barnwell is located, said: "It's my opinion that your administration's definition truly misrepresents the scale of this crisis as a result. So let's try and get the full picture here and now: How many of New York's nursing home residents died in hospitals?"
Zucker insisted the state couldn't say because it didn't yet have a fully accurate count.
"You don't have a ballpark that you can give? So the total official number is about 6,500. Are we talking with the hospital deaths: 8,000? 10,000? 15,000? What are we looking at?" Skoufis countered.
"I'm not prepared to give you a specific number. We are in the middle of a pandemic obviously, we always forget about that sometimes," Zucker said. "We are looking at all the numbers, we are looking at the data, when the data comes in and I have an opportunity to piece through that, then I will be happy to provide that data to you and to the other members of the committee."
State Senate Health Committee Chairman Gustavo Rivera, a Democrat from the Bronx, suggested a final count wasn't needed to see what the administration was doing.
"It seems, sir, that in this case you are choosing to define it differently so you can look better," he said. "That is a problem, bro."
ProPublica asked the state Health Department if it had ever excluded fatalities of residents transferred to hospitals in counting deaths of nursing homes residents during outbreaks of the flu or other infectious diseases.
The state did not directly respond but said in a statement, "This is a global pandemic, the likes of which we have never seen before. There is no precedent."
Elaine Healy, acting president of the New York Medical Directors Association, said it shouldn't be hard for the state to have an accurate count of how many nursing home residents died of COVID-19 in hospitals. They'd counted these deaths in the nursing home totals early on, she said, and "the numbers would be quite easy to get from the hospitals."
The outbreak at Barnwell was one of two involving local nursing homes in Columbia County.
When the outbreak at Barnwell became public in early May, Patsy Leader, the town supervisor in nearby Kinderhook, called for the state to intervene, accusing Barnwell of trying to cover up the dumping of dying residents. Leader repeated the allegation in a brief interview with ProPublica.
Gendron, the Barnwell executive, eventually traveled to Barnwell to personally handle the crisis.
In a series of interviews and exchanges with ProPublica, Gendron said he was not aware of the state's claim that Barnwell's first case of COVID-19 involved a hospital transfer. He said the company had been alarmed by the Cuomo administration's policy requiring nursing homes to accept COVID-19 patients being discharged from hospitals. The chance that such patients could trigger or worsen an outbreak in nursing facilities was real, he said.
"We were very concerned," Gendron said. "It's a very contagious virus. And nursing homes provide very hands on care."
The challenge, he said, was only worsened by the fact that the state's policy prohibited homes from testing arriving hospital transfers to see if they were still positive and thus possibly contagious. Gendron said he was not even sure if the hospitals were obligated to notify the home that the arriving patient had been treated for COVID-19.
"One would think they should have disclosed that," Gendron said. "We always believed the best practice was to isolate any COVID residents. But we didn't even know who was or wasn't."
A House panel says "gullible" White House negotiators overpaid for Phillips ventilators, and it has asked the Department of Health and Human Services Office of Inspector General to investigate evidence of fraud in the deal.
This article was published on Friday, August 7, 2020 in ProPublica.
Citing “evidence of fraud, waste, and abuse,” a congressional subcommittee investigating the federal government’s purchase of $646.7 million worth of Philips ventilators has asked the U.S. Department of Health and Human Services Office of Inspector General to launch its own investigation of the deal.
The House subcommittee launched its review after ProPublica stories in March and April showed how a U.S. subsidiary of Royal Philips N.V. received millions in federal tax dollars years ago to develop a low-cost ventilator for pandemics but didn’t deliver it. Instead, as the coronavirus began spreading around the globe and U.S. hospitals were desperate for more, Philips was selling commercial versions of the government-funded ventilator overseas from its Pennsylvania factory. Then in April, despite having not fulfilled the initial contract, the Dutch company struck a much more lucrative deal to sell the government 43,000 ventilators for four times the price.
Under this new deal, ventilators that the Obama administration had agreed to buy for $3,280 each suddenly cost $15,000. When the deal was announced in April, neither HHS nor Philips would say how the more expensive ventilators differed from the cheaper ones.
It turns out that they were “functionally identical,” according to investigators with the House Committee on Oversight and Reform’s Subcommittee on Economic and Consumer Policy, and the “waste of taxpayer funds” may have reached $500 million.
The investigators reviewed thousands of pages of emails and other records obtained from Philips and concluded that “inept contract management and incompetent negotiating by the Trump Administration denied the country the ventilators it needed.” And the subcommittee’s report, which it shared with the inspector general’s office, named names: Peter Navarro, President Donald Trump’s director of trade and manufacturing policy, was the administration’s point man on the deal. In addition, Jared Kushner, the president’s son-in-law and senior adviser, and HHS Secretary Alex Azar participated in calls with Philips’ executives.
In a letter to the inspector general, Rep. Raja Krishnamoorthi, the Illinois Democrat who chairs the subcommittee, wrote: “The Subcommittee requests that you immediately open an investigation into this apparent waste of taxpayer funds, how it was able to happen unchecked, and how to prevent it in the future. Moreover, the Subcommittee requests that your office’s review include an assessment of the reasonableness of the price of the contract and the amount of excess profits received.”
He attached the subcommittee’s 49-page report of its investigative findings.
In a written statement, Philips said that it has been transparent about its ramp-up plans, pricing and allocation policies, and that it cooperated with the subcommittee. “We do not recognize the conclusions in the subcommittee’s report, and we believe that not all the information that we provided has been reflected in the report,” Philips CEO Frans van Houten said. “I would like to make clear that at no occasion has Philips raised prices to benefit from the crisis situation.”
White House Deputy Press Secretary Judd Deere called the House investigators’ report “a stunt that is only meant to politicize the coronavirus.”
“Because of the president’s leadership, the United States leads the world in the production and acquisition of ventilators,” Deere said. “No American who needed a ventilator was denied one, and no American who needs a ventilator in the future will be denied one. Democrats should be ashamed of themselves for this misleading and inaccurate report.”
An HHS spokesperson said the department moved with “deliberate and determined speed” and followed federal contracting rules in reaching the deal. She noted that some of the Philips ventilators are already being used to treat patients with COVID-19.
The federal government’s quest for a cheap, durable ventilator that could be stockpiled for emergencies began a decade ago during the Obama administration. The first deal fell apart after a small California ventilator manufacturer was bought by a much larger competitor, which dropped the project. Philips in 2014 struck a $13.8 million deal with HHS’ Biomedical Advanced Research and Development Authority to develop a low-cost, portable ventilator that would be easy to use by people with limited medical training. (In their report, the congressional investigators wrote that Philips later was granted an additional $547,000 to develop the ventilator.) The original deal included an option to purchase 10,000 of the ventilators for $3,280 each with delivery by June 2019.
HHS under the Obama administration granted one extension, and then the Trump administration allowed several more. When Philips finally won Food and Drug Administration clearance for the stockpile ventilator in July 2019, it also got the green light to sell a commercial version, which the company sold at far higher prices. The government didn’t exercise the option to buy the stockpile ventilators until September 2019. Under the timeline in the original contract, there would have been four waves of deliveries starting in June 2020 and ending in June 2021 and the government would have the power to increase its order in times of need, the House investigators wrote in their report.
Among the most surprising findings of the investigation was an email communication between the company and the government on the day the U.S. reported its first coronavirus case. On Jan. 21, a Philips manager sent a news story about that case to an HHS contracting officer and asked “how we could help out or if you may expect a need to accelerate any shipments.” Yet nobody from the federal government responded to Philips for six weeks, the investigators found.
On March 4, the HHS contracting officer told Philips managers in an email that Azar’s office had directed him to “expedite production of the ventilators.” Philips responded the same day suggesting a contract modification “to allow for the earlier shipments.”
Rather than speed up delivery, though, the modification Philips suggested gave the company until September 2022 to deliver any of the stockpile ventilators. Still, HHS signed off on the deal, the investigators found.
“Philips appears to have duped the Administration into thinking that this amendment, which permits a lengthy delay, was necessary for it to expedite production,” the congressional investigators wrote.
That same month, as the administration sought to cut a new deal, a Philips executive shared with Azar the slide deck he planned to present to Navarro. In the presentation, Philips described the government-funded stockpile ventilator design as “the best solution to confront exactly the pandemic we are facing.”
However, Philips soon steered Navarro and his colleagues to a more expensive option, the $15,000 Trilogy EV300, saying in one email to an associate director in Navarro’s office that this hospital ventilator had “more clinician friendly screens.”
Yet, the House investigators found the screens of the pricier model were identical to the less-expensive stockpile version. “The Administration’s willingness to spend hundreds of millions of extra dollars for non-existent ‘more clinician-friendly screens’ constitutes waste,” they wrote.
The White House negotiators were “gullible,” the investigators wrote, “and conceded to Philips on all significant matters, including price.” The contract called for Philips to make monthly deliveries between April and December 2020 with more than half arriving in the final three months.
Philips spokesman Steve Klink on March 28 told ProPublica that the company had only made the stockpile version of the ventilator in small batches and didn’t want to ramp up production on a model it had never mass produced. Rather, he said, the company wanted to “stick with what we have and ramp up and not lose time because we cannot afford to lose time.” HHS echoed that sentiment in a written statement at that time, saying the agency was purchasing “what was immediately available.”
But the congressional investigators wrote that the records Philips turned over showed that was false. Philips did not have a long track record making the $15,000 Trilogy EV300; the company did not start making that version until March, the month the federal negotiators agreed to buy them. And the White House knew this, the investigators wrote.
“In a March 18, 2020 email to the White House, Philips explained that the Trilogy EV300 was a new product being introduced and that it would take time to build up inventory,” they wrote. “By selecting the $15,000 model, the Administration demonstrated that it either failed the most basic duty of reading what Philips sent it or that it was not concerned about overpaying.”
Navarro and his colleagues never tried to lower the $645 million price and agreed to pay an additional $1.7 million for circuits and filters, the investigators found.
In its statement, Philips said the list price of the EV300 ventilator, stand and accessories that HHS selected is “over $21,000,” so the final price does reflect a discount “while taking into account part of the higher costs for the expedited delivery schedule.”
The records Philips turned over to the congressional subcommittee showed that before May 27, Philips sold 5,339 other Trilogy EV300 ventilators in the U.S. No buyer paid more than HHS did. One Missouri purchaser bought a single ventilator for $9,327, records show.
“It would stand to reason that a purchaser of 43,000 units would be able to negotiate a better deal than a purchaser of a single unit,” the House investigators wrote.
The ranking Republicans on the House committee and subcommittee said they disagreed with the findings of the investigation. In a prepared statement, James Comer of Kentucky, who sits on the House committee, and Michael Cloud of Texas, who sits on the subcommittee, accused the congressional investigators of failing to take “the most basic investigative steps to ensure they get the facts right.”
“Democrats read a few documents produced by the cooperating company and made a bundle of assumptions,” they wrote. “They received no briefings, conducted no transcribed interviews or depositions, and did not try to engage with the Administration to understand their side of the story.”
Krishnamoorthi, the subcommittee chairman, sent his letter and the investigators’ report to Christi Grimm, who remains in charge of the HHS Office of Inspector General, though President Donald Trump has sought to replace her after her office in April wrote about shortages of testing supplies and protective equipment at hospitals.