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.
Anesthesiologist Claire Rezba started tracking lost health workers almost instinctively. Researchers and industry professionals say the lack of good official data on these deaths is "scandalous" and is putting lives in danger.
This article was published on Sunday, August 2, 2020 in ProPublica.
When police discovered the woman, she'd been dead at home for at least 12 hours, alone except for her 4-year-old daughter. The early reports said only that she was 42, a mammogram technician at a hospital southwest of Atlanta and almost certainly a victim of COVID-19. Had her identity been withheld to protect her family's privacy? Her employer's reputation? Anesthesiologist Claire Rezba, scrolling through the news on her phone, was dismayed. "I felt like her sacrifice was really great and her child's sacrifice was really great, and she was just this anonymous woman, you know? It seemed very trivializing." For days, Rezba would click through Google, searching for a name, until in late March, the news stories finally supplied one: Diedre Wilkes. And almost without realizing it, Rezba began to keep count.
The next name on her list was world-famous, at least in medical circles: James Goodrich, a pediatric neurosurgeon in New York City and a pioneer in the separation of twins conjoined at the head. One of his best-known successes happened in 2016, when he led a team of 40 people in a 27-hour procedure to divide the skulls and detach the brains of 13-month-old brothers. Rezba, who'd participated in two conjoined-twins cases during her residency, had been riveted by that saga. Goodrich's death on March 30 was a gut-punch; "it just felt personal." Clearly, the coronavirus was coming for healthcare professionals, from the legends like Goodrich to the ones like Wilkes who toiled out of the spotlight and, Rezba knew, would die there.
At first, seeking out their obituaries was a way to rein in her own fear. At Rezba's hospital in Richmond, Virginia, as at healthcare facilities around the U.S., elective surgeries had been canceled and schedules rearranged, which meant she had long stretches of time to fret. Her husband was also a physician, an orthopedic surgeon at a different hospital. Her sister was a nurse practitioner. Bearing witness to the lives and deaths of people she didn't know helped distract her from the dangers faced by those she loved. "It's a way of coping with my feelings," she acknowledged one recent afternoon. "It helps to put some of those anxieties in order."
On April 14, the Centers for Disease Control and Prevention published its first count of healthcare workers lost to COVID-19: 27 deaths. By then, Rezba's list included many times that number — nurses, drug treatment counselors, medical assistants, orderlies, ER staff, physical therapists, EMTs. "That was upsetting," Rezba said. "I mean, I'm, like, just one person using Google and I had already counted more than 200 people and they're saying 27? That's a big discrepancy."
Rezba's exercise in psychological self-protection evolved into a bona fide mission. Soon she was spending a couple of hours a day scouring the internet for the recently dead; it saddened, then enraged her to see how difficult they were to find, how quickly people who gave their lives in service to others seemed to be forgotten. The more she searched, the more convinced she became that this invisibility was not an accident: "I felt like a lot of these hospitals and nursing homes were trying to hide what was happening."
And instead of acting as watchdogs, public health and government officials were largely silent. As she looked for data and studies, any sign that lessons were being learned from these deaths, what Rezba found instead were men and women who worked two or three jobs but had no insurance; clusters of contagion in families; so many young parents, she wanted to scream. The majority were Black or brown. Many were immigrants. None of them had to die.
The least she could do was force the government, and the public, to see them. "I feel like if they had to look at the faces, and read the stories, if they realized how many there are; if they had to keep scrolling and reading, maybe they would understand."
It's been clear since the beginning of the pandemic that healthcare workers faced unique, sometimes extreme risks from COVID-19. Five months later, the reality is worse than most Americans know. Through the end of July, nearly 120,000 doctors, nurses and other medical personnel had contracted the virus in the U.S., the CDC reported; at least 587 had died.
Even those numbers are almost certainly "a gross underestimate," said Kent Sepkowitz, an infectious disease specialist at Memorial Sloan Kettering Cancer Center in New York City who has studiedmedical worker deaths from HIV, tuberculosis, hepatitis and flu. Based on state data and past epidemics, Sepkowitz said he'd expect healthcare workers to make up 5% to 15% of all coronavirus infections in the U.S. That would put the number of workers who've contracted the virus at over 200,000, and maybe much higher. "At the front end of any epidemic or pandemic, no one knows what it is," Sepkowitz said. "And so proper precautions aren't taken. That's what we've seen with COVID-19."
Meanwhile, the Centers for Medicareand Medicaid Servicesreports at least 767 deaths among nursing home staff, making the work "the most dangerous job in America," a Washington Post op-ed declared. National Nurses United, a union with more than 150,000 members nationwide, has counted at least 1,289 deaths among all categories of healthcare professionals, including 169 nurses.
The loss of so many dedicated, deeply experienced professionals in such an urgent crisis is "unfathomable," said Christopher Friese, a professor at the University of Michigan School of Nursing whose areas of study include healthcare worker injuries and illnesses. "Every worker we've lost this year is one less person we have to take care of our loved ones. In addition to the tragic loss of that individual, we've depleted our workforce unnecessarily when we had tools at our disposal" to prevent wide-scale sickness and death.
One of the most potentially powerful tools for battling COVID-19 in the medical workforce has been largely missing, he said: reliable data about infections and deaths. "We don't really have a good understanding of where healthcare workers are at greatest risk," Friese said. "We've had to piece it together. And the fact that we're piecing it together in 2020 is pretty disturbing."
The CDC and the Department of Health and Human Services did not respond to ProPublica's questions for this story.
Learning from the sick and dead ought to be a national priority, both to protect the workforce and to improve care in the pandemic and beyond, said Patricia Davidson, dean of the Johns Hopkins School of Nursing. "It's critically important," she said. "It should be done in real time."Bottom of Form
But data collection and transparency have been among the most glaring weaknesses of the U.S. pandemic response, from blind spots in the public health system's understanding of COVID-19 in pregnancy to the sudden removal of hospital capacity data from the CDC's website, later restored after a public outcry. The Trump administration's sudden announcementin mid-July that it was wresting control over hospitalcoronavirus data from the CDC has only intensified the concerns.
"We'd be the first to agree that the CDC has been deficient" in its data gathering and deployment, said Jean Ross, a president of National Nurses United. "But it's still the most appropriate federal agency to do this, based on clear subject-matter expertise in infectious diseases response."
The CDC's basic mechanism for collecting information about healthcare worker infections has been the standard two-page coronaviruscase report form, mostly filled out by local health departments. The form doesn't request much detail; for example, it doesn't ask for employers' names. Information is coming in delayed or incomplete; the agency doesn't know the occupational status of almost 80% of people infected.
The data about infections and deaths among nursing home staff is more robust, thanks to a rulethat went into effect in April that requires facilities to report directly to the CDC. The agency told Kaiser Health News that it is also "conducting a 14-state hospital study and tapping into other infection surveillance methods" to monitor healthcare worker deaths.
Another federal agency, the U.S. Occupational Safety and Health Administration, investigates worker infections and deaths on a complaint basis and hasprioritized COVID-related cases about the healthcare industry. But it has suggested that most employers are unlikely to face any penalties and has issued only four citations related to the outbreak, to a Georgia nursing home that delayed reporting the hospitalization of six staffers and three Ohio care centers that violated respiratory protection standards. Of the more than 4,500 complaints OSHA has received about COVID-19-related working conditions in the medical industry, it has closed nearly 3,200, a
The Trump administration told hospitals to stop reporting data to the CDC, and report it to HHS instead. Vice President Mike Pence said the information would continue to be released publicly. It hasn't worked out as promised.
Data problems aren't just a federal issue; many states have fallen short in collecting and reporting information about healthcare workers. Arizona, where cases have been surging, told ProPublica, "We do not currently report data by profession." The same goes for New York state, though a report in early July hinted at just how devastating the numbers there might be: 37,500 nursing home employees, about a quarter of the state's nursing home workforce, were infected with the coronavirus from March through early June. Other states, including Florida, Michigan and New Jersey, provide data about employees at long-term facilities but not about healthcare workers more broadly. "We are not collecting data on healthcare worker infections and/or healthcare worker deaths from COVID-19," a spokesperson for the Michigan Health Department said in an email.
This problem is global. Amnesty International, in a July report, pointed to widespread data gaps as part of a broader suppression of information and rights that has left workers in many countries "exposed, silenced [and] attacked." In Britain, where more than 540 medical workers have died in the pandemic, the advocacy group Doctors' Association UK has begun legal action to force a government inquiry into shortages of personal protection equipment in the National Health Service and "social care" facilities such as nursing homes. And in May, more than three months after the first known medical worker's death, the International Council of Nurses calledfor governments across the world to start keeping accurate data on such cases, and for the records to be centrally held by the World Health Organization. The WHO estimates that about 10% of COVID-19 cases worldwide are among health workers. "We are closely following up (on) these cases through our global networks," a spokesperson said.
"Governments' failure to collect this information in a consistent way" has been "scandalous," said the council's CEO, Howard Catton, and "means we do not have the data that would add to the science that could improve infection control and prevention measures and save the lives of other healthcare workers. … If they continue to turn a blind eye, it sends a message that [those] lives didn't count."
So regular people, like Rezba, have stepped up with their makeshift databases.
Dr. Claire Rezba, an anesthesiologist who tracks the COVID-19 deaths of healthcare workers. (Carlos Bernate for ProPublica)
Rezba, 40, initially wanted a career in public health. While finishing her master's degree at Emory University in Atlanta and for a few months afterward, she worked as a lab tech at the CDC, analyzing nasal swabs to track cases of MRSA, the flesh-eating bacteria. But she decided she cared more about people than bugs, so she headed to Virginia Commonwealth University medical school in Richmond, graduating in 2009 with plans to specialize in the treatment of chronic pain.
During her residency at VCU, her first rotation was in the neonatal intensive care unit. "There was a little baby I helped take care of for three weeks. And the very last day of that rotation, his parents withdrew care. ... He was the first little person I pronounced dead. I went and cried in the stairwell after that." Her next rotation was in the burn unit, then the emergency department. "It seemed like death was just everywhere," Rezba said. Witnessing it "is something very separate from the rest of your life experiences. People look different when they're dying. It's not like TV. They don't look like they're sleeping. CPR is pretty brutal. Codes are pretty brutal."
She began keeping a list as a way to process the grief. "In residency, you record everything — your case logs, the procedures you do. It was just sort of second nature to record their names." Whenever a patient died she would make another entry in her notebook, then "I would kind of perseverate" — ruminate — "over their names." At the end of the year, she took the notebook to church. "I lit candles for them. I prayed. And then I let it go."
A decade later, Rezba was working full time as an anesthesiologist and raising three small children, her list-compiling days long past her, she thought. Then COVID-19 hit. The onetime infectious disease geek became obsessed with the videos leaking out of China — the teams of healthcare workers in full protective gear, the makeshift wards in tents, the ERs in chaos: "I knew early on that this was going to be a big problem." In her job, Rezba was often called upon to do intubations. "The possibility of not having enough PPE caused a lot of anxiety for her," said her husband, Tejas Patel, whom she met in medical school. "She would be the one, if we did hit that level of New York, who could potentially be at risk and bring it home to the kids."
As it turned out, Rezba's hospital wasn't inundated, nor did it experience the PPE shortages that plagued many healthcare facilities. But her anxiety didn't disappear; it just took a new shape. If healthcare workers were front-line heroes, she decided, her role was to search the trenches for the bodies left behind.
Rezba is the first to admit she's not great at technology; she rarely uses a computer at home. Patel discovered what she was doing because their iPhones and iCloud accounts are linked. "Whenever she saves a picture to the phone, I can see it. And I noticed a bunch of pictures of, you know, these strangers." He remembered how, in their student days, Rezba had insisted on humanizing the cadaver in their anatomy lab: "It upset her that it was just this anonymous person. Knowing his birthday and little things like that would make her feel better." Patel figured the photos were part of a similar coping strategy. "It wasn't until much later that I found out she was putting them up on Twitter."
Much of Rezba's digging happens in the middle of the night, when she can't sleep. She usually starts by Googling for local news stories; if she's still not tired, she turns to the obituary site Legacy.com. The hunt for a person's occupation and cause of death invariably takes her to Facebook, where she follows the trail to relatives and co-workers, to vacation slideshows and videos of old men serenading their grandkids on the guitar. Every few days, she checks GoFundMe, where she's recently been struck by the number of people who linger for weeks or months before dying. She's still discovering deaths that occurred in April and May. Anyone under 60 gets special scrutiny. "If the obit says, 'They died surrounded by family,' I usually don't bother trying to find out more, because those people didn't have COVID. The people with COVID are mostly dying alone."
Doctors and nurses are the easiest to find. "If someone worked in the laundry service at the nursing home, the family doesn't put that in," Rebza said. Yet it's the nonmedical staff that she feels a special obligation to uncover — the intake coordinators and supply techs, the food service workers and janitors. "I mean, the hospital's not going to function if there's nobody to take out the trash." Every so often, a news story mentions that several staffers from a particular nursing home or rehab center have died, without mentioning their names, and Rezba feels the rage start to bubble. "What it comes down to is, these are people that are making $12 an hour. And they get treated like they're disposable."
If she can't find someone's identity right away, or if the cause of death isn't clear, she'll wait a couple of days or weeks and try again. Because she comes across them anyway, she's started to keep track of other categories of COVID-19 deaths, like kids and pregnant women, as well as healthcare workers in their 30s and 40s who don't appear to have the virus but suddenly perish from heart attacks or strokes or other mysterious reasons. "I have a lot of those," she said.
Once she's certain she's found someone who belongs on her list, she selects a photo or two and writes a few words in their honor. Sometimes, these read like a scrap of poetry; sometimes, like a howl.
He enjoyed crazy-dancing at home to Bruno Mars, with the moves becoming wilder the more his family laughed.
As a child, she would wrap her clothes around Dove soap so they would smell like America.
This poor baby should have his mother in his arms. Instead he has her in an urn.
A preprint studyout of Italy last week hinted at the kind of lessons researchers and policy makers might glean if they had more complete data about healthcare workers in the U.S. The study pooled data from occupational medical centers in six Italian cities, where more than 10,000 doctors, nurses and other providers were tested for coronavirus from March to early May. Along with basic demographic information, the data included job title, the facility and department where the employee worked, the type of PPE used and self-reported COVID-19 symptoms.
The most important findings: Working in a designated COVID-19 ward didn't put workers at greater risk of infection, while wearing a mask "appeared to be the single most effective approach" to keeping them safe.
In the U.S., many medical facilities are similarly monitoring employee infections and deaths and adjusting policies accordingly. But for the most part, that information isn't being made public, which makes it impossible to see the bigger picture, or for systems to learn from each other's experiences, to better protect their workers.
Imagine all of the opportunities it would present if everyone could see the full landscape, said Ivan Oransky, vice president for editorial content at Medscape, where amemorial page to honor global front liners has been one of the site's best-read features. "You could be doing some real great shoe-leather epidemiology. … You could go: 'Wait a second. That hospital has 12 fatalities among healthcare workers. The hospital across town has none. That can't be pure coincidence. What did this one, frankly, do wrong, and what's the other one doing right?'"
To Adia Harvey Wingfield, a sociologist at Washington University and author of "Flatlining: Race, Work, and Healthcare in the New Economy," some of the most pressing questions relate to disparities: "Where is this virus hitting our healthcare workers hardest?" Is the impact falling disproportionately on certain categories of workers — for example, doctors vs. registered nurses vs. nursing aides — on certain types of facilities, or in certain parts of the country? Are providers who serve lower-income communities of color more likely to become ill?
"If we aren't attuned to these issues, that puts everybody at a disadvantage," Wingfield said. "It's hard to identify problems or identify solutions without the data." The answers are especially important in Black and Latino communities that have suffered the highest rates of sickness and death — and where healthcare workers are themselves more likely to be people of color. Without good information to guide current and future policy, she said, "we could potentially be facing long-term catastrophic gaps in care and coverage."
Not only are Hispanics catching coronavirus at higher rates in Texas' largest county, they also suffer some of the worst outcomes.
The near-term consequences have also been enormous. The lack of public data about healthcare workers and deaths may have contributed to a dangerous complacency as infections have surged in the South and West, Friese said — for example, the idea that COVID-19 is no more dangerous than other common respiratory viruses. "I've been at this for 23 years. I've never seen so many healthcare workers stricken in my career. This whole idea that it's just like the flu probably set us back quite a way."
He sees similar misconceptions about PPE: "If we had a better understanding of the number of healthcare workers infected, it might help our policymakers recognize the PPE remains inadequate and they need to redouble their efforts. … People are still MacGyvering and wrapping themselves in trash bags. If we're reusing N95 respirators, we haven't solved the problem. And until we solve that, we're going to continue to see the really tragic results that we're seeing."
The misconceptions appeared to stretch to the highest reaches of the federal government, even as infections and deaths started surging again. At a White Houseevent in July focused on reopening schools in the fall, HHS secretary Alex Azartold the people gathered, "healthcare workers … don't get infected because they take appropriate precautions."
Even some medical workers have continued to be in denial. A few days before Azar spoke, Twitter was abuzz over an Alabama nurse who worked the COVID-19 floor at a hospital by day and decompressed at crowded bars by night, where she often went maskless. "I work in the healthcare industry," she was quoted as saying, "so I feel like I probably won't get it if I haven't gotten it by now."
Piercing that sense of invulnerability — making the enormity of the COVID-19 disaster seem real — isn't only Rezba's mission. From The New York Times' iconic front page marking the first 100,000 American deaths to the Guardian/Kaiser Health News project "Lost on the Frontline," news organizations and social media activists have grappled with how to convey the scale of the tragedy when people are distracted by multiple world-shattering crises and the normal rituals for processing grief are largely unavailable.
"The point at which accountability usually happens is when our leaders have to reckon with the families of those who've been lost, and that has not happened," said Alex Goldstein, a Boston-area communications strategist behind the wrenching @FacesOfCOVID Twitter account, which has posted almost 2,000 memorials since March. With COVID-19, "no one has had to look in the eye of a crying parent who wants to show you a picture of their child or listen to someone telling you about who their mom or dad was. There has been no consequence. What would our policy decisions have looked like if [the people making them] had to come face to face with that death and loss in a more visceral way?"
It's a question that weighs especially heavily on healthcare professionals, who have seen, in the most visceral way possible, the worst that COVID-19 can do. Erica Bial, a pain specialistin the neurosurgery department at a Boston-area hospital, fell dangerously ill from COVID-19 in March, her respiratory symptoms lingering for more than six weeks. She lived alone and opted not to go to the hospital, in part because she worried about infecting other people. "At that point [in the outbreak], they would have intubated me, given me hydroxychloroquine and azithromycin and probably killed me." As her recovery dragged on, she wondered how other doctors were faring: "I couldn't believe that I was the only physician I knew who was sick." But as she searched online, "I could not find any data. I just started getting really frustrated at the lack of information and the disinformation. … And then I started thinking about, well, what happens if I die here? Will anybody know?"
Like Rezba, Bial has a background in public health; the Facebook page she created, COVID-19 Physicians Memorial, was an attempt to build "a network where there's accountability. I wasn't necessarily trying to create, you know, reverence or memorialization. I was trying to understand the scope of the problem."
Rezba soon began posting memorials on the page; as it grew to include more than 4,800 members, Bial asked her to help moderate it. Among the things the two women share is a determination to stick to facts. "I didn't want any politics and I didn't want any garbage," Bial said. "(Rezba) was 100% like-minded and trustable." She was also someone Bial could talk to, doctor to doctor, as she recovered. "It wasn't just two people obsessed with something kind of morbid," Bial said. "She was a source of support."
Emergency room doctor Cleavon Gilman also gained a following for his posts on Facebook, a diary about what he witnessed as an ER resident in the NewYork-Presbyterian hospital system, battling the virus as it engulfed Washington Heights. "It was just … overwhelming," he recalled. "We were intubating 20 patients a day. We had hallways filled with COVID patients; there was nowhere to put them." In the space of a few brutal days in late April, three of Gilman's colleagues died, including one by suicide. "When it's a colleague that you're taking care of and you know them as a person you've been on a journey with ... man, that's hard."
A tweet from Rezba's account sharing the work of Dr. Cleavon Gilman, who is also compiling healthcare workers who have died from COVID-19.
Though much of the media focus was on the risks faced by older patients, Gilman was struck by how many of the critically ill were in their 20s, 30s and 40s. In mid-April, his own 27-year-old cousin, a gym teacher at a New Jersey charter school, suddenly died; he went to the ER twice with chest pain but was diagnosed with anxiety and sent home, according to his relatives, only to collapse in his car on the side of the road.
As the crisis in New York City ebbed, Gilman could see trouble ahead in other parts of the country, including in Yuma, Arizona, where he was about to start a new job. It seemed vitally important to help younger people understand the risks they faced — and that they created for others — by not adhering to physical distancing or wearing masks, not to mention the dangers that healthcare workers faced from continuing shortages of PPE. So Gilman began gathering the memorials he saw on Twitter and Facebook, many of them found by Rezba or on @FacesOfCOVID, and organizing the dead on his website in the type of gallery that he knew would pack an emotional wallop. Then he went a step further, making the photos and obituaries — more than 1,000 people — sortable by age and profession.
"You begin to see a pattern here," he said. "When someone says, 'Oh people aren't dying, they're not that [young],' you can come back with actual names, actual articles, quickly. It's more powerful. You have your evidence there."
One of the most overtly political projects is Marked by COVID, formed by Kristin Urquiza in honor of her father, Mark, after her "honest obituary" of him went viral in early July. To Urquiza, who earned her master's in public affairs from the University of California, Berkeley, and works as an environmental advocate in the San Francisco area, "the parallels between the AIDS crisis and what is happening now with COVID are just mind-boggling [in terms of] the inaction by governments and the failure to prioritize public health." She and her partner, Christine Keeves, a longtime LGBTQ activist, hope the projectwill be both "a platform for people to come forward and share their stories" and the COVID-19 version of the anti-AIDS group Act Up.
They're also raising money on GoFundMeto help other families pay for obituaries; the second honest obit on their site was for a respiratory therapist in Texas named Isabelle Odette Hilton Papadimitriou: "Her undeserving death is due to the carelessness of politicians who undervalue healthcare workers through lack of leadership, refusal to acknowledge the severity of this crisis and unwillingness to give clear and decisive direction to minimize the risks of coronavirus. Isabelle's death was preventable; her children are channeling their grief and anger into ensuring fewer families endure this nightmare."
It's a trend that Rezba supports wholeheartedly. By the end of July, she had posted almost 900 names and faces of U.S. healthcare workers who had perished from COVID-19. She fantasized about what it would be like to leave the counting behind her. "It would be great if I could stop. It would be great if there was nobody else to find." But she had a backlog of dozens of stories to post, and the number of deaths kept climbing.
A global pandemic ravaging America is no time to forget the first rule of American health care: There is no set price. One out-of-network medical provider in Texas seeks permission from patients to charge fees as high as six-figures to their insurance.
This article was first published on Saturday, August 1, 2020 in ProPublica.
As she waited for the results of her rapid COVID-19 test, Rachel de Cordova sat in her car and read through a stack of documents given to her by SignatureCare Emergency Center.
Without de Cordova leaving her car, the staff at the freestanding emergency room near her home in Houston had checked her blood pressure, pulse and temperature during the July 21 appointment. She had been suffering sinus stuffiness and a headache, so she handed them her insurance card to pay for the $175 rapid-response drive-thru test. Then they stuck a swab deep into her nasal cavity to obtain a specimen.
De Cordova is an attorney who specializes in civil litigation defense and maritime law. She cringes when she’s asked to sign away her rights and scrutinizes the fine print. The documents she had been given included disclosures required by recent laws in Texas that try to rein in the billing practices of stand-alone emergency centers like SignatureCare. One said that while the facility would submit its bill to insurance plans, it doesn’t have contractual relationships with them, meaning the care would be considered out-of-network. Patients are responsible for any charges not covered by their plan, it said, as well as any copayment, deductible or coinsurance.
The more she read, the more annoyed de Cordova became. SignatureCare charges a “facility fee” for treatment, the document said, ranging “between five hundred dollars and one hundred thousand dollars.” Another charge, the “observation fee,” could range from $1,000 to $100,000.
De Cordova didn’t think her fees for the test could rise into the six figures. But SignatureCare was giving itself leeway to charge almost any amount to her insurance plan — and she could be on the hook. She knew she couldn’t sign the document. But that created a problem: She still needed to get her test results.
Even in a public health emergency, what could be considered the first rule of American health care is still in effect: There is no set price. Medical providers often inflate their charges and then give discounts to insurance plans that sign contracts with them. Out-of-network insurers and their members are often left to pay the full tab or whatever discount they can negotiate after the fact.
The CARES Act, passed by Congress in March, includes a provision that says insurers must pay for an out-of-network COVID-19 test at the price the testing facility lists on its website. But it sets no maximum for the cost of the tests. Insurance representatives told ProPublica that the charge for a COVID-19 test in Texas can range from less than $100 to thousands of dollars. Health plans are generally waiving out-of-pocket costs for all related COVID-19 treatment, insurance representatives said. Some costs may be passed on to the patient, depending on their coverage and the circumstances.
As she waited, de Cordova realized she didn’t want to play insurance roulette. She changed her mind and decided she’d pay the $175 out-of-pocket for her test. But when the SignatureCare nurse came to collect the paperwork, de Cordova said the nurse told her, “You can’t do that. It’s insurance fraud for you to pay for our services once we know you have insurance.”
Dr. Hashibul Hannan, an emergency room physician, lab director and manager at SignatureCare, told ProPublica his facility is an emergency room that offers testing, not a typical testing site. He said de Cordova should have been allowed to pay the $175 cash price. The staff members were concerned about being accused of fraud because they had already entered her insurance information into the record, he said. So they didn’t want it to appear she was being double-billed. Hannan also said he regrets that she was upset by the disclosure forms that are now required under state law.
Unable to pay cash and unwilling to take a chance on the unknown cost, de Cordova decided to leave without getting the results of her COVID-19 test.
“I Would Have Signed Anything”
Later that day, de Cordova couldn’t get past what happened. She wondered what happened to patients who didn’t read the fine print before signing the packet.
Then she realized she and her husband, Hayan Charara, could investigate it themselves. In June, the couple’s 8-year-old son had attended a baseball tryout. They thought the kids would be socially distanced and that precautions would be taken. But then the coaches had crowded the players in a dugout, with no masks or social distancing, and a couple days later the boy said he wasn’t feeling well.
So just to be safe, on June 12, Charara took their son to the same SignatureCare, the Heights location, for a COVID-19 test. The line was so long they had to wait for hours, go home, come back and wait for hours again in their car in the 100-degree heat. Charara, a poet who teaches at the University of Houston, said he didn’t take a close look at the financial disclosure paperwork. De Cordova wasn’t with them. It had been 10 hours of waiting by the time the boy was tested, so “I would have signed anything,” he said. (The child tested negative.)
Charara, de Cordova and their children are covered by the Employees Retirement System of Texas, a taxpayer-funded benefit plan that covers about half a million people. They hadn’t received any notices about the charges for their son. So they contacted the SignatureCare billing department and asked for an itemized statement. The test charge was indeed $175. But the total balance, including the physician and facility fees associated with an emergency room visit, came to $2,479.
The facility fee was $1,784 and the physician fee $486.
The couple were dumbfounded. Their son’s vital signs had been checked but there had been no physical examination, they said. The interactions took less than five minutes total, and the child stayed in the car. “You’re getting a drive-thru test, and they’re pretending like they’re giving you emergency services,” de Cordova said.
The SignatureCare charges shocked experts who study health care costs. Charging $2,479 for a drive-thru COVID-19 test is a “nauseating” example of profiteering during a pandemic, said Niall Brennan, president and CEO of the Health Care Cost Institute, a nonprofit organization that studies health care prices. “It’s one of the most egregious examples of giving the fox the keys to the henhouse I’ve ever seen and yet another example of the absurdity of U.S. health care pricing.
“Imagine a vendor in any other walk of life being allowed to bill a third party for whatever amount they wanted,” Brennan said.
Insurance companies in Texas typically pay between $100 and $300 for drive-thru COVID-19 tests, said Jamie Dudensing, CEO of the Texas Association of Health Plans. But the association’s members have seen hundreds of out-of-network COVID-19 test charges come in far higher, some in the thousands of dollars.
“There’s no excuse for that, especially in a public health crisis,” said Chris Callahan, spokesperson for Blue Cross and Blue Shield of Texas, which likewise has seen high charges for COVID-19 tests from out-of-network providers.
The reimbursement rates negotiated between insurance companies and in-network providers are much lower, but they still vary, according to data provided by the nonprofit FAIR Health, which tracks spending by private insurers. For the same test billed by SignatureCare, an in-network insurer pays a median price of $23 in Utah and $75 in Wisconsin, according to FAIR Health estimates.
Texas is notorious for its high-priced out-of-network emergency bills and free-standing emergency departments. Some of the facilities appear to be using COVID-19 testing to draw in patients so their insurance plans can be charged for additional services, said Blake Hutson, associate state director for AARP Texas, the advocacy organization for older Americans. “It’s not a surprise they would be racking up the charges and adding on everything they can and billing the health plan,” he said.
In some cases, insurers do pay the exorbitant out-of-network charges, Hutson said, but they typically get reduced. In 2019, Texas lawmakers voted to ban billing patients in state-regulated insurance plans for charges not covered by their policy, Hutson said, which is known as “balance” or “surprise” billing. But consumers may still be responsible for any deductibles and other cost-sharing under their health plan. And the costs covered by the health plan get passed back to the consumers over time in the form of higher premiums, he said. “It’s all problematic for the cost of care,” Hutson said.
Hannan defended SignatureCare’s high out-of-network charges by blaming insurance companies for refusing to give what he considers to be fair in-network rates. The charges are a starting point for negotiating a fair deal from out-of-network insurance plans, he said. He described SignatureCare, which has 18 locations, as “small players. When it comes to negotiating with insurance companies, we have no luck.”
Was the Bill Accurate?
The medical record portrays the visit as an emergency and contains details that are not consistent with how Charara and de Cordova describe their son’s condition. The chief complaint in the record is “body fluid exposure,” and elsewhere it says “confirmed COVID exposure.”
But that’s not accurate, according to the parents. No one had coughed or sneezed on their son, and they knew of no one from the tryout who had tested positive for COVID-19, they said. The child’s temperature is registered in the record as 102.8, which is high. But Charara said that could have been caused by sitting in the Texas heat, waiting for the test.
Shelley Safian, a Florida health care coding expert who has written four books on medical billing, examined the bill and medical records of Charara and de Cordova’s son at ProPublica’s request. She said the medical records don’t justify the charges. SignatureCare billed the case as if the exam were an emergency that required an “expanded problem focused history” and “medical decision making of moderate complexity,” she said.
In order to qualify for reimbursement of an exam at that level, the encounter would need to include examining the affected organ system, Safian said. But the medical records do not document any check of the respiratory system, which would be indicated for suspected COVID-19.
Much of the medical record appeared to be cut and pasted from other electronic records, Safian said. “This is boilerplate B.S.,” she said, “and I don’t mean ‘bachelor of science.’”
Hannan, the SignatureCare doctor and manager, stands by the charges associated with the child’s COVID-19 test. The facility has to treat every case like a possible emergency, and that requires an examination, he said. He pointed out that the charges are in line with what other out-of-network providers would charge in the area, according to FAIR Health, though they are far higher than in-network prices.
A doctor’s examination may not be as hands-on during COVID-19, but, similar to a telemedicine visit, a lot can be examined visually, Hannan said. Hannan said the company he uses for coding said COVID-19 requires a higher level of care and vigilance because it’s an infectious disease.
In light of the questions raised by ProPublica and Safian, Hannan said he asked his billing company to audit the charges. Sharon Nicka, president and CEO of Nicka and Associates, the billing company used by SignatureCare, took issue with Safian’s assessment and said the billing codes used were justified by the medical record. She said the charges are high for a drive-thru test, but those are set by SignatureCare.
ProPublica identified several apparent errors and contradictions in the medical record and billing documentation. For example, the notes in the medical record alternatively refer to the boy as “symptomatic” and “asymptomatic.” The record also says the physical exam showed a skin wound that “was not red, swollen or tender,” but the child had no wound of any kind, the family said. And the billing documentation shows a charge for an antibody test when the medical record showed that the patient actually received a diagnostic test, which is something different.
In response to ProPublica’s questions, a SignatureCare medical director reviewed the record. The error about the “wound” may have been caused by a software template adding something that was not in the physician chart, the reviewer wrote. The facility now uses a different template. The charge for the antibody test is likely a billing error, as the physician had ordered the correct test, the reviewer wrote. “We will continue to update and improve our (electronic medical records),” the reviewer said.
Hannan stressed that SignatureCare is upfront with patients about the possible fees associated with its treatment, including the disclosure paperwork and explanations on its website. It’s an emergency room, he said, so patients should expect emergency room fees. Patients who do not have a medical emergency should not come, he said, though the ER allows patients to book appointments a day in advance for a COVID-19 test.
Dudensing, the chief executive of the Texas Association of Health Plans, said she’s heard Hannan’s contention before and it’s true that freestanding emergency rooms have a license that allows them to charge more. But she still believes that they handle many nonemergency cases and are forcing facility fees of thousands of dollars on them. “They’re hiding under the guise of emergency rooms when they’re really dressed-up urgent care,” she said.
Diana Kongevick, director of group benefits for the Employees Retirement System of Texas, said the health plan had only recently received the bill for the 8-year-old’s test. It hadn’t been processed, so she could not speak to it directly. But, in general, the health plan will pay 100% of the cost of the test, in this case $175, she said. The claim would be processed using out-of-network provisions, she said. So for the other charges, the patient may be responsible for paying in the range of $600, she estimated, for the out-of-network copay and deductibles. “This is a nonemergent patient self-referral to an out-of-network provider,” Kongevick said.
“Testing Should Be Free”
Even if the Employees Retirement System of Texas determines that Charara and de Cordova should pay $600 for their son’s test, SignatureCare will not be sending the family a bill, Hannan said. He said insured patients are not being sent bills for COVID-19 treatment beyond what their insurance companies cover.
De Cordova never did get her test results, and she didn’t seek a test elsewhere. She felt better later and now believes she had just been suffering from allergies. But what if it had turned out to be COVID-19, she wondered. Might she have gone on to infect others, she’s asked herself.
From a public health perspective, the haggling about out-of-network charges and payments puts patients in the middle, and it might discourage them from getting tested for COVID-19 during the pandemic, said Stuart Craig, an economist at the University of Pennsylvania who studies health care costs. “It’s another part of the fragmentation of the health care system that makes patients’ lives miserable,” Craig said.
It’s especially frustrating, he said, because COVID-19 testing is so essential to making it safely through the pandemic. Craig said he believes there should be a nationally mandated price and government subsidies to make sure medical providers and manufacturers are motivated financially to provide tests. “Testing should be free,” Craig said. “In fact, we should probably be paying patients to get tested.”
The Trump administration told hospitals to stop reporting data to the CDC, and report it to HHS instead. Vice President Mike Pence said the information would continue to be released publicly. It hasn't worked out as promised.
This article was first published on Friday, July 31, 2020 in ProPublica.
In mid-July, the Trump administration instructed hospitals to change the way they reported data on their coronavirus patients, promising the new approach would provide better, more up-to-the-minute information about the virus’s toll and allow resources and supplies to be quickly dispatched across the country.
Instead, the move has created widespread confusion, leaving some states in the dark about their hospitals’ remaining bed and intensive care capacity and, at least temporarily, removing this information from public view. As a result, it has been unclear how many people are in hospitals being treated for COVID-19 at a time when the number of infected patients nationally has been soaring.
Hospitalizations for COVID-19 have been seen as a key metric of both the coronavirus’s toll and the health care system’s ability to deal with it.
Since early in the pandemic, hospitals had been reporting data on COVID-19 patients to the U.S. Centers for Disease Control and Prevention through its National Healthcare Safety Network, which traditionally tracks hospital-acquired infections.
In a memo dated July 10, the U.S. Department of Health and Human Services told hospitals to abruptly change course — to stop reporting their data to the CDC and instead to submit it to HHS through a new portal run by a company called TeleTracking. The change took effect within days. Vice President Mike Pence said the administration would continue releasing the data publicly, as the CDC had done.
Almost immediately, the CDC pulled its historical data offline, only to repost it under pressure a couple days later. Meanwhile the website for the administration’s new portal promised to update numbers on a daily basis, but, as of Friday morning, the site hadn’t been updated since July 23. (HHS is posting some data daily on a different federal website but not representative estimates for each state.)
“The most pernicious portion of it is that at the state level and at the regional level we lost our situational awareness,” said Dave Dillon, spokesman for the Missouri Hospital Association. “At the end of this, we may have a fantastic data product out of HHS. I will not beat them up for trying to do something positive about the data, but the rollout of this has been absolutely a catastrophe.”
The Missouri Hospital Association had taken the daily data submitted by its hospitals to the CDC and created a state dashboard. The transition knocked that offline. The dashboard came back online this week, but Dillon said in a follow-up email, “the data is only as good as our ability to know that everyone is reporting the same data, in the correct way, for tracking and comparison purposes at the state level.”
Other states, including Idaho and South Carolina, also experienced temporary information blackouts. And The COVID Tracking Project, which has been following the pandemic’s toll across the country based on state data, noted issues with its figures. “These problems mean that our hospitalization data — a crucial metric of the COVID-19 pandemic — is, for now, unreliable, and likely an undercount. We do not think that either the state-level hospitalization data or the new federal data is reliable in isolation,” according to a blog post Tuesday on the group’s website.
Making matters more complicated, the administration has changed the information that it is requiring hospitals to report, adding many elements, such as the age range of admitted COVID-19 patients, and removing others. As of this week, for instance, HHS told hospitals to stop reporting the total number of deaths they’ve had since Jan. 1, the total number of COVID-19 deaths and the total number of COVID-19 admissions. (Hospitals still report daily figures, just not historical ones.)
“Massachusetts hospitals are continuing to navigate the dramatic increase of daily data requirements,” the Massachusetts Health and Hospital Association said in a newsletter on Monday. “MHA and other state health officials continue to raise concerns about the administrative burden and questionable usefulness of some of the data.”
“Hospitals across the country were given little time to adjust to the unnecessary and seismic changes put forth by the U.S. Department of Health and Human Services, which fundamentally shift both the volume of data and the platforms through which data is submitted,” the association’s CEO, Steve Walsh, said in the newsletter.
A number of state websites also noted problems with hospital data. For days, the Texas Department of State Health Services included a note on its dashboard that it was “reporting incomplete hospitalization numbers … due to a transition in reporting to comply with new federal requirements.” That came just as the state was experiencing a peak in COVID-19 hospitalizations.
California likewise noted problems.
A spokesperson for HHS acknowledged some bumps in the transition but said in an email: “We are pleased with the progress we have made during this transition and the actionable data it is providing. We have had some states and hospital associations report difficulty with the new collection system. When HHS identifies errors in the data submissions, we work directly with the state or hospital association to quickly resolve them.
“Our objective with this new approach is to collaborate with the states and the healthcare system. The goal of full transparency is to acknowledge when we find discrepancies in the data and correct them.”
Last week, HHS noted, 93% of its prioritized list of hospitals, excluding psychiatric, rehabilitation and religious nonmedical facilities, reported data at least once during the week. (The guidance to hospitals asks them to report every day.)
Asked about the lack of timely data on its public website, HHS said it will update the site to “make it clear that the estimates are only updated weekly.” HHS is now posting a date file each day on healthdata.gov with aggregate information on hospitalizations by state.
But unlike the prior releases from CDC, which provided estimates on hospital capacity based on the responses, this file only gives totals for the hospitals that reported data. It’s unclear which hospitals did not report, how large they are, or whether the reported data is representative.
It’s also unclear if it’s accurate. New York state, for instance, reported that fewer than 600 people were currently hospitalized with COVID-19, as of Friday. Federal data released the same day pegged the number of suspected and confirmed COVID-19 hospitalizations at around 1,800.
Louisiana says more than 1,500 people are currently hospitalized with COVID-19. The federal data puts the figure at fewer than 700.
Nationally, The COVID Tracking Project reports that more than 56,000 people were hospitalized around the country with the virus, as of Thursday.
The data released by HHS on Friday puts the figure at more than 70,000.
NPR reported this week that it had found irregularities in the process used by the Trump administration to award the contract to manage the hospital data. Among other things, HHS directly contacted TeleTracking about the contract and the agency used a process that is more often used for innovative scientific research, NPR reported.
An HHS spokesperson told NPR that the contract process it used is a “common mechanism ... for areas of research interest,” and said that the system used by the CDC was “fraught with challenges.”
Ryan Panchadsaram, co-founder of the tracking website CovidExitStrategy.org, has been critical of the problems created by the hospital data changeover.
“Without real-time accurate monitoring, you can’t make quick and fast and accurate decisions in a crisis,” he said in an interview. “This is just so important. This indicator that’s gone shows how the health system in a state is doing.”
Dillon of the Missouri Hospital Association said the administration could have handled this differently. For big technology projects, he noted, there is often a well-publicized transition with information sessions, an educational program and, perhaps, running the old system and the new one in parallel.
This “was extremely abrupt,” he said. “That is not akin to anything you would expect from HHS about how you would implement a program.”