TSA stockpiled a huge shipment of N95 masks they knew they didn't need. Airport traffic fell 95 percent, and the masks have sat unused as hospitals searched desperately for them.
This article was first published on Wednesday, May 6, 2020 in ProPublica.
By J. David McSwane
The Transportation Security Administration ignored guidance from the Department of Homeland Security and internal pushback from two agency officials when it stockpiled more than 1.3 million N95 respirator masks instead of donating them to hospitals, internal records and interviews show.
Internal concerns were raised in early April, when COVID-19 cases were growing by the thousands and hospitals in some parts of the country were overrun and desperate for supplies. The agency held on to the cache of life-saving masks even as the number of people coming through U.S. airports dropped by 95% and the TSA instructed many employees to stay home to avoid being infected. Meanwhile, other federal agencies, including the Department of Veterans Affairs' vast network of hospitals, scrounged for the personal protective equipment that doctors and nurses are dying without.
"We don't need them. People who are in an infectious environment need them. Nobody is flying," Charles Kielkopf, a TSA attorney based in Columbus, Ohio, told ProPublica. "You don't take things for yourself. It's the wrong thing to do."
Kielkopf shared a copy of an official whistleblower complaint he filed Monday. In it, he alleges the agency had engaged in gross mismanagement that represented a "substantial and specific danger to public health."
TSA has not required its screeners to wear N95s, which require fitting and training to use properly, and internal memos show most are using surgical masks, which are more widely available but are less effective and lack the same filtering ability.
Kielkopf raised a red flag last month about the TSA's plan to store N95 respirators it had been given by Customs and Border Protection, which found more than a million old but usable masks in an Indiana warehouse. Both agencies are overseen by DHS. That shipment added to 116,000 N95s the TSA had left over from the swine flu pandemic of 2009, a TSA memo shows. While both stockpiles were older than the manufacturer's recommended shelf life, the Centers for Disease Control and Prevention said that expired masks remain effective against spreading the virus.
Kielkopf and another TSA official in Minnesota suggested that the agency send its N95 masks to hospitals in early April, records show. Instead, TSA quietly stored many of them in its warehouse near the Dallas-Fort Worth airport and dispersed the rest to empty airports across the nation.
"We need to reserve medical masks for health care workers," Kielkopf said, "not TSA workers who are behind an X-ray machine."
The TSA didn't provide answers to several detailed questions sent by ProPublica, but spokesman Mark Howell said in an email that the agency's "highest priority is to ensure the health, safety and security of our workforce and the American people."
"With the support of CBP and DHS, in April, TSA was able to ensure a sufficient supply of N95 masks would be available for any officer who chose to wear one and completed the requisite training," the statement read.
"We are continuing to acquire additional personal protective equipment for our employees to ensure both their and the traveling public's health and safety based on our current staffing needs, and as supplies become available," TSA said.
A review of federal contracting data shows the agency has mostly made modest purchases such as a $231,000 purchase for gallons of disinfectant, but has not reported any new purchases of N95s.
An internal TSA memo last month said the surplus of N95s was expected to last the agency about 30 days, but the same memo noted that estimate did not account for the drastic decline in security officers working at airports. ProPublica asked how long the masks were actually going to last, accounting for the decreased staffing levels.
"While we cannot provide details on staffing, passenger throughput and corresponding operations have certainly decreased," the TSA statement said.
The trade journal Government Executive reported this week that internal TSA records showed most employee schedules have been "sharply abbreviated," while an additional 8,000 security screeners are on paid leave over concerns that they could be exposed to the virus.
More than 500 TSA employees have tested positive for COVID-19, the agency reported, and five have died.
The CDC has not recommended the use of N95s by TSA staff, records show, but that doesn't mean workers who have or want to wear them can't.
In one April 7 email, DHS Deputy Under Secretary for Management Randolph D. Alles sent guidance to TSA officials, urging them to wear homemade cloth face coverings and maintain social distancing. But the N95s, which block 95% of particles that can transmit the virus, were in notoriously short supply and should be "reserved" for health care workers.
"The CDC has given us very good information about how to make masks that are suitable, so that we can continue to reserve medical masks and PPE for healthcare workers battling the COVID-19 pandemic," Alles wrote.
But two days later, on April 9, Cliff Van Leuven, TSA's federal security director in Minnesota, followed up and asked why he had been sent thousands of masks despite that guidance.
"I just received 9,000 N-95 masks that I have very little to no need for," he said in the email, which was first reported by Government Executive. "We've made N95s available to our staff and, of the officers who wear masks, they overwhelmingly prefer the surgical masks we just received after a couple months on back order."
Minnesota Gov. Tim Walz had publicly asked that anyone who had PPE donate their surplus to the state's Department of Health, Van Leuven said in the email to senior TSA staff.
"I'd like to donate the bulk of our current stock of N-95s in support of that need and keep a small supply on hand," he wrote, adding the Minneapolis-St. Paul International Airport had screened fewer than 1,500 people the previous day, about a third of which were airport staff.
Van Leuven declined to comment, referring questions to a TSA spokesperson.
Later that day, Kielkopf forwarded the concerns to TSA attorneys in other field offices, trying to get some attention to the stockpile he felt would be better used at hospitals.
"I am sharing with you some issues we are having with n95 masks in Minnesota," he wrote. "And the tension between our increasing supply of n95 masks at our TSA airport locations and the dire need for them in the medical community."
Weeks went by, and finally, on May 1, Kielkopf wrote: "I have been very disappointed in our position to keep tens of thousands of n95 masks while healthcare workers who have a medical requirement for the masks — because of their contact with infected people — still go without."
DHS did not respond to ProPublica's questions about why it transferred N95 masks to TSA despite a top official saying they should be reserved for healthcare workers.
"So now the TSA position is that we desperately need these masks for the protection of our people," Kielkopf said. "At the same time, most of our people aren't even working. It's a complete 180 that doesn't make any sense."
One of every four Filipinos in the New York-New Jersey area is employed in the health care industry. With at least 30 worker deaths and many more family members lost to the coronavirus, a community at the epicenter of the pandemic has been left reeling.
This article was first published on Sunday, May 3, 2020 in ProPublica.
When Alfredo Pabatao told his family that he had helped move a suspected coronavirus patient through the hospital where he’d worked as an orderly for nearly 20 years, he didn’t make a big deal out of it. “My parents are the type of parents who don’t like to make us worry,” his youngest daughter, Sheryl, recalled. But Sheryl was concerned that her father’s vulnerabilities weren’t being given more consideration as he toiled on the pandemic’s front lines in hard-hit northern New Jersey. “Why would they let a 68-year-old man with an underlying heart condition … transport a suspected COVID patient when there’s younger transporters in the hospital who could do it?”
Sheryl’s mother, Susana, was an assistant nurse in a long-term care facility where she often pulled double shifts, saving money for her annual trips back to the Philippines. At 64, she wasn’t much younger than the elderly patients she helped bathe and feed, and she had diabetes, which increased her risk of severe complications if she got sick. The nursing home wasn’t providing adequate personal protection equipment, Susana reported, so Sheryl brought home a stash of surgical masks for her mother to wear on the job. That didn’t go over well with Susana’s managers, Sheryl said: “They gave her a warning, saying she shouldn’t be wearing that. … She was really mad.”
Alfredo fell ill first, his symptoms flaring on March 17. Susana soon developed a fever. The couple had grown up on the same street in Manila and shared a romance that reminded their daughter of a telenovela; after 44 years of marriage and five children, they were all but inseparable. “Where mom goes, my dad goes. Where my dad goes, my mom goes. That’s the way they are,” Sheryl said. The day Alfredo was admitted to the ICU, his heart failing, Susana checked into the same hospital. They died four days apart.
Filipino American medical workers have suffered some of the most staggering losses in the coronavirus pandemic. In the New York-New Jersey region alone, ProPublica learned of at least 30 deaths of Filipino health care workers since the end of March and many more deaths in those peoples’ extended families. The virus has struck hardest where a huge concentration of the community lives and works. They are at “the epicenter of the epicenter,” said Bernadette Ellorin, a community organizer.
Some of the largest Filipino enclaves on the East Coast are in the New York City borough of Queens and northern New Jersey — the very places now being ravaged by COVID-19.
Filipinos are on the front lines there and across the country, four times more likely to be nurses than any other ethnic group in the U.S., experts say. In the New York-New Jersey region, nearly a quarter of adults with Filipino ancestry work in hospitals or other medical fields, a ProPublica analysis of 2017 U.S. census data found. The statistic bears repeating: Of every man and woman in the Filipino community there, one in four works in the health care industry.
“So many people can rattle off five, 10 relations that are working in the medical field,” said filmmaker Marissa Aroy, whose most recent documentary is about Filipino nurses. Her parents were registered nurses in California, and various relatives are in health care professions, including a cousin who works in a rehab center in the Bronx and recently recovered from COVID-19. “Think about all of those family members who are going to be affected,” Aroy said. “We’re talking about huge family structures here.”
The scale of the trauma and the way it is unfolding are “similar to times of war,” said Kevin Nadal, a professor of psychology at John Jay College of Criminal Justice and The Graduate Center of the City University of New York who has written extensively about Filipino American psychology and culture.
The majority of the reported deaths have involved nurses, including Susan Sisgundo and Ernesto “Audie” DeLeon, who worked at Bellevue Hospital in New York City, and Marlino Cagas, who spent 40 years as a pharmacy tech at Harlem Hospital before embarking on a nursing career at the age of 60. A handful, including Jessie Ariel Ferreras, a family practitioner in Bergen County, were doctors. Others worked in support roles, like Louis Torres, 47, the director of food services at a nursing home in Woodside, Queens, and his 73-year-old mother, Lolita, or Lely, a clerk at a nearby hospital. They lived together and fellsick around the same time, both developing pneumonia. Lolita died on April 7, her son, the following day.
Don Ryan Batayola, a 40-year-old occupational therapist, was from a big, tight-knit family and lived in Springfield Township, New Jersey. He is believed to have caught the virus from a patient and was rushed to the hospital on March 31. By April 4, he had improved enough to FaceTime with his wife, also an occupational therapist who was sick and self-isolating at home, their children sheltering with relatives. Then, an hour later, he went into cardiac arrest.
One of the most wrenching aspects of the epidemic is the sense of disconnection and helplessness in a community that stakes its economic well-being on providing care and comfort and cherishes its closeness. So many members of Batayola’s extended family are health care workers, “we could almost open our own hospital,” said his oldest sister Aimee Canton, an oncology nurse in Northern California. But to protect each other, they’ve had to remain apart, with no idea when they’ll be able to come together again. “It’s so sad when you’re a nurse,” Canton said, “and you can’t even help your own family.”
Almost all the deaths of Filipino American health care workers that ProPublica found involve people, like the Batayolas, who immigrated during the 1970s to 2000s, when critical shortages created opportunities for medical personnel with the right training.
But the story of Filipino nurses in the U.S. goes back much further, to the end of the Spanish-American War in 1898, when the Philippines became a U.S. territory, said Catherine Ceniza Choy, a professor of ethnic studies at the University of California, Berkeley, and author of “Empire of Care: Nursing and Migration in Filipino American History.” One legacy of the colonial era is a network of hundreds of Americanized nursing schools that eventually produced tens of thousands of caregivers a year, making the country “the leading exporter of nurses in the world,” Choy said.
Nursing offered an escape route from economic and political instability and a path to the middle class for those who had few other options. It also appealed to deeply held cultural values: “kapwa,” Tagalog for “a feeling of interconnectedness to all people, putting others before yourself and taking care of the community,” Nadal said, and “utang ng loob,” the idea that people owe a debt to each other and to those who came before.
Most nurses trained in the Philippines who sought work abroad hoped to end up in the U.S. (They also migrated in large numbers to the Middle East and the U.K.) American immigration policies ebbed and flowed depending on labor shortages and political expediency. In the first third of the 20th century, the numbers of Filipino nurses were small; most workers from the islands were sent to the fields of California and the plantations of Hawaii. Then, in the wake of the Great Depression, Filipino immigrants were capped at just 50 per year, rising to 100 after World War II.
After the war, U.S. nursing shortages grew acute. Even as the passage of Medicare and Medicaid made health care more accessible to the elderly and poor, the rise of the feminist movement, which opened up professional opportunities for American women, made caregiver work less appealing, Choy said. The Immigration Act of 1965 swept aside the long-standing system of country-based quotas, instead giving preference to immigrants with professional degrees. Tens of thousands of Filipino nurses answered the call.
Many ended up at inner-city and rural hospitals that had the greatest difficulty recruiting staff, often working the least desirable jobs and shifts, including, in the 1980s and ’90s, on the front lines of the AIDS epidemic. It was part of a historical pattern, said Nadal, of “immigrants doing a lot of the dirty work that people don’t want to do... being painted as heroes, when in reality they are only put in these positions because their lives are viewed as disposable.”
Yet it was a template for economic security that many of their American-born children and grandchildren embraced. “It’s like any kind of family dynamic,” Aroy said. “You see your parents do the job. And so then you know that that’s accessible to you. As a second- generation kid, I always knew that was a path for me if I wanted it.”
Today, people of Filipino ancestry comprise about 1% of the U.S. population but more than 7% of the hospital and health care workforce in the United States — nearly 500,000 workers, according to census data. They find themselves fighting not just a potentially lethal illness, but the scapegoating stoked by President Donald Trump and supporters who have taken to calling COVID-19 the “Chinese virus.” Since late March, civil rights organizations have received nearly 1,500 reports of anti-Asian hate incidents, mostly from California and New York, including against Filipino Americans.
“This anti-Asian racism that’s happening right now,” Aroy said, “what it makes me want to do is scream out: ‘How dare you treat us like the carriers? We are your caregivers.’”
A host of factors, from medical to cultural, have put large numbers of Filipinos in harm’s way and made them vulnerable to the types of severe complications that often turn deadly. They begin with the specific type of health care work they do.
A survey by the Philippine Nurses Association of America published in 2018 found that a large proportion of respondents were concentrated in bedside and critical care — “the opposite of social distancing,” said executive director Leo-Felix Jurado, who teaches nursing at William Paterson University in Wayne, New Jersey. Many of the organization’s members have contracted the virus, he said, including the current president, New Jersey-based registered nurse Madelyn Yu; she is recovering, but her husband died.
For Daisy Doronila, employed at the Hudson County Correctional Facility in northern New Jersey for more than two decades, the profession was almost a religious calling. “My mom had a very, very humble beginning,” said her only child, Denise Rendor. “She really wanted to take care of people that no one wanted to take care of.”
Doronila saw her responsibilities to her colleagues no less seriously. The single mother and devout Catholic “was always the most reliable person at the job,” Rendor said. “If there was a snowstorm, people called out, nope, not her: ‘I’ll be there.’” As a kid, Rendor sometimes resented the missed volleyball games and dance recitals. Looking back now, “I don’t think I would have the life that I had had my mom not worked so hard.”
It’s not clear how Doronila contracted the virus, though the Hudson County jail has had at least four deaths. Once she fell ill in mid-March, she was turned away for testing by clinics and doctors on three occasions because her symptoms didn’t meet the criteria at the time, Rendor said. On March 21, Doronila started feeling breathless and drove herself to urgent care, which sent her by ambulance to the hospital. She died on April 5 at the age of 60.
If she hadn’t gotten sick, Rendor is sure she would have been volunteering for extra shifts. “That’s just who my mother was. She was just always willing to help.”
That selflessness is common among Filipino immigrants, said Zeine Cortez, a registered nurse in the San Francisco Bay Area who is the president of the California Nurses Association/National Nurses United. “They have such a profound willingness to work that they would forget their own well-being,” she said. “They would think of their loved ones in the Philippines — if they don’t work, then they can’t send money back home.”
In 2019, Filipinos abroad sent $35 billion back to the Philippines, making it the fourth-largest recipient of overseas remittances in the world; many are also helping to support networks of relatives in the U.S. “That’s the economic factor that is on the minds of a lot of Filipino nurses,” Cortez said. “If we miss work, there will be no income.”
It’s a worry that keeps many Filipinos doing sometimes-grueling labor well into their 70s. Doronila’s colleague at the Hudson County jail, nurse Edwin Montanano, was 73 when he died in early April. Jesus Villaluz, a much-beloved patient transporter at Holy Name Medical Center in Teaneck, one of the worst-hit hospitals in northern New Jersey, was 75. “They cannot in their conscience walk away from patients who need them,” said Maria Castaneda, a registered nurse and the secretary-treasurer of 1199SEIU United Healthcare Workers East, who immigrated from the Philippines in 1984. “At the same time, they are there in solidarity with other co-workers. If they are not there, it adds to the burden of those who are working.”
COVID-19 risks are magnified in people who are older or suffer underlying chronic conditions. Filipinos have very high rates of Type II diabetes and cardiovasculardisease, both of which render the virus more dangerous. “They’re doing amazing things and helping others to survive,” Nadal said. “But they’re putting themselves at risk because they have immuno-compromised traits that make them susceptible to severe sickness and death.”
And in many situations, they’ve been forced to do that work without proper PPE and other safeguards, said Ellorin, the Queens-based community organizer and executive director of the advocacy group Mission to End Modern-Day Slavery. They are “being infected and not being protected, and then their families, or whoever they live with, are getting infected.”
Sheryl Pabatao thinks of the many people she knows who are working in hospitals and other medical settings and feel unable to speak out. “Even though they don’t want to do things, they still do it because they don’t want to lose their jobs.”
When they first applied to immigrate to the U.S. in the 1980s, Alfredo Pabatao was in the car business; Susana was a former nursing student turned housewife and mother of two. By the time their petition was approved about 14 years later, their two eldest children were too old to qualify to come to the U.S. with their parents, so the Pabataos were forced to leave them behind, bringing only their youngest two daughters and son. “To this day, that was one of the hardest things — being separated from everyone,” Sheryl said.
They arrived in the U.S. a few weeks after 9/11. One of Alfredo’s sisters, a registered nurse, helped him get a job transporting patients at her hospital, now known as Hackensack Meridian Health Palisades Medical Center, in North Bergen, New Jersey. “My father grew up with wealth, and when he came here, he had to be modest and humble,” Sheryl said. Susana earned her assistant nursing certification while working as a grocery store cashier, then went to work at what is now called Bergen New Bridge Medical Center in Paramus, the largest hospital and licensed nursing home in the state. Taking care of elderly people helped ease the sadness and guilt at what she had left behind. “She was not able to take care of her own mother,” Sheryl said. “So when she does her job here, she cares for them like her own.”
America proved to be both generous and hard. The couple prospered enough to buy a house, then lost it in the Great Recession. They managed to rebuild their lives and gained their U.S. citizenship, the kids choosing careers in the pharmaceutical side of health care. After 18 years in the same job, Alfredo was waiting for Susana to retire so he could, too.
Then came the pandemic.
Sheryl had been following the news reports from China since early February and was concerned enough about her family to procure a small supply of masks before vendors ran out; “I’d put my parents in a bubble if I can,” she said. Her father was more easygoing: “He has survived so many things in his life. His attitude is: ‘If I get it, I get it. I’ll be OK with it.’”
Sheryl doesn’t know how the responsibility fell to him to transport a patient suspected of having COVID-19 during the second week in March. “But knowing my dad, he agrees to anything. He has that work ethic: ‘This is my job. If I can do it, l do it.’ Knowing him, if one of the other [orderlies] didn’t want to transfer the patient, they asked him and he said yes.”
When Susana found out her husband had been exposed to the virus that way, she was not happy, Sheryl said. Susana was having her own issues at the nursing home. In mid-March, she received an email from her bosses that warned in boldface, “Facemasks are to be used only by staff who have an authorized or clinical reason to use them. Do not wear non-hospital issued facemasks.” It was a policy Susana complained was being made by people who weren’t doing bedside care and didn’t understand the real risks. She was also told the masks would scare patients. She pretended to obey the directive when her managers were around, Sheryl said, “but my mom was stubborn, so when they left, she put [her mask] back on.”
Bergen New Bridge called Susana a “valued” employee who is “greatly missed.” The hospital denied that it has experienced any PPE shortages, but it noted that “guidance from federal and state health officials regarding the use of PPE has been evolving.” Early on, “it was recommended that masks were to be worn only by those individuals who were sick or those who were caring for COVID-19 patients.” Once the virus began spreading within the community, “we quickly moved to universal masking of all employees,” the hospital said. “Like all healthcare facilities, our Medical Center has stressed the importance of using hospital-issued PPE, as guided by the CDC.”
As of April 29, New Bridge’s long-term care facility had recorded 120 confirmed COVID-19 cases and 26 deaths. Hackensack Meridian Health didn’t respond to ProPublica’s requests for comment about Alfredo’s case.
It wasn’t just Alfredo and Susana who fell ill. Sheryl and her brother, both living at home, caught the virus, too. The weekend before Alfredo’s symptoms emerged, he and the rest of the family attended a gathering in honor of a relative who had died in January from cancer. Alfredo spent much of the party talking to his younger brother; later, the brother ended up with COVID-19 and on a ventilator for nearly three weeks. An aunt of Sheryl’s who is a housekeeper in the same hospital system as Alfredo wasn’t at the gathering but fell ill anyway and was out sick for two weeks. Her symptoms weren’t as severe as those of some of the others; she’s already back at work.
The spread of the virus has been unrelenting for Sheryl. When she returned to her own job as a pharmacy tech this past week, a month after her parents died, she learned that someone who worked at her company — who was also Filipino — had died during her absence. “You have no idea about the extent of this,” she said, “until it hits you.”
Darcel Richardson knows she's fortunate in one sense: She still has her job as a vocational counselor in Baltimore. But despite that, she won't be able to make her rent payment this month because she's not getting her full salary for a while. More than $400 per biweekly paycheck — about a quarter of her after-tax income — has been siphoned off by Johns Hopkins University for unpaid medical bills at one of its hospitals.
Richardson, 60, got word of the garnishment from her employer just as the coronavirus pandemic was arriving in full force last month. "My job was going to take the money out. They don't want to get in trouble," she said. "I spoke with our payroll accountant, and the bottom line was, even though the crisis had begun, they still had to pay my money to them."
In a moment when hospitals nationwide are being heralded for their role at the front lines of fighting the pandemic, some Americans continue to experience a less favorable side of hospital operations: aggressive collection for unpaid medical bills, even at a time when many of the debtors are seeing their income plunge. Debt collection is occurring on other fronts as well, over unpaid college and bank loans among others, prompting debates over protecting people's economic stimulus checks from collection agencies or suspending garnishments outright. But collection by the very hospitals that are treating coronavirus patients brings the health and economic exigencies of the moment into especially stark relief.
In a few cases, hospitals have brought new cases against former patients in recent weeks, such as in Wisconsin, where Froedtert Hospital in Milwaukee filed 46 small-claims lawsuits even after the governor declared a state of emergency on March 12, and other hospital systems in the state filed dozens more, according to a report by Wisconsin Public Radio and Wisconsin Watch. Steve Schoof, Froedtert's director of external communications, told ProPublica in a statement that the hospital stopped filing small claims suits on March 18. "Moving forward," the statement continued, "Froedtert Health will no longer be filing small claims suits for medical debt collection. Unfortunately, there was a miscommunication that resulted in small claims filings after March 18. We immediately rectified this miscommunication and dismissed these small claims cases that were filed after March 18."
More often, though, the collection stems from cases filed months before the pandemic arrived, as the legal process grinds its way forward. "Where debt collection is underway for pre-COVID medical debt, they will continue to do that," said Jenifer Bosco, a staff attorney for the National Consumer Law Center.
In Richardson's case, the debt stemmed from a two-day 2018 visit to Johns Hopkins Bayview Medical Center in southeast Baltimore, one of a string of medical visits she has had to make over the years to deal with a knee injury from a fall, a hip injury from a car accident, hernia repairs and back trouble. She had insurance coverage through her job, which at the time was with the state Division of Correction, but it left a balance of almost $1,000 for her to pay. Richardson, who lives by herself in a modest apartment complex just east of the city, started hearing from a collections lawyer for Hopkins last fall and tried to work out a payment schedule with him, but she couldn't make it work.
"I just didn't have the money," she said. "I said to the lawyer, I might be able to pay an amount monthly, but when it came time, I just didn't have it. What can you do when you're caught between a rock and a hard place? I prioritize. I'm going to try to pay my rent first, pay for gas and electric, cellphone costs. And I've got to eat."
The court judgment was finally entered against Richardson in Baltimore City District Court in January: $923.21, plus $34 in court costs and $138.49 in attorney's fees. The notice of wage garnishment went out on March 6 — the day after Maryland Gov. Larry Hogan announced the state's first three coronavirus cases. The garnishment was confirmed by Richardson's new employer, the nonprofit drug treatment organization Gaudenzia, on March 16, the day that Hogan decreed the closure of all bars, restaurants, gyms and movie theaters, and three days after Richardson and her colleagues were barred by safety precautions from providing counseling inside prisons. She now works at a small treatment center that houses seven women, where social distancing is easier.
Johns Hopkins, by far the largest private-sector employer in the state and the largest beneficiary of billionaire Michael Bloomberg's charitable giving, has long faced scrutiny for its aggressive collection of medical debt, including from the many low-income Baltimore residents it serves, who in theory should be able to qualify for the hospital's charity care programs. In 2008, The Baltimore Sun reported that Hopkins and other Maryland nonprofit hospitals had filed more than 32,000 debt-collection suits over the past five years, winning at least $100 million in judgments. Last May, a coalition that includes the AFL-CIO and National Nurses United, which has been trying to organize Hopkins nurses, released a report finding that Hopkins had launched 2,400 lawsuits in Maryland courts since 2009 against patients with unpaid bills, increasing from 20 in 2009 to a peak of 535 in 2016.
In response to the 2019 report, Hopkins officials said they offered considerable free and discounted services, and that "for patients who choose not to pursue those options or who have a demonstrated ability to pay, we will make every effort to reach out to them and to accommodate their schedule and needs. In those rare occasions when a patient who has the ability to pay chooses not to, we follow our state required policies to pursue reimbursement from these patients."
The cases have slowed in pace but not stopped altogether since the report. Bayview, one of several hospitals under the Hopkins umbrella, has filed about 60 cases over the past year, according to Maryland court records. Dozens of them, including Richardson's, remain open.
Kim Hoppe, vice president for communications for Johns Hopkins Medicine, said in a statement that after looking into the matter, the medical system has become aware of nine garnishments that went into effect in February and March, and that it has now placed a "hold" on them. "Johns Hopkins remains committed to providing affordable access to all patients in need of our care, regardless of ability to pay," Hoppe said. "We also make numerous efforts to communicate with patients who have overdue bills. Typically, patients receive more than a dozen contacts via mail or phone call along with multiple opportunities to file for medical or financial hardship. At all points in that process, patients are encouraged to speak with financial counselors; their bills will be forgiven if they can show financial hardship or inability to pay."
Politicians have touted debt relief, but the various proposals are patchwork. Many homeowners and renters won't get much help; those struggling with credit card, car and other loan payments will get none.
For Cheri Long, aggressive medical debt collection came with less warning than it did for Richardson. Long, a nurse at an assisted living center in northern West Virginia, had stopped by a Dollar General on March 23 to pick up some groceries for her kids and some requests for residents at the center: prunes, caramel candies and adult diapers. When she went to pay with her debit card, the machine told her she had insufficient funds. She checked the account after leaving the store and found there had been a debit for about $900. She assumed her account had been hacked and the funds would be restored. In fact, the bank told her, her account had a hold on it from the magistrate court.
She told the bank she had not received any notification. But that night, a card was waiting in her mailbox alerting her that there was a certified letter waiting for her at the post office. She picked the letter up the next day and rushed to the magistrate court, and she learned that the account had been garnished by West Virginia University Hospitals, the official name for J.W. Ruby Memorial Hospital, the large nonprofit academic medical center in Morgantown that is the flagship of the WVU Medicine system.
The bills were for care received by her husband, Seth — after a motorcycle accident seven years ago and after a visit for alcohol rehab after he had started drinking heavily upon losing his coal mining job three years ago. He had insurance coverage at the time of both hospital stays, even supplemental motorcycle insurance, but the coverage had left a balance of about $3,500. Seth had gotten work at another mine but lost it again two years ago, leaving the family relying on Cheri's income, about $3,000 per month in take-home pay. "Times are hard," she said in an interview. "That [medical bill] was my last priority. I didn't think they would do anything over $3,500."
The bank garnishment sent her into a panic. She was in tears at the courthouse, pleading for someone to help her. She eventually filed for an "affidavit for exemption" through the sheriff, seemingly got the garnishment lifted temporarily and changed her direct deposit to another account to be on the safe side. But when she went for groceries again on April 3, her card was declined. Her account had been zeroed out again despite the exemption, apparently due to a bureaucratic oversight.
She borrowed money for groceries and gas from her co-workers, nursing aides who make minimum wage. Her father-in-law offered to cover the house payment. And, on Easter Sunday, she started writing emails — to the governor, to the attorney general. "It was a very depressing time," she said later. "I'm out working, busting my butt, and they're going to take my money."
At last, she got help. The National Consumer Law Center put her in touch with a local legal aid lawyer, Jennifer Wagner with Mountain State Justice. Wagner filed a lawsuit on behalf of Long, arguing that it was unconstitutional to seize her property when the closure of the court system undermined her ability to seek due process.
On April 15, Preston County Judge Steven L. Shaffer issued an emergency order halting seizure of both Long's bank account and her imminent stimulus funds, thereby restoring the money already taken. "Seizure of personal property during the court closure and stay at home order and related state of emergency ... violates due process of law," he wrote in the order, first reported by the Times West Virginian newspaper.
In a statement, WVU Medicine spokeswoman Angela Knopf said that the system gave guidance to its third-party collection vendors in March to be mindful of the economic impact of the pandemic crisis in seeking repayment, but it did not order them to hold back entirely. "At WVU Medicine, we need to balance our need to liquidate patient balances with the needs of our community, especially during times of disruption," read the guidance. "Collection calls and letters can continue. However, please take a soft approach to calls and express the compassion that WVU Medicine has for our community during this difficult time. We do not want to beat our patients up as they are sequestered in their homes, compounding the stress of the current situation. We want to be a partner in helping them through this." The guidance instructed vendors not to file any new lawsuits for "at least the next 60 days," but it does not explicitly address the garnishing of accounts from cases launched before the crisis.
Wagner, the legal aid lawyer, said she is getting calls from more than a dozen other people in the area facing collection from the hospital and is considering filing a class-action lawsuit over the garnishments. "We're contemplating seeking broader relief because of our concerns that they haven't stopped, notwithstanding the order," she said. "It's actually going to dissuade people from seeking medical care during a time when it's really important to seek medical care, and that is really alarming."
Governors have issued orders temporarily banning wage and bank garnishments in several states, including in Illinois, Massachusetts and Washington. The Texas Supreme Court has decreed that any new garnishment orders not be served until after May 7. Governors or state attorneys general have taken the more limited step of barring the seizure of stimulus checks during bank account garnishments in some other states, among them California, New York and Ohio. But this leaves several dozen states where medical debt collection can still carry forward, with or without the ability to seize stimulus checks in the process.
Meanwhile, though, another Memphis hospital, Baptist Memorial, has kept up aggressive collection during the economic crisis. The Shelby County court system lists about 20 garnishments for Baptist Memorial debts initiated last month alone, some of them for debts going back more than a decade.
In Memphis, Methodist Le Bonheur Healthcare has brought 8,300 lawsuits for unpaid medical bills in just five years.
One of the Baptist Memorial targets found out that she was about to have her paycheck garnished for a 13-year-old debt when she received a letter in the mail from a lawyer seeking to represent her in the matter. "It's just been very hard," said the woman, who asked that her name not be used. "I had offered a settlement, but they wouldn't work with me. They're playing hardball."
A Baptist Memorial spokeswoman said in a written response, "These are not new cases; these judgments were made months ago. You're looking at renewals that were filed in January — well before the first known COVID case was diagnosed in the U.S. If any of these people lost their jobs, we would stop trying to collect. If they have other financial issues, they can contact us and we'll work with them. We have modified payment plans for hundreds of patients since the COVID pandemic began."
Critics of the hospital debt collection say they are aware that hospitals may be more sympathetic creditors at the current moment, when they are strapped by the demands of treating victims of the pandemic, while losing much of their usual business. Johns Hopkins, for one, announced this week that it was running a $100 million deficit, due largely to a dropoff in the elective medical procedures that provide much of its revenue base.
But the National Consumer Law Center notes that hospitals nationwide are receiving $100 billion in the federal relief packages to help recover some of the costs of the crisis. And Cecilia Behgam, an AFL-CIO researcher who helped produce the 2019 report on Hopkins, notes that collection on unpaid bills makes up just a tiny sliver of hospital revenue — for a giant institution like Hopkins, typically less than one-tenth of a percent. "This is not making a significant difference in the budget of these hospitals," she said.
Behgam also noted that in cities such as Baltimore and Memphis, the lawsuits and garnishments are being brought mostly against exactly the demographic that has been shown to be most vulnerable in the pandemic: lower-income African Americans with underlying health conditions. "These are people who are already disproportionately feeling the impact of the epidemic," she said.
In Baltimore, Darcel Richardson says she has so far managed to talk the managers of her apartment complex into letting her pay the outstanding balance of her rent once the garnishments stop. They might even be willing to cancel the usual fees for late payment, she said. "I am a firm believer in trusting God," she said. "He'll meet my needs. So far, he's still kept the roof over my head."
When a 27-year-old critical care nurse volunteered for Santa Clara Valley Medical Center’s COVID-19 unit last month, she knew that caring for patients with failing lungs and an untreatable disease would be frightening and heartbreaking. What she didn’t expect was to be shunned by fearful workers in other departments, surrounded by uncollected trash and forced to use up health benefits on a technicality.
She had graduated from nursing school in 2017 and worked for a year at an urban hospital in the Midwest. Last fall, she joined the staff of Santa Clara Valley, a public hospital in San Jose, California. She had barely acclimated to her new job before patients began testing positive for COVID-19 in February.
Santa Clara County had several of the earliest confirmed cases of COVID-19 in California, including what are now the first two known coronavirus-related deaths in the U.S. More than 1,900 people in the county have tested positive and 94 have died, according to the Johns Hopkins University COVID-19 dashboard. As of Wednesday, 52 employees at Santa Clara Valley had tested positive, according to the hospital.
In a written statement, Santa Clara Valley acknowledged its health care workers have been under significant strain during the pandemic.
“Protecting our healthcare workers and our patients, including our patients’ privacy, is our highest priority,” the hospital said. “We understand this is a very stressful time for our staff, particularly those who are on the front line caring for patients. We truly appreciate and care deeply about all of our healthcare workers and all of our patients and remain committed to doing everything possible to ensure everyone is supported and safe.”
The nurse spoke with ProPublica reporter Ryan Gabrielson at least twice a week throughout late March and April, describing her experience. She requested anonymity for fear of online harassment or career repercussions. The following is an edited transcript.
Santa Clara Roulette
With few volunteers for the hazardous duty, staffing of the COVID-19 unit is left to the luck of the draw.
“When the COVID-19 unit opened in early March, we opened it in one day. It’s a pandemic and no one had time to really prepare. We didn’t have a process for how to select who goes there to work.
Assignments are normally based on rank. It’s union policy. The nurses working as per diem, as extra help, they don’t get health benefits but they get paid a ton per shift. So they’re the ones who have to float on whatever units the nursing office needs them on. Per diem people were being forced to float almost every single shift to the COVID unit.
It got to be too much for one of them. He just started yelling at the charge nurse. They were both under so much stress and really angry at each other. She didn’t want to change things after she had already planned it out. And he didn’t want to go again to the COVID unit. It wasn’t fair for him to go so much when some staff nurses didn’t have to.
There were days where no one volunteered to go, and after that argument, the charge nurses didn’t force it anymore, because it was unfair. They asked if there were any volunteers, and no one wanted to. The medical ICU nurses, we agreed to change the process, to be fairer.
It was 10 minutes before the shift started and the charge nurse had to choose someone to go. And you have to do it quickly because no one likes to lose time. You want to be ahead of your work, because it’s a super stressful job anyway.
We came up with something on the spot. It was kind of funny. We have these patient belongings bags, they got one of those. The nurses wrote their names on pieces of paper and put them in the bag, and the charge nurse just drew a name. Whoever got picked got up to go to the unit.
One day last week, they were going to start drawing names again, so I told them: ‘I volunteer. I’ll go.’
I live with just one other person, my boyfriend, who’s also isolating. I’m fairly young and healthy. He’s fairly young and healthy. I’m extremely cautious; my first degree was in microbiology, so I bleach everything. I felt like I was in a better position to not get sick or, if I got sick, to recover faster.
Plus, there’s too much uncertainty with this virus going around. I’d rather have a patient I know is positive.”
In its written statement, Santa Clara Valley said nurse assignments to the COVID-19 unit are rarely left to chance, except when choosing between two “floaters,” or nurses who move from one unit to another. “For the COVID-19 unit, the hospital does ask for volunteers first because there may be nurses who want to work on that specific unit, but if there are no volunteers, then the float log will be used,” it said. “The only time there may be a situation of picking names from a bag is the unusual occurrence where there are two people with the exact same float date and no volunteers.”
A Reason Not to Be Tested
When the nurse felt ill, she got herself checked for COVID-19. But policies were changing on the fly.
“There’s a lot of paranoia going around, and I was really worried a couple weeks ago because I was sick with sort of atypical symptoms.
I insisted on getting swabbed. Then I had to call in sick until I got my results. It was a whole thing; it took a very long time and I lost all of my sick leave during that wait.
The policy was changing really frequently that week, it was the middle of March and it was chaotic for everyone. Originally they told us if we are tested we’ll be put on paid administrative leave. I got tested on Wednesday and I called my nurse manager and the employee health department. They said different things. My manager said I’d go on paid admin leave. Employee health said it was up to the manager’s discretion, but we’re supposed to use our sick leave unless we were exposed.
I was working in the COVID ICU, I was exposed every day.
Turns out, the hospital changed policy the next day and said if you’re using PPE, you’re not considered exposed, which is unfair because we’re reusing PPE in a way it’s not meant to be reused.
On Friday, I got a call from my nurse manager saying that since I wasn’t technically exposed, I didn’t meet the criteria to be swabbed or tested. She couldn’t put me on paid admin leave, it was denied by the hospital. It was all coming out of my sick leave.
I asked her: ‘Can I go back to work then? I’m afebrile, my symptoms have resolved and it looks like a cold that was really bad for one day.’ She said, ‘Sure.’ It was 3 in the afternoon. At 6:30, employee health called and said I can’t go back to work until I get my results.
I remember specifically saying, ‘If I don’t qualify to be tested, then why can’t I go back to work?’ She said, ‘Because it’s policy, you’ve been tested, now you can’t return.’
I didn’t get my results until Sunday. They were negative, and I finally got to go back to work that day.
This is encouraging people not to be tested because we don’t want to lose all of our sick leave. They’re not intentionally doing that, but that’s definitely an outcome. What if we fall sick later during this pandemic? Since this all happened, the hospital started giving nurses 80 hours of paid leave while we wait for test results.
It’s kind of disappointing, to find out that you weren’t positive and you might still get sick and be hospitalized and go through what your patients are going through.”
Santa Clara Valley confirmed that employees with symptoms are not allowed to work until the hospital has received test results and that it now provides 80 hours of emergency paid sick leave for all COVID-19 related absences. “We currently have expanded and rapid testing capacity where results are returned in much shorter time frames,” the hospital said.
Contingency Plans
Constantly exposed to the virus, she prepared for the worst.
“A lot of people that I work with are sleeping in separate rooms from their partners. They’re getting undressed in their garage after finishing a shift so they don’t bring dirty scrubs inside. One of my friends has a 2-year-old daughter that she sent to live with her parents weeks ago, because she doesn’t want to get her daughter sick.
When we started seeing COVID patients in the community, my boyfriend and I discussed what we would do if we get sick.
I said, ‘Hey, I’m going to be working in the COVID unit, we’re both going to have to isolate.’
I might get more sick than someone who just has, like, a passing meeting with someone who’s COVID positive. I’m exposed to a much higher viral load, so it could hit me all at once.
If I start feeling sick, I’ll limit contact with my boyfriend as much as possible. We are lucky we have an extra room in our house, not the norm for most people in the Bay Area. I would sleep in the spare room and use the spare bathroom. He would leave food for me outside the door, on the hallway floor.
We don’t go out anywhere, we can’t get our own groceries, we’re pretty much under the impression that we’re infectious all the time, just in case. We drive around to get fresh air and wait to go out on walks when it’s raining so that we don’t run into other people.
My boyfriend’s parents and his grandfather both live pretty close to us and normally they’d come over frequently. All three of them are high risk, from age and comorbidities. They haven’t been in our house for a month, he hasn’t been to their house or hugged them or anything.
They bring food to our house when they take walks and wave to us from outside. We have conversations through the door.
My boyfriend’s very concerned, he doesn’t want us to get sick at the same time. If that happens, he won’t ask his parents for help, and obviously I won’t ask my parents for help. So if both of us are really, really sick, but not sick enough to go to the hospital, we will be stuck taking care of each other.
We’ll be alone.”
A Mystery Disease
The nurses had never seen anything quite like COVID-19 before.
“We get some patients that are really, really stable. Then we get some patients where, you look at them, and you’re not sure how they’re still alive after a week.
Many of our sickest patients are relatively young. It’s kind of freaking out some of my co-workers.
There’s no clear reason why COVID made these guys so sick. They don’t really have much of a medical history, apart from maybe having an infection a week before they got sick. An infection lowers your immune system, and maybe it makes you more susceptible to a very severe COVID infection.
Some of them smoke, that’s the only other thing. Not all of them, and they weren’t chain smokers.
One guy, his chest X-ray looks better than others on the unit, but he’s not doing well. He still fights the ventilators if we pause the vecuronium [a drug that relaxes the skeletal muscles], for even a little bit of time.
Another patient arrived at the emergency department in full-blown hypoxic respiratory failure, there wasn’t enough oxygen going into his brain and the neurons started to die. You normally want to have a blood-oxygen saturation of 92 to 100. His was far lower. Which is, like, how are you alive? I’ve never had a patient that bad before.
I’m worried he won’t make it. Even if he survives, he’s probably going to need a lung transplant. What I’ve seen on his chest X-rays, it doesn’t look like there’s any function. He’s still breathing, still getting oxygen. But listening to his lungs, it sounds like a dishwasher, you just hear water.”
New Responsibilities
With other workers scared of even indirect contact with COVID-19 patients, nurses have taken on cleaning jobs.
“Auxiliary staff in the hospital are starting to avoid our COVID unit. Environmental services, the custodians, they don’t want to go in the patient rooms. Some nurses agreed to clean everything to help protect the rest of the hospital from exposure. Now we take out our own trash. I get really frustrated sometimes. It’s one thing for the nurses to do it to be nice, but we’re not getting any bonuses. They won’t empty the sharps container for needles and other dangerous medical waste. They’ll just give us one and tell us to put it on the ground in the room. Now we have trash all over the floor until we get a chance to sweep it up. Our nurse manager offered to take out the unit’s trash for us, which was really nice. She comes into the unit and talks to us in person.
A few days ago, the plumbers refused to go into a room when the toilet backed up. We literally gave a nurse a plunger and told him to go unplug it. And he did, because he had no other choice.
I’m sorry, if someone tells me that I need to unclog the toilet, I will lose it. I will absolutely lose my mind. We’re an ICU, we had someone code last night.
There was a custodial worker today who refused to clean another room that was empty and had been empty for over 12 hours. It’s like any hospital room, you don’t know what’s living in there. We have C-diff patients all the time and it’s not like you want to get C-diff either. That’s a spore that’s very hard to kill. There’s so much misinformation about COVID. People are scared and it gives the unit a stigma.
A pharmacy technician told us that she’s not comfortable going into the COVID unit and refilling our pyxis, the med dispensing machines. It is in a completely different location. It is not in a patient room. She wore an N95 just to go into the unit and restock our machine when all of us around her were not wearing N95s. In the hallway we’re wearing our surgical masks. And I know that she’s probably going to take it off the minute she goes out of our unit, and there’s no point, she used it for five minutes.
Maybe they’re living with someone who has asthma or is immunocompromised or something. Not everyone can self-isolate. We get desensitized to the danger. I need to keep that in mind.
We’re getting more and more exposure. We’re seeing other units getting things that we’re not getting. All donations go through the command center, so we don’t know what we’ll get or when.
They’re saying it’s a safety argument. When I asked if I could earmark donations specifically for our unit, they said that I could try to do that, but if they’re needed in other places the resources have to go there.
We still have PPE, but we have no idea how much we have left, everything is under lock and key. They keep telling us not to worry about it, but they also start locking up more and more things. We seem to be running out of gloves, those are now being locked up. I’ve heard we’re running out of disposable stethoscopes, so we’re going to have to start bleaching our own stethoscopes. The N95s, the face masks and CAPR shields have already been locked up for weeks now.
We don’t know where the future is going here. And I think that’s more stressful to us.”
Santa Clara Valley said that it currently has “sufficient” PPE. “The hospital needs to monitor and control the usage to ensure that PPE is appropriately used,” it said.
“To minimize the number of people who enter the patient room, nurses do collect trash, linen, and sharp containers and hand to housekeeping staff outside the room,” the hospital said.
The Turn of Death
COVID patients have to be flipped onto their stomachs to keep their lungs open, but some don’t survive it.
“Our COVID patients have ARDS (Acute Respiratory Distress Syndrome), so we pronate them, we put them face down. It helps lungs stay open because the only thing that would compress them is the spine. When you’re on your back, all of your internal organs compress your lungs.
We’d never pronated before and we practiced on one of the nurses. We figured out how to do it safely.
But as you can imagine, it’s kind of hard to do that in an ICU when someone is intubated and has a bunch of IV lines. They’re knocked out when they have really bad ARDS, paralyzed and sedated. They’re dead weight and very heavy. It takes, like, six people. Two RT’s (respiratory therapists) to deal with the tube, two nurses, two doctors. All those people to flip the patient over and we do it every six or eight hours. We have to turn their heads every two hours. Otherwise it’ll cause pressure injuries to the face, corneal abrasions, really bad damage to the eyes.
In our ICU we talk about the turn of death. There are patients who are really unstable and you just turn them a little and they code. Our nurse manager is buying beds specially made to help pronate patients, which is gonna be a lot of help. She’s very protective of her nurses.
We are full on the COVID unit. We found out last shift that a negative pressure room didn’t have negative pressure. It’s supposed to be a specially designed patient room that keeps air inside the room so staff and patients in the rest of the unit won’t be contaminated. The hospital was cautious and set up every COVID room that way, which is a luxury other places don’t have.
But things go wrong, machines break. The patient in that room was intubated and might have had treatments that aerosolized the virus and would have spread it throughout the whole unit yesterday. Nobody knew, so no one was wearing their N95s in the hallway.
We told everyone to put on their N95s and moved the patient into a working room. Not a big deal, but now we have one less room available for other COVID-positive patients.
We actually check the negative pressure every shift. It’s very archaic: We used a syringe like the ones that take snot out of kids’ noses. We filled it with charcoal powder and squeezed it in front of each room and saw which way the powder went.
The weird thing is we have an alarm if the pressure isn’t right. If someone leaves the room doors open, that alarm will go off. So the fact that the alarm didn’t go off is kind of worrying. How long had the room not been working properly? The high-tech thing is supposed to tell us.”
A Disturbing Report
On April 10, the Los Angeles Times revealed a complaint by an anonymous Santa Clara Valley Medical Center employee that hospital administrators had not informed staff of a potential outbreak among nurses. It was news to her.
“I was so worried. The nurses work on a medical-surgery unit on the same floor as the ICU. It’s not that close, technically, because we don’t give patients to them. Hospital admin sent an email to us saying they’re doing their best. And if you have any concerns, you should talk to us first, instead of going to national media.”
Burnout
After a month, she left the COVID-19 unit.
“The last few days working COVID, I’ve been so stressed out, I’ve been missing things. There are a ton of travel nurses. They aren’t staff but fill in. Some don’t know how to chart in our system, documenting the patient’s condition and medications. It’s hard to feel sure things were done right with all the travel nurses, and I feel like I’m far too new to catch everything. I think they are training those travel nurses so we can rely on them if there is like a peak in hospitalizations. Luckily, it kind of looks like we’ve already had our peak.
There was a patient I had all of last week on COVID. After I left, his condition dipped. That’s what we see with a lot of the patients. They’ll go in, they’ll be OK on the ventilator for a week. And then suddenly they’ll start tanking. You have to put them on vecuronium, increase the air pressure to expand their lungs. It’s a crucial phase, maybe they’re gonna make it, maybe they won’t.
Afterwards, I stopped volunteering for the COVID unit. So last night (April 14), I was back in the medical ICU, my regular floor. And it’s just business as usual over there, apart from the fact that we have, like, no patients. The other patients aren’t coming to the hospital, maybe out of fear.
It’s weird, on the regular medical ICU, the lack of pandemic conversations. They talk about the nice stuff that happens now, the recognition that health care workers are getting because we’re getting a lot of it. This morning, all of the county police departments and the fire departments, they all lined up outside of the hospital to welcome the day shift.
There’s less concern about the whole pandemic away from the COVID unit. I never thought that work would be the one place where I wouldn’t hear about this constantly.
I missed the COVID unit a little last night, because every time a patient coughed or someone touched my workstation, I felt like I had to bleach it down and protect myself. Even if I’m not in the COVID unit, anyone could have it.”
Eight nurses are the majority of employees who remain at Oklahoma's Haskell County Community Hospital. The future of the 25-bed hospital is increasingly grim.
This article was first published on Thursday, April 23, 2020 in ProPublica.
By Brianna Bailey
Eight nurses at the lone hospital in the rural Oklahoma town of Stigler now double as the cleaning crew. They stabilize patients with life-threatening conditions, mop floors and scrub toilets.
The nurses, along with an office manager and a part-time maintenance worker, are the only remaining employees at the Haskell County Community Hospital, which two years ago had a staff of 68 and provided some of the highest-paying jobs in the southeastern Oklahoma town.
Andrea Randall, a nurse who also serves as the hospital's interim administrator, has watched it claw through years of financial turmoil in the decade since she started working. None, she said, have been as difficult as the past two years.
And now, the novel coronavirus is threatening to scuttle a sale that would help the bankrupt hospital escape closure.
Before the Haskell County hospital entered bankruptcy in 2019, many employees went weeks without pay. In October, about 85% of the staff was laid off to save money and entice buyers at a bankruptcy auction.
For the past several months, the hospital's remaining employees have performed housekeeping duties and avoided taking time off when they've been sick. The facility barely has enough employees to comply with state and federal laws, which require the emergency room to be staffed with at least two nurses and an on-call physician.
"We know we can't do this forever," Randall said in an interview. She's been praying for a new owner to take over and "help bring us back to life."
But the future of the 25-bed hospital, which has been whittled down to operating only an emergency room during the bankruptcy, is increasingly grim.
In January, Haskell Regional Hospital Inc., a company controlled by a spine surgeon from Indiana, submitted the sole bid of $200,000 at a bankruptcy auction to purchase the hospital. The sale was to be finalized in March.
William Janvier, an attorney for the company, told a bankruptcy court at a March hearing that the coronavirus' damage to the economy upended the proposed investment. The company had enough money to buy the hospital but couldn't afford to operate it, Janvier said.
"Our expected source of operating capital has obviously gotten very concerned because of the events that have been going on," Janvier said. He asked for more time to gather the needed money. "We are very hopeful that we will be able to close on the deal, but we're not there yet."
Hospital closures in the nearby towns of Eufaulaand Wilburtonin the past four years have made access to health care more urgent in Stigler, a community of about 2,700 people. The closest hospital is now an hour away, a distance that could be life-threatening for residents experiencing a stroke or a heart attack.
The Haskell hospital is one of many Oklahoma rural medical centers trying to remain open under financial conditions that can feel insurmountable and suffocating for the communities trying to save them.
Nearly 130 rural hospitals have closed across the country in the past decade while contending with razor-thin margins caused by a declining and aging patient pool, a greater dependence on lower reimbursement rates from the federal government and higher numbers of uninsured patients. Last year, rural hospitals suffered their largest blow with 19 closures, according todata from the Cecil G. Sheps Center for Health Services Research.
Nine rural hospitals have already shut their doors in 2020. The Maine-based Chartis Center for Rural Health released a study in February identifying about 450 rural hospitals that are vulnerable to closures. The coronavirus threatens to speed up those closures, said Michael Topchik, a national leader for the company.
In Oklahoma, rural hospitals are navigating the higher costs of treating COVID-19 cases while suffering a loss of revenue after being forced to halt elective medical procedures. More than 60% of the 2,894 COVID-19 cases in the state and 70% of the 170 deaths come from communities outside of Oklahoma City and Tulsa.
"We've essentially shut our business down," said Jay Johnson, chairman of the Oklahoma Hospital Association. "The only way we're all surviving is on whatever cash we had."
The Haskell County hospital had already reduced medical services, including elective procedures, by the time the coronavirus began reaching rural communities across the country. Nurses perform some laboratory tests and stabilize patients before transferring them to better-equipped facilities about 50 miles away.
But the number of patients still declined. Before the coronavirus pandemic, the Haskell County emergency room treated three to four patients daily. That number has dwindled to two or three patients a day in the past month.
Some days the hospital has no patients at all.
Waiting on the Promise of a Sale
By the time the Haskell County hospital entered bankruptcy in 2019, it was about $6 million in debt. It operated at a loss of more than $193,000 that year. The hospital still owes money to the employees who worked up to six weeks without pay to keep it open.
"I was so angry and I was so bitter over all of it," Darla Barger, a former human resources manager, said in an interview with The Frontier and ProPublica. "I finally just had to let it go for my own mental health."
The Haskell County hospital is one of 18 facilities owned or connected with EmpowerHMS, a private management company, that entered bankruptcy or closed in the past five years. Many of the hospitals experienced financial problems after insurance companies flagged ballooning laboratory costs as fraud. The U.S. Department of Justice is investigating the company, which allegedly took advantage of higher reimbursement rates designated for rural communities by billing for blood and urine tests that the hospitals did not perform.
Representatives for the now-defunct company could not be reached for comment. In court filings, the company denied wrongdoing, saying it followed federal guidelines.
Three of the former EmpowerHMS hospitals that sold at auction are still waiting for buyers to finalize the deals. Several companies received extensions after failing to come up with the money.
The company purchasing the Haskell hospital is the only one that pointed to the coronavirus as the reason for the delay.
Thomas Waldrep, the trustee overseeing the Haskell sale, said in court documents on April 8 that the buyer was waiting to secure federal stimulus money to help finance the purchase.
Waldrep said in an email that he didn't know what type of stimulus funding the Haskell buyer was seeking.
Oklahoma hospitals this month received nearly $500 million as part of a $30 billion federal rescue package to help health care providers with the loss of revenue from the coronavirus pandemic.
This month, Waldrep said he expected the sale of the Haskell hospital to be completed by the end of the month.
But as of Tuesday, Waldrep, who would only answer questions via email, could not provide a specific date of sale. If the deal fails, Waldrep would have to find a new buyer or close the hospital and use any remaining money and assets to pay off debts.
Brent King, a bankruptcy trustee who in 2019 oversaw the successful sale of another former EmpowerHMS hospital in Hillsboro, Kansas, said it's a challenge to find buyers even without the threat of an ongoing global pandemic.
Eight rural hospitals, previously operated by EmpowerHMS, have already closed. King says he expects more will soon suffer the same fate.
"We can only be hopeful that those hospitals can stay open but, bottom line, I suspect some of them won't," King said.
"I Have to Believe That We Have a Future Here"
A sale doesn't guarantee financial stability for the Haskell County hospital, which will need an infusion of money to reopen parts of the facility and hire additional employees.
But it would provide some sense of stability for its remaining employees.
"I have to believe that we have a future here and we have to just keep moving as if it's going to happen," Randall said.
Barry Smith, CEO of Cohesive Healthcare Management and Consulting, which has been running the Haskell hospital during the bankruptcy, said revenue from the emergency room is not enough to sustain operations.
The temporary fix that came in October 2019 was meant only to save money and meet the minimum state and federal requirements to remain open while a sale was completed, Smith said.
If the hospital closed during the bankruptcy, it would lose its critical access status, a federal designation that qualifies remote communities like Haskell County to receive higher Medicare payments than many other facilities. The hospital could also struggle to reopen under current building code requirements.
"Every day that they don't come in makes it harder," Smith said.
Smith initially said that if a sale of the hospital wasn't finalized by mid-April, financial losses would force the company to walk away. He later reversed course, saying the company understood the uncertainty caused by the coronavirus and would not place deadlines on its commitment to the hospital.
Court documents filed in March say Cohesive is owed $3.3 million for 2019, about half of which is management fees. The remaining amount owed is for other expenses paid by the company, including payroll and health benefits for employees.
"We can maintain the status quo for a while," Smith said in a text. "Hopefully, much sooner than later, a long-term solution is found for the hospital."
For Randall, maintaining the status quo means wrestling with the possibility of closure while juggling duties that include cleaning out the ice machine, planning for an influx of patients with COVID-19 and contending with new costs, including fixing the hospital's leaky roof.
But Randall said she'll keep working, as she did when the hospital stopped paying her salary and when nearly all of the staff was laid off.
"If you don't show up for work, people are going to die," Randall said.
Help us investigate: Do you live near or work with rural hospitals in Oklahoma? ProPublica and The Frontier want to connect with you to learn about your experiences.
Email us at OKhospitals@propublica.org or text us at (949) 439-4855 and one of our reporters will follow-up with you.
While cutting benefits for ER doctors and other medical workers, TeamHealth and Envision have spent millions on ads to pressure politicians working on legislation to cap out-of-network costs for Americans.
This article was first published on Monday, April 20, 2020 in ProPublica.
Private equity-backed medical staffing companies that have cut doctors' pay are continuing to spend millions on political ads, according to Federal Communications Commission disclosures.
The ads amount to $2.2 million since Health and Human Services Secretary Alex Azar declared a public health emergency on Jan. 31. About $1.2 million has been spent since President Donald Trump's national emergency declaration on March 13, the disclosures show.
The companies behind the ads, TeamHealth and Envision Healthcare, are among the staffing firms that havecut pay and benefits for emergency room doctors and other medical workers. The companies say the cuts are needed to cope with falling income because non-coronavirus patients are avoiding hospitals. Executives at TeamHealth and Envision also took pay cuts.
"Our attention will be focused on our clinicians so they can provide care for patients who need it," Envision CEO Jim Rechtin said in a statement this month.
But Envision and TeamHealth have continued to pour money into a joint political ad campaign. Their TV and radio spots are aimed at pressuring lawmakers working to address "surprise billing," where patients get stuck with huge medical costs from out-of-network providers they had no say in choosing. The ads oppose capping out-of-network costs based on median prices in the area.
The air time was bought through Doctor Patient Unity, an advocacy group funded by staffing firms TeamHealth and Envision. TeamHealth, which has more than 16,000 clinicians, is owned by Blackstone, and KKR owns Envision, with more than 25,000 medical providers.
Doctor Patient Unity has spent $57 million on ads since its campaign started last June, making it the largest political advertiser other than presidential campaigns, according to Advertising Analytics, an ad-tracking firm.
Doctor Patient Unity stood by its campaign and vowed to continue fighting against legislation that the group says would hurt doctors. "It was a misguided proposal before COVID-19 – it's reckless in this current environment," spokesman Greg Blair said in a statement. "While the big insurance companies continue to report massive earnings amid an unprecedented economic downturn, we remain committed to defending our doctors and clinicians as they fight COVID-19 on the frontlines."
TeamHealth and Envision declined to comment beyond Blair's statement. Blackstone and KKR didn't respond to requests for comment.
The spending totals don't include digital ads, which aren't reported to the FCC. Facebook's own disclosures show several thousand dollars more on recent ads invoking the coronavirus pandemic to make their case. Some of the ads name individual lawmakers and target their constituents.
"Doctors are stepping up to face the coronavirus crisis," an ad from April said. "During this crisis, Congress needs to ensure they have the resources they need to continue saving lives."
A professional group representing ER doctors asked Azar to provide $3.6 billion of aid to emergency physician practices. The professional group's president who signed the request is an executive at Envision.
Sen. Elizabeth Warren, D-Mass., and Rep. Katie Porter, D-Calif., called on the companies' private equity backers to reverse the pay cuts, citing ProPublica's earlier reporting. "As business leaders who direct and manage billions of dollars, you should be stepping up to protect the financial security of frontline essential workers," Porter and Warren said in an April 15 letter. "They are putting themselves at risk every single day to provide for those fighting COVID-19, and to put them at risk of financial harm during this time is unacceptable."
Lawmakers have spent months hammering out a deal on surprise billing that balances the interests of patients, doctors and insurers. House and Senate committee chairs and ranking members struck a bipartisan compromise but weren't able to get it included in the December spending deal or the March coronavirus stimulus package.
The ads from Doctor Patient Unity oppose that bill because it would settle out-of-network bills according to median costs in the area, an approach that the ads attack as "government rate setting." The ads urge viewers to call their representatives to thank them for opposing the proposal or urge them to oppose it.
Companies that employ emergency room medical personnel, many owned by private equity firms, say they are reeling from vanishing demand for non-coronavirus care. But critics worry that bailout money would be a windfall for rich investors.
Blair, the group's spokesman, said the legislation would "impose a 20% pay cut on our medical professionals, risking hospital closures and making it harder for patients to get the critical care they need." The 20% figure, Blair said, is based on a Congressional Budget Office report from July. But the CBO report does not predict a 20% drop across to board; rather, it says the proposal to pay out-of-network bills based on local median rates would push the average (mean) rate to converge on the median, a difference of 15% to 20% nationwide.
"Under current law, the distribution of payment rates across all providers is highly skewed — some command rates that are well above the median," the CBO analysts wrote. "Although the national average rate may drop by such an amount, the effects within a given market for any particular insurer and for specific providers will be quite different, with payment rates rising in some cases and falling in others."
An advocacy group representing health insurers, who are at odds with the staffing firms over the proposed legislation, called Doctor Patient Unity's ads misleading. "At a time when they are cutting back benefits and pay for their own employees, they prefer to invest more resources in running a disingenuous ad campaign about their support for doctors," the Coalition Against Surprise Medical Billing said in a statement to ProPublica. "Give us a break. Millions of patients are at risk of receiving a bankrupting surprise medical bill because these companies and out-of-network providers continue to exploit the market."
Envision has said it won't send surprise bills to COVID-19 patients, so patients will be responsible only for in-network copays. TeamHealth said it won't bill patients above what insurers pay (known as "balance billing").
"They've always just been worried more about the bottom line than being appreciative of their people," said an Envision doctor whose pay was cut and who spoke on the condition of anonymity because the company has prohibited employees from speaking publicly. "Physicians don't feel like they're being heard and respected for what they do, but we still show up and take care of patients. This is part of what's breaking the system down."
We spoke to frontline experts from around the globe and have compiled a list of recommendations for reopening U.S. states. Their consensus? It’s tough to find policies that simultaneously save lives and livelihoods.
This article was first published on Saturday, April 18, 2020 in ProPublica.
After insisting that he had absolute power to decide when to reopen the American economy, President Donald Trump has turned over to all of you what he initially called “the biggest decision I’ve ever had to make.”
Trump is often guilty of hyperbole, but he’s right in this case. Figuring out how and when to let people go back to work during an outbreak of life-threatening disease is the most consequential decision any of you will ever face. You’ve already seen the stakes in New York, New Jersey and Michigan. Get this wrong and thousands of people in your state will die. As the presidential election campaign heats up, count on the president to blast you for high unemployment rates in your state (you lifted restrictions too slowly) or clusters of deaths (you went too far, too soon).
To help you and your aides think about this decision over the next few weeks, we’ve interviewed experts and frontline officials from Italy, Germany, Spain, Singapore, Taiwan and South Korea. While they differ on the details, their views formed a startlingly united consensus of what’s needed:
Massive, ongoing testing to detect where the disease is spreading,
a real-time ability to trace contacts of those infected and isolate them,
a willingness of people to wear masks in crowded public spaces,
reserves of personal protective equipment (PPE) and other equipment for hospital workers to handle any surge in cases,
and reliable, easily administered blood tests to find out the number of people who have been infected. If they work well, such tests could eventually be used to identify people with immunity who could work at higher-risk jobs.
We also asked American experts whether states can meet all or most of these benchmarks. Their answers coalesced around a single point: None of you are close to being ready.
There were differences among the people we interviewed about tactics and strategy. Some saw promise in the smartphone-based tools that would allow disease detectives to quickly find people with whom an infected person was in close contact. Others doubted that a critical mass of Americans would ever let the government track their movements, whatever promises were made about privacy.
One theme emerged again and again. Experts from across the world said it’s crucial to correctly interpret the recent drop in the rate of hospitalizations and deaths reported by New York City, ground zero for the epidemic. This result was achieved only by a month of slamming the brakes on the economy and banning the most basic interactions (and pleasures) of human society.
The bad news, they said, is that everything we’ve been through so far has merely allowed us to reset the clock to mid-January, when the virus was already seeded in many parts of America and we were on the cusp of the biggest public health crisis in a century. Allow people to return to offices, streets, malls and mass transit without a well-thought-out plan, and you stand a substantial chance of triggering a second wave of infections.
Reopening is essential to save the economy, they said, but don’t kid yourself: The new normal will look nothing like the old normal. Until there’s a vaccine or a reliable treatment, you and your states will be living and working very differently, constantly at risk from a wave of disease that could overwhelm your hospitals. You may borrow ideas from Asia and Europe that would have been unimaginable a few months ago: Isolating infected people from their families in hotels, requiring masks for everyone on a bus or subway, ordering restaurants to seat people at every other table, limiting certain jobs to people who have proven immunity to the virus.
“We have to all acknowledge that we will have to live with Corona for at least a year and probably two or three years,” said Dr. Ansgar Lohse, a professor at University Medical Center in Hamburg and co-author of a paper that sets out a “flexible, risk-adjusted strategy” for reopening commerce in Germany.
“All of our societies will have to adapt to this challenge, and this will be different in different societies,” Lohse said in an interview. “Even in a country like Germany, we will have to regionally and locally and also probably seasonally adapt to this tragedy.”
America’s continuing inability to roll out widespread testing means you’re flying blind on the most pivotal questions. How many people in your state have already had the virus? The percentage is almost certainly in single digits, but there may be pockets in which more significant numbers of people have been exposed and have immunity.
You can assume that upwards of 90% of your state remains vulnerable to infection from a single sneeze or cough by someone standing or sitting near them. A single highly contagious person in a crowded space can start a chain of disease that quickly encompasses dozens if not hundreds of people.
“It’s like after a forest fire,” said Jerome Kim, director general of the International Vaccine Institute in Seoul. “There are still embers and warm spots on the ground. If you drop a gallon of gas on top of that, the fire will restart.”
1. Build an Army of Contact Tracers
Without exception, every expert we talked to stressed the imperative of being able to know exactly where the virus is spreading. That sounds incredibly obvious and basic, but comes with demanding logistics that few — if any — states are able to carry out right now.
By now, we know that the virus has been relentlessly effective at spreading itself through a population because people are highly contagious in the first few days of their illness, often before they start to experience symptoms. The only way to track the spread of the virus, then, is to maintain a massive army of “contact tracers” who can track down the contacts of anyone who tests positive.
Places that have been most successful in slowing the spread of the virus, such as Hong Kong, South Korea and Singapore (at least initially), have been relentless in tracking down the contacts of every infected person, testing them and then instructing people who aren’t infected to self-isolate and monitor their own symptoms.
“It usually takes four or five people over three days to do one full contact trace, on average,” said Andy Slavitt, former head of the Centers for Medicare and Medicaid Services during the Obama administration. California, which has a population of 40 million people, could need anywhere from “several thousand to 20,000” contact tracers, depending on the number of cases and how fast the virus is spreading, Slavitt said.
Wuhan, China, a city of 11 million, employed more than 9,000 contact tracers, split into 1,800 teams of five. In Shenzhen, a city just across the border from Hong Kong in southeastern China, contact tracers had identified 2,842 close contacts of coronavirus patients and found that 88 were infected, as of mid-February, according to a World Health Organization report. That’s only 3%. But imagine what would have happened if all 88 had continued wandering around the city for the next several weeks.
Technology has been used by some countries to supplement the detailed human interviews. In South Korea, the government swept up everyone’s cellphone and credit card information and used it to identify anyone who came physically close to an infected person.
Kim, the director general of the International Vaccine Institute in Seoul, is a former officer in the U.S. Army’s Medical Corps who has lived in Seoul for five years. He said the South Korean government has combined 21st-century technology and old-fashioned shoe leather to trace contacts.
The initial outbreak of the virus was brought into the country by members of a church that had a branch in Wuhan, where the epidemic began in December. Soon, Korean authorities noticed that new cases were being seeded by international travelers, so they instituted a system in which people arriving from certain countries were met at the gate, tested and told to begin quarantine. A tracking app was put on their phones and over the next two weeks, they were asked to provide daily reports on their health. Authorities made at least one in-person visit to make sure they were healthy and following the rules.
Korean law gives health officials access to anyone’s credit card purchases and cellphone location data during an outbreak, allowing disease trackers to identify and alert anyone who crossed paths with an infected person.
Here in the U.S., our legal framework and historic commitments to civil liberties preclude us from doing anything like this. Apple and Google are adding features to the operating systems of their smartphones so that they will create an encrypted record of every other phone you encounter. The system, which would require users to opt in, will use the Bluetooth technology that connects phones to cars, wireless headphones or speakers. People who test positive for COVID-19 can enter that information into their phone, and any users in recent contact with them will be alerted. It’s hard to say how many people would ultimately agree to participate, but if it’s less than a large percentage of the population, as is likely, the app probably won’t be of enormous use.
Our reporting suggests that few major cities or states are yet prepared to do contact tracing at scale. New York City’s health department did not respond to a request for comment on the question of how many disease detectives it employs, but The Daily News reported last month that the city was hoping to triple the number from 50 to 150. The New York State Department of Health wouldn’t say how many contact tracers it currently has, noting that it is “actively working on a plan to greatly expand capacity at local and state levels to perform contact tracing.” Massachusetts has said it is hiring and training 1,000 workers.
Given the number of line cooks, waiters, airline flight attendants, mall employees and factory workers who are now unemployed, you might consider creating a contact tracing version of the WPA, the Depression-era employment program that bolstered society with projects like public roads, buildings, parks and art. Given that all of you are required to balance your budgets every year, paying the salaries of all these new public health workers is going to have to come out of your already-strapped budgets.
2. Be Prepared to Test Constantly
We know you’re sick of hearing about it, but our experts agreed that the inability to do widespread testing for the virus is the central reason it has spread so widely in the U.S.
As you look toward reopening, testing is going to be just as important. There are two types of tests, and you’ll need both of them at a massive scale.
You’re already familiar with the first test, the one used to diagnose an active infection. While more and more have become available, there are still nowhere near enough. If you go to a system of contact tracing as described above, you’re going to need to test every single close contact of every infected person, not just those who are showing symptoms.
In Italy, much has been made of the contrast between how the epidemic unfolded in Lombardy, a region of about 10 million, and neighboring Veneto, which has almost 5 million. Lombardy was the hottest of Italy’s hotspots, accounting for about 11,581 of the country’s estimated 22,745 deaths. Veneto, by contrast, has had only about 1,026 deaths, reflecting a very different approach to testing and tracing. Relatively early, authorities locked down the town of Vo Euganeo and began widespread testing of everyone, regardless of whether they had symptoms of the virus. The suspicion, later proven correct, was that asymptomatic carriers were spreading the disease. Carriers and their close contacts were isolated for 10 to 15 days.
Different numbers have been thrown around for what sort of diagnostic test capacity the U.S. would need to fully reopen. Dr. Scott Gottlieb, the former commissioner of the U.S. Food and Drug Administration under Trump, has suggested testing everyone who visits a doctor, which would mean about 3.8 million tests per week. Slavitt, the former CMS administrator under Obama, calls for 10 million tests a week.
We are nowhere near that capacity right now (we’re currently at about 1 million a week, according to the COVID Tracking Project), due to shortages in the supply chain for all aspects of testing.
It’s not just a lack of test kits, but also chemicals needed to run the tests, called reagents, collection tubes, swabs and other equipment like pipettes, explained Scott Becker, chief executive officer of the Association of Public Health Laboratories. “Many labs aren’t just running one instrument with one extraction platform and one kit, they’re using multiple, because it’s like whack-a-mole. When you run out of reagents for this one, you switch to that one,” Becker said.
One of the key indicators that you are testing widely enough is the rate at which people test positive. If a significant percentage of tests keep finding COVID-19, it means you’re likely still reserving tests for people with obvious symptoms and likely missing those who are asymptomatic.
“If you’re at 15%, 20%, then you’re not testing enough,” according to Dr. Farzad Mostashari, former National Coordinator for Health IT for the U.S. Department of Health and Human Services.
Mostashari says a 5% positive rate would be appropriate as one metric for reopening, but he cautioned: “You have to be testing the right population. You can’t be like, I’m only testing asymptomatic basketball players and the positivity rate is less than 5%. It has to be everyone, including people coming in with cough and fever, and you still have that low positivity rate.”
A second test just coming online could be a game changer. It’s a blood test that measures whether you’ve been exposed to the disease and developed antibodies against it.
With many diseases, like chickenpox, the presence of antibodies means you’re immune and can’t get the disease a second time. Here’s the issue, and it’s not a trivial one: This novel coronavirus is such a new organism, we don’t yet know if the antibodies from the first infection protect you against a second one. Furthermore, with the FDA rushing to green-light tests and lowering the bar for validation, it’s unclear how accurate many of these diagnostics are.
Let’s say the accuracy of these tests is ultimately validated by scientists and it is established that a certain level of antibodies guarantees immunity, at least for a while. It would then be possible to give people a quick blood test that would allow them to return immediately to work.
One thing to keep in mind: While the models differ on specific numbers, all agree that coronavirus has so far infected just a small percentage of the more than 320 million people in America. Hundreds of millions of people nationwide, and the vast majority of your state’s citizens, still have no defense against this disease. This will be true until a vaccine is widely available, which probably won’t happen for more than a year, if we’re lucky.
3. Isolate People With Suspected Infections From Their Families
This is a really tough one. It goes against everything your constituents treasure in our family-centered society. That said, what we’ve learned in Italy, Taiwan and now our country is sobering.
In New York, health authorities’ initial approach to someone with a fever and dry cough was to send them home to “self-isolate” in a single room for 14 days. (There weren’t enough tests to confirm diagnoses in these cases.)
In many cases, the result was disastrous. The disease spread to the entire family, sometimes sickening multiple generations.
It turns out that the average American, when asked to turn a room of their home or apartment into a sealed zone, falls well short of perfection.
Yes, the person being quarantined is told to spend every waking (and nonwaking) hour behind closed doors, eat food left on a tray outside their door, and use a separate bathroom. But that goes against a lot of fundamental facts of life. Some people share single-room apartments. Many don’t have two bathrooms. And not everyone is meticulous about wiping down door handles or wearing gloves and masks when they wash dishes. The result, visible in city after city, has been horrifying stories about first one parent, then a second parent, then the children ending up dead or ill from sequential infections.
Separating people from their families for 14 days is a very tough thing to do. It would be massively unpopular. But if you look at what worked and didn’t in Taiwan, Italy and Singapore, you can see why this is so essential.
Sergio Romagnani, an immunologist at the University of Florence, said the traditional, multigenerational closeness of Italian families played a role in spreading the disease. “In Italy, there is a lot more mixing of young people and elderly relatives,” he said. “Kids have a lot of contact with their grandparents, and in this case that caused deaths.”
Romagnani noted that authorities in Tuscany had begun putting infected people in hotels, which would ordinarily be filled with people visiting one of the world’s most beautiful tourist destinations. “It’s a good idea,” he said. “The hotels make some money since they are all closed. And you have isolation, which is necessary.”
Dr. C. Jason Wang, director of Stanford University’s Center for Policy, Outcomes and Prevention, said Taiwan has been a leader in isolating infected people from their families. The government pays hotel owners as much as $200 a night to house people under quarantine, providing three meals a day, a book to read and a stipend roughly equivalent to a young person’s daily salary. Anyone caught breaking quarantine faces a massive fine.
Wang said Taiwan learned from the 2003 outbreak of SARS, when people who were forced to isolate thought they were being jailed, and ran away. “We learned that when you put people in quarantine, you need to be very nice to them.” Now, patients are checked by health workers three times a day. “If a person gets sick, their symptoms worsen, they will make sure they get care,” he said.
While in the U.S., it may be impossible to force people to isolate away from their homes, “I think you can say, ‘Hey, wouldn’t you like to protect your family, and we prepared a nice room at the Hilton for two weeks for you, and you don’t need to pay for it.’ and you know, hopefully people will,” said Slavitt, who is now hosting a new podcast about the pandemic, “In the Bubble.”
Slavitt added that to pull this off, the federal government would need to provide funding to help pay for hotels.
Here’s some incentive for you: Xihong Lin, a Harvard biostatistician, and colleagues in China found that when the outbreak began in Wuhan, the average person was infecting 3.86 other people. When the city closed businesses and imposed the sorts of social distancing measures that we now have in New York and California, the number of people infected by each person dropped to 1.26, which is good, but not good enough. (You need to get below 1 to get things under control and even consider restarting the economy.) When China got really tough, locking down every resident, isolating suspected cases in dorms and hotels and vigorously tracing contacts, it dropped to 0.32. Here’s Lin’s webinar on the group’s findings, if you’re curious to learn more.
4. Protect, Protect, Protect Health Care Workers
If we are lucky enough to get the infection rate below epidemic levels in New York and elsewhere, there are still going to be people who get infected.
One of the lessons from Wuhan and Italy is that you have to be utterly meticulous about protecting doctors and nurses. If you don’t, the hospitals become a vector for infection and you lose the frontline people you need to treat the sick.
There’s another problem with not protecting your doctors and nurses: If you need them to handle a second wave of infections, even a smaller one, they may stop coming to work. Many are showing up right now out of a sense of duty and mission. But none of these people signed up for their profession with the idea that they would be risking their lives on a minute-by-minute basis. These are not combat infantry troops, and if they don’t believe they have appropriate personal protective equipment, there’s every reason to believe that some of them will simply quit.
While the Chinese have revised their numbers more than once, leading to some hesitation over how much we can trust their reporting, there are still lessons we can learn from their experience. As of late February, the joint WHO-China mission reported 2,055 cases of COVID-19 among health care workers, the vast majority, 88 percent, were at hospitals in Hubei province where the outbreak began. It appears that after the initial disaster in Wuhan, in which a doctor who raised the alarm died, the hospitals figured out what they needed to do to protect their medical workers.
This story describes how Johns Hopkins doctors consulted with Chinese colleagues about best practices. Wuhan hospitals, after being hit with a wave of deaths and infections, asked staff members to check that each other’s gear was being used correctly. They worked four-hour shifts to prevent fatigue. A committee helped support the children and elderly parents of the health care workers.
The past few weeks have already inflicted a powerful psychological blow on your state’s health care workers. To bolster their morale and keep them at work, you need to make a commitment to protecting their health. That means stockpiling an enormous supply of gowns, N95 masks, gloves and goggles. This is not optional. If you don’t have enough equipment set aside, don’t even think about restarting the economy. Lose the trained health care workers and it’s game over.
Obviously, this stockpile should also include ventilators, oxygen, the drugs needed for intubation and all the other stuff that should have been waiting in reserve back in January when we had our first bite at this apple. But you know that already.
5. Normal Is Not the Goal
One question we asked the experts we interviewed is: What would it take to put 5.4 million people back on the New York City subway every day? Invariably, they all said: masks.
Masks, especially when we’re talking about home-made ones, are not going to be perfect at preventing infection, but they can help reduce transmission. “Face masks are the only option in situations where social distancing can not be practiced,” said Lohse, from University Medical Center in Hamburg.
In Madrid, police handed out masks for riders on public transit as Spain announced a partial return to work in certain sectors of the economy, including heavy industry and construction, on April 13.
“We would probably go with Austria in forcing the population to wear masks more widely, maybe in retail outlets, maybe in factories,” said Gabriel Felbermayr, president of the Kiel Institute for the World Economy and economic advisor for Chancellor Angela Merkel’s government, talking about what Germany’s plans for reopening its own society.
“We should have learned right away from the Asian experience, that was a huge mistake,” said Romagnani, in Florence. “But in the beginning, our authorities actually told people not to wear masks. They said, ‘Masks don’t do anything.’ Well, they were saying that because they didn’t have enough masks. They feared a stampede to buy them. They worried about price-gouging.”
In the United States, our surgeon general initially did much the same thing, tweeting on Feb. 29 that masks are “NOT effective in preventing general public from catching #Coronavirus.” This week, Gov. Andrew Cuomo ordered New York residents to wear face coverings in public whenever social distancing is not possible.
The international experts’ responses were a reminder that your goal isn’t to get back to a pre-pandemic way of life, but instead to employ whatever tools it takes to keep transmission as low as possible while restarting your economy. Things like masks, temperature checks and maintaining a six-foot distance are new concepts for the U.S., and many of your constituents are going to find them weird, uncomfortable and unappealing. It’s worth your time helping them understand why these measures are so necessary, because you’ll save lives.
One aspect of returning to normal is certain to arise in the coming months: Do you reopen schools? Early reports that COVID-19 can endanger only older people with other serious health problems have been demolished as the virus spread across the globe. The numbers are tiny, but infants, toddlers and teenagers have died from this disease. School closings, of course, were seen as a way of protecting older people, the assumption being that kids with mild or asymptomatic cases would infect their teachers, parents or grandparents.
Taiwan is one of a handful of countries in the entire world that have kept their schools open. In February, it adopted rules that require closing any school for 14 days if two or more cases are detected.
Singapore’s Dr. Li Yang Hsu, said reopening schools is a plausible step. Hsu noted that countries tracing the “index,” or initial case, in a disease cluster have found few instances that trace to school-age children, “which is unusual for a respiratory virus.”
Hsu, program leader of infectious diseases at the National University of Singapore’s Saw Swee Hock School of Public Health, said in an email that recent studies “seem to suggest that the impact of school closures is far less compared to other physical distancing measures. Therefore, provided nothing changes, the general conditions,” for resuming school “would be similar to that of reopening mass transit and other services.”
6. Keep Your Eyes Peeled for the Second Wave
The initial success stories in fighting COVID-19 — Singapore, Hong Kong, South Korea — all saw a rise in cases in March. Nearly all of these involved travelers who brought the infection from other countries and came into contact with locals. Remember, even once you get the number of new cases caused by each infected person below 1, you still have a population largely composed of people with no immunity, so you have to maintain constant vigilance to keep the rate low.
We’re going to need a national system of the sort we should have had in the first place. Epidemiologists call it sentinel surveillance, and what it used to mean was that we would watch out for people with flu-like symptoms for signs of a new pandemic-type illness like H1N1.
Even though we knew the coronavirus was coming, and even though epidemiology experts wanted to start sentinel surveillance in major cities like Seattle, New York and San Francisco by early February, it never happened because the CDC bungled the design of the tests. Your state will need to get this right. Not only do we need to be testing constantly, but we should also be using all the tools we can to pick up any suspicious patterns of flu-like illness, whether that’s Google searches or heightened temperatures on web-linked thermometers, besides the traditional surveillance apparatus that public health departments already have.
Here’s the tough reality for people hoping to go back to the old normal and, say, sit in a stadium and watch Tom Brady try to defy Father Time as a Tampa Bay Buccaneer: There are some things — no, there are a lot of things — in which the crowds are too large and tightly packed to be safe. NASCAR races? Baseball stadiums packed with 50,000 people? NBA playoffs? Ballet? Broadway? Hard to imagine putting that many people close together without a vaccine or unimpeachable proof that people have antibodies that make them immune. (You’d still have to find an impossible-to-counterfeit, non-transferrable form of ID so that only fans with antibodies would be admitted to large events. Good luck figuring out how to do that.)
It’s sad to say this, but until there’s a way to verify immunity, or a vaccine, you can’t allow visitors back into nursing homes. The elderly are just too vulnerable, and we’ve seen over and over how the virus just tears through those settings.
You should keep an eye on Wuhan. The extra hospitals are closed, the extra 40,000 health care workers have gone home, and the city is slowly going back to work. If there’s no second wave in Wuhan, this might just work out. On the other hand, if the virus kicks up again despite everything they’ve done and are doing, hitting that restart button becomes a lot more complicated.
7. Clear Communication Is Critical
There are an array of political skills that get you elected governor in America. Some of you built reputations as nuts-and-bolts technocrats, good at getting things done but not given to stirring oratory. Others have a gift for explaining complicated issues in ways that can move ordinary people to action. Several of you have run for president.
One thing that came through in many of our interviews around the world was the importance of communicating clearly and consistently about the actions you take. China was able to take draconian steps to contain the Wuhan outbreak because it is a single-party state with virtually unlimited powers.
You will need comparable levels of commitment from your citizenry, but will have to achieve it through persuasion rather than coercion.
Manuel Gimenez, the minister of Economy and Employment for the regional government of Madrid, said that Spanish leaders were able to articulate reasons for one of the strictest lockdowns in the world in a country where congregating in cafes, restaurants and large family groups is an ingrained cultural tradition.
For more than 45 days, Gimenez said, his 3-year-old and 8-month-old have not left his family’s 650-square-foot apartment, adhering to rules that require all children to remain indoors. Adults are permitted to go only to the nearest grocery store or pharmacy; exercising outdoors or walks for leisure are prohibited, and police have been enforcing the rules aggressively. Although at first there were complaints about people crowding parks and driving en masse to summer homes, over all the response has been remarkably disciplined.
“What the Spanish government has done is send a series of messages preparing citizens for each phase of the response and the restrictive measures. This isn’t China,” said Miquel Porta, an epidemiologist at the Hospital del Mar in Barcelona. “In Spain, we had to communicate, accustom people to the idea of a lockdown, and create consensus. You can’t do what a dictatorship can do. The idea was disseminated that we are not staying home for ourselves. We are doing it for our fellow citizens.”
“The Spanish people have reacted well with great solidarity and even humor,” Porta said. “People shopping for the elderly, people singing on balconies. The media and the people have approved of the fact that scientists are telling them there is a certain amount of uncertainty and lack of knowledge in this crisis. Nobody is clear on how this is going to evolve.”
Stanford’s Wang said Taiwan learned this lesson in the wake of the country’s widely criticized response to SARS, a coronavirus that flared in Asia in 2003 but was ultimately brought under control and did not become a global pandemic.
“In a democracy, we need to build trust and confidence so that when you say something to people, they’ll trust you and do what you say,” said Wang. “The communications part is critical and that’s what Taiwan did after SARS.”
As governors, you’re going to have to persuade voters to do things they won’t like at a moment of unparalleled partisan rancor, record unemployment, disarray in your state’s traditional media outlets and divisions among eminent scientists. Inevitably, you’re going to be using imperfect data to strike a balance between the possible loss of lives and the certain loss of jobs that keep food on the table of your state’s citizens. Remember when you thought battling the legislature and balancing the budget was hard?
This is much, much harder, and the clashing messages from the national level complicate things even more. The good news is that you have a better feel for your state’s character and quirks than any federal bureaucrat and are best equipped to figure out what your citizens can tolerate. Trump was right about one thing. These are the biggest decisions you’ll ever make. Good luck.
As the coronavirus spreads, hitting health care providers especially hard, doctors and nurses across the country report inadequate protective measures from their hospitals. Some feel they’ve been forced out of work — right when the country needs them most.
This article was first published on Saturday, April 18, 2020 in ProPublica.
On March 31, Florida emergency room nurse Naomi Moya took a big risk. Though her hospital didn’t allow staff to wear N95 masks when treating patients who were not diagnosed with the coronavirus, Moya brought one from home and put it on to protect herself.
A supervisor noticed the N95 right away and ordered her to remove it.
“I have my own supply,” Moya recalled saying. “It’s protection for me and you and my coworkers and the community and my family when I come home.”
The impasse was polite, but both sides held firm. Thus, at the height of a pandemic, when there’s a shortage of nurses, Moya stepped away. She and the hospital agreed that she would go on unpaid leave.
Clinicians across the country are weighing similar choices when their hospitals lack the protective gear they believe they need to care for patients. A New Jersey doctor said she left her urgent care position because of safety concerns. “This is an unstable situation with a novel coronavirus with a company that could be protective but is not being adequately protective,” she said.
In North Carolina, Angela Allen said she watched warily as the coronavirus spread, waiting for her hospital to do something to protect the staff. Administrators considered the psychiatric unit where she works as a nurse “low risk,” Allen said. By mid-March, she said she asked for the staff to be tested for the coronavirus, so they could also be sure to avoid infecting the patients, and her manager said that wasn’t necessary. “If we can’t rule out that we are carriers then we have to assume that we are,” Allen said. “And if you’re not giving us the right equipment to at least protect our patients, then I can’t do my job.”
Allen said she didn’t quit but took a leave of absence and hasn’t been back since March 19.
ProPublica spoke to 15 doctors and nurses from New Jersey to California to North and South Carolina who said their administrators have normalized poor infection control practices — putting them at risk and likely spreading the virus. A study published Tuesdayby the Centers for Disease Control and Prevention found that health care workers are getting infected at high rates, which also makes them a source of transmission.
ProPublica and others have reported on staff who were suspended or fired for bringing their own gowns and masks and other protective equipment, or speaking up about it. But clinicians are saying there’s an even deeper problem. The conditions are so unsafe they’re being forced to choose between their livelihoods and risking their lives — and that means some are walking away.
Moya works at AdventHealth Heart of Florida, a 193-bed facility in Davenport, near Orlando.
AdventHealth did not respond to ProPublica’s questions about Moya. But it said in a statement that it does not have a shortage of N95 masks or other gear. Its statement said staff are not allowed to wear masks unless they are issued by the hospital, to ensure they are medical-grade and properly fitted. The N95 masks are provided to staff who care for suspected or known COVID-19 patients, the statement said.
Lowering Infection Control Standards
In the upside-down world of American health care in the era of coronavirus, a nurse in an N95 is often considered both safe and defiant.
But the policy doesn’t account for the spread of disease by people who have not yet tested positive or who aren’t showing symptoms, Moya knew.
“We know the disease process,” Moya said. “I don’t know who may be infected or not.”
The United States was caught so unprepared for the pandemic that hospitals don’t have enough N95 masks and other important gear. So facilities have been lowering their infection control standards — and demanding compliance from staffers.
Moya had been prepared. She purchased her own N95 masks, and on that final day of March she put one on under the surgical mask AdventHealth had given her.
When she was told to remove it, she got called to the office of the emergency department director, she said, who told her if she wore the N95 other staff would also want one. Also, the hospital didn’t want patients to feel scared by seeing everyone in a mask, Moya recalled the director saying.
Moya is known for her calm demeanor, according to a nurse who works with her. She speaks English, Spanish and American Sign Language and is nonplussed by even the most aggressive patients.
The problem isn’t just a lack of supplies, Moya and other clinicians who spoke to ProPublica said. The administrators are not acknowledging the hazards, causing a breakdown of trust.
“They know this is real and that people are dying,” Moya said of her administration. “Would you send a firefighter into a burning building without appropriate gear?”
The Joint Commission, which establishes quality and safety standards for hospitals, accredits AdventHealth. It put out a statement on March 31 — the same day Moya went on leave — supporting clinicians bringing their own face masks, including N95s, to work. “It is better to allow staff the opportunity to enhance their protection, even if the degree of that increased protection is uncertain,” the statement said.
Moya said she went on unpaid leave at great cost, having to defer her mortgage and car payments. She wants to return to her job. AdventHealth is a large organization that operates in nine states. It should be aware of the Joint Commission’s recommendations, she said. It’s also a Christian organization that pledges to “extend the healing ministry of Christ,” she said. So it should do better at the command to “love thy neighbor,” she said, when it comes to protecting its staff and patients.
Clinicians Getting Silenced
Most of the clinicians who spoke to ProPublica would not speak on the record because they feared retaliation. They said their administrators have been changing policies to try and adapt to the pandemic. But the rules are often not consistent with what’s known about the virus.
A nurse in northern New Jersey said her hospital is reassigning staff to units for which they may not have adequate training. One supervisor suggested that refusing an assignment could result in a complaint against the nurse’s license, the nurse said. “My problem is they feel like they own us or something,” the nurse said.
Kate McLaughlin, a nurse who runs the advocacy organization NJ Safe Ratios, said she has heard of hospitals threatening to file complaints against nurses’ licenses if they quit or refuse to take assignments they consider unsafe. The intimidation “will make nurses reconsider whether they should come back to the bedside,” she said.
The widespread nature of retaliation against health care workers who complain about the lack of personal protective equipment led to the creation of Beacon, a nonprofit advocacy organization in Massachusetts. Dr. Sejal Hathi, a co-founder of the group and a resident at Massachusetts General Hospital, said Beacon sent a letter Thursday to hospitals that had suspended or fired workers, demanding fair treatment and threatening legal action if they didn’t respect the rights of their staff. Health care workers are being forced to choose “between professional duty and personal safety,” Hathi said. “Those are competing ethical and existential obligations.”
Allen, the North Carolina nurse, works in a unit that’s part of the emergency room at Mission Hospital in Asheville. She has launched a website, The Unmasked RN, to give voice to nurses around the country who believe they are being muzzled. “We have executives making medical and scientific decisions without consulting the people who went to school for this,” she said.
April Creamer, a behavioral health technician who works with Allen, said she is also thinking about leaving Mission Health because of the conditions. She’s been told the hospital has N95 masks, but the management doesn’t think they’re necessary in the psychiatric unit, she said. “For a while they were not providing us with any protection,” Creamer said. “They were ignoring the fact that COVID is a real thing.”
Mission Health spokeswoman Nancy Lindell said in a statement that “all our departments are appropriately equipped with hygiene supplies for both our staff and patients.” She did not address the specific concerns raised by Allen and Creamer.
Many hospital executives say publicly they have the gear to keep their staff safe. But then their workers say they are not getting what they need.
Mark O’Halla, president and CEO of Prisma Health in South Carolina, gave a reassuring message in an April 8 video. “We have plenty of personal protective equipment to cover all of our employees and team members across the system,” he said.
But two Prisma Health nurses who spoke to ProPublica said that has not been the case. Both the nurses said they have not been given N95 masks for use throughout their shifts and that staff have not been allowed to bring them from home. They said nurses have resigned because of the lack of protective equipment. Others were sent home with threats that they would be fired. Still others are looking for other jobs, the nurses said.
Prisma Health told ProPublica in a statement that it “is able to provide the appropriate personal protective equipment for treating suspected or confirmed COVID-19 patients.” Prisma has “sufficient stock of surgical masks” which are “deemed appropriate for COVID-19 patient contact excluding aerosol generating procedures,” the statement said.
Rick Boothman, who retired as chief risk officer for the University of Michigan Health System in 2018, said the coronavirus crisis is cracking open the fissures that sometimes exist between hospital administrators and clinicians. Health care providers are remarkably resilient, he said, and that’s allowed administrators to be too cavalier with them. “It’s unethical and immoral to shove somebody into harm’s way when that’s not what they signed up for,” Boothman said.
The administrators should be up front with the clinicians and tell them that they’re sorry, but the resources are limited and the challenge is at the doorstep, Boothman said. The leaders should tell the staff that they see that the safety situation is not optimal, he said, but that nobody will be pushed into an avoidably dangerous situation. Such an approach would build trust and be well received by doctors and nurses, he said.
“I think you’d find an amazing number of people who would step up and not complain,” Boothman said.
We talked to a doctor about what hospitals in the throes of the coronavirus epidemic could learn from far less developed hospital systems in times of crisis and came away with three main points.
This article was first published on Saturday, April 11, 2020 in ProPublica.
As New York City strains under COVID-19 cases and health care workers scramble for every bit of equipment they can get, hospitals are starting to look less like part of a wealthy country’s medical system and more like the makeshift clinics in disaster zones or the developing world. In those places, experts say, doctors need to think about care differently: managing resources to best serve all the patients who will need help over the duration of a crisis, even if it means not being able to save every person to walk through the door.
Dr. Sean Runnels is an associate professor at University of Utah Health and a working anesthesiologist who manages the supply room for his department. The wave of coronavirus cases hasn’t really hit yet in Salt Lake City, but he’s been stocking up on as much equipment as he thinks will be needed for sedating patients if they need to go on ventilators. Already, Runnels says he’s noticed normal supply ordering patterns breaking down, as hospital administrators working from home try to prepare for a potential flood of COVID-19 patients.
What’s happening in cities overwhelmed with COVID-19 cases reminds him of the year he spent based in Guinea working for Mercy Ships, a nonprofit that deploys floating hospitals to African countries with little surgical capacity, and the subsequent two years he spent in Rwanda training clinicians. We talked about what American cities in the throes of the coronavirus epidemic could learn from places with far less developed hospital systems in times of crisis, and came away with three main points.
This interview has been edited and condensed for clarity.
You need more than a ventilator to save someone’s life.
I worked for three years in Africa and really came to appreciate how complex an ICU is. You’ve got the ventilators, that’s the thing that you can see. But all the little pieces have to be sourced, someone has to clean it, someone has to order the cleaning solution, someone’s got to write the protocol to train the person that cleans it. It’s this really complex ecosystem, and each of the pieces of the ecosystem are required for the thing to work. Everyone’s focused on producing more ventilators, but the real capacity is the smallest thing in that ecosystem.
I worked for Mercy Ships, and we would get donations of all sorts of stuff, but if we got a donation of an odd-sized tube that doesn’t hook to our anesthesia circuits, it’s just stuff we have to move around. That’s something I’ve taken to heart with our system. If we start sourcing from all over the place, we’ll just create more chaos. I think we’re better off trying to strengthen our normal supply chains. If we get overloaded while the chains are weak, that’s a problem.
You are only viable if your health care workers are healthy.
Running medical systems in under-resourced environments is completely different. In some sense it would be better to have the health minister for Rwanda, Agnes Binagwaho, come show us what to do, because they were very intentional about capacity. I was never allowed to walk into a room and examine a patient unless I had gloves on. If we didn’t have gloves that day, we didn’t have a clinic. They completely understood that the real risk was to get your providers sick, because they’re actually the system. The machines and drugs and everything we do, they enable all of those things to work. As soon as you take out your providers, then you end up in a death spiral. You and your mortality jumps from 1% to 10%.
If you’ve got 200 ventilators, but you only have enough personal protective equipment to keep enough providers well to take care of 100 ventilators, then that’s your capacity. If you exceed it, you end up with these horrific rates of sickness. And then you end up with morale problems, and the system works less efficiently because those teams are now broken up.
The rule No. 1 in a resource-constrained system is keep your providers healthy.
Sometimes you have to make a decision to give up on a patient for the greater good of the system. And that’s hard.
When I was in Rwanda, I ran an anesthesia department and took care of keeping the system safe for the new American providers for the first three months before they knew what they were doing. You would say: “OK, I know in America we can save this child. But [here] if we try to deliver medical care, are we just prolonging the suffering and depleting resources?” I would have people turn around and visualize the 10,000 babies that were coming in the next few years, and say, “All right, I’ve got to balance this life in front of me with the lives of those that are coming.”
The shift internally they have to go through is from that heroic archetype of the doctor-patient relationship to “my most important relationship is to my colleagues and the system because that’s what’s going to take care of these people in the future.”
I went through it in Africa. It’s an incredibly painful experience, and there’s no road map for it. The worst thing you can have to do as a doctor is going to be not do everything for the patient in front of you. And yet that’s exactly what you have to do.
Companies that employ emergency room medical personnel, many owned by private equity firms, say they are reeling from vanishing demand for non-coronavirus care. But critics worry that bailout money would be a windfall for rich investors.
This article was first published on Friday, April 10, 2020 in ProPublica.
Medical staffing companies — some of which are owned by some of the country’s richest investors and have been cutting pay for doctors on the front lines of the coronavirus pandemic — are seeking government bailout money.
Private equity firms have increasingly bought up doctors’ practices that contract with hospitals to staff emergency rooms and other departments. These staffing companies say the coronavirus pandemic is, counterintuitively, bad for business because most everyone who isn’t critically ill with COVID-19 is avoiding the ER. The companies have responded with pay cuts, reduced hours and furloughs for doctors.
Emergency room visits across the country have fallen roughly 30%, and the patients who are coming tend to be sicker and costlier to treat, the American College of Emergency Physicians said in an April 3 letter to Health and Human Services Secretary Alex Azar. The professional group asked the Trump administration to provide $3.6 billion of aid to emergency physician practices.
“Without immediate federal financial resources and support separate from what is provided to hospitals, fewer emergency physicians will be left to care for patients, a shortfall which will only be further exacerbated as they try to make preparations for the COVID-19 surge,” the organization said in the letter.
The American College of Emergency Physicians’ 38,000 members include employees of large staffing firms as well as academic medical centers and small doctor-owned practice groups. The letter was signed by the group’s president, William P. Jaquis, whose day job is as a senior vice president at Envision Healthcare, a top staffing firm owned by private equity giant KKR.
Envision, which has 27,000 clinicians, said it’s cutting doctors’ pay in areas that are seeing fewer patients, as well as delaying bonuses and profit-sharing, retirement contributions, raises and promotions. The company also cut senior executives’ salaries in half and will impose pay cuts or furloughs for nonclinical employees. However, Envision said that it’s adding doctors in hard-hit New York and other coronavirus hot spots.
“Where they lose their normal billing revenue, medical groups are losing money. Where medical groups are losing money, they have to reduce salaries and furlough workers,” Envision CEO Jim Rechtin said in a statement. “Unfortunately, we are no different.”
KKR didn’t respond to requests for comment. Co-founders Henry Kravis and George Roberts said they’ll donate $50 million to first responders and health workers, as well as forgoing bonuses and the rest of their salaries for the year, Forbes reported. Forbes estimates Kravis’ wealth at $5.6 billion and Roberts’ at $5.8 billion.
Before the pandemic, Envision made a lucrative business out of buying practice groups in specialties where patients don’t choose their provider, such as ER physicians and anesthesiologists, according to Dr. Marty Makary, a surgical oncologist at Johns Hopkins Medicine who studies health care costs. Envision could then charge patients high prices for out-of-network care, a practice known as “surprise billing.” The model was profitable until a public backlash led lawmakers to investigate the practice, according to Makary.
“Private equity consolidated large physician groups in an unprecedented financial gamble using capital and banking on revenue not skipping a beat,” Makary said. “When the investment model works, investors get rich. When the investment goes sour, who bears the risk? As in the mortgage crisis of 2008, taxpayers are bearing the risk of financial gambles of investors.”
Envision won’t send surprise bills to COVID-19 patients, the company said; patients will be responsible only for in-network copays.
Health insurance companies, which are often at odds with doctors and staffing companies over payment disputes, have said they support government aid to hospitals and doctors, but they specified that relief should go to “small and independent practices.” A lobbying group representing insurers and business groups raised concerns about the potential for investors to benefit from the emergency physicians’ request for $3.6 billion.
“We need to do everything to support health care workers on the frontlines of this pandemic, and we want to make sure they get the resources they need to care for patients and protect themselves,” the Coalition Against Surprise Medical Billing said in a statement to ProPublica. “At the same time, federal funds should not be used to bail out private equity firms during a public health emergency, especially when there are no federal surprise billing protections in place to protect consumers at their most vulnerable.”
The top lobbyist for the American College of Emergency Physicians, Laura Wooster, warned that efforts to single out companies with rich backers could catch patients in the crossfire. “If you start trying to parse big or small, independent or not, it’s going to get messy really quickly,” Wooster said in an interview. “This isn’t the time to figure out too late that unintended consequences left a rural emergency department understaffed because it happened to be staffed by one of the bigger groups.”
Wooster noted that it’s not only big private equity-backed staffing firms that are hurting, and she provided data from small practice groups that are also losing business and scaling back. She said she couldn’t commit to conditions on receiving aid — such as restricting “surprise billing,” investor payouts or executive bonuses — without seeing how the terms are structured. She said the administration hasn’t offered a proposal at that level of detail nor asked for one.
Katy Talento, a health adviser to President Donald Trump from 2017 to 2019, offered a different view. “If they’re private equity-owned, I have no sympathy, and I don’t think any patient out there struggling paycheck to paycheck — if they have a paycheck — is remotely interested in the crocodile tears of private equity firms and their revenue losses,” she said. “We have to target rescue funds to the hardest-hit areas, and emergency physicians are not the hardest-hit target of our charity.”
The administration hasn’t said much about how it plans to distribute a $100 billion fund for health care providers that was part of the $2 trillion coronavirus stimulus package. Last Friday, Azar said “a portion” of the money would reimburse hospitals for caring for uninsured patients. He said providers would get paid at Medicare rates and prohibited from billing patients beyond that.
Lawmakers have spent months working on legislation to address surprise billing, attempting to accommodate the interests of patients, doctors and insurers. Medical staffing companies including Envision launched attack ads against some proposals but agreed to a provider-friendly bill advanced by Sen. Bill Cassidy, R-La. (who is a gastroenterologist). A bipartisan compromise failed to make it into the December spending deal because of a turf war between congressional committees. Lawmakers briefly considered reviving the compromise as part of the coronavirus stimulus package but didn’t want to slow down getting relief into the economy quickly, according to congressional aides.
Medical staffing companies said they have benefited from tax relief and advance Medicare payments included in the stimulus package. Still, Envision and other private equity-backed staffing firms have swiftly responded to lost income by cutting pay and hours for doctors.
One Envision anesthesiologist in the mid-Atlantic region said his base salary was cut by 30% even as he’s being asked to intubate COVID-19 patients — a procedure that puts providers at high risk of exposure to the virus.
“My hope in any type of bailout going toward health care providers is it should go to them,” said the anesthesiologist, who spoke on the condition of anonymity for fear of losing his job. “It should not be going toward rewarding executives or shareholder profits. Anybody actually coming in physical contact is taking all the risk, so that’s where the relief should be going.”
