Opinion: A critical role now for health professionals
Communicating effectively with the public and patients will be key as COVID-19 accelerates.
By Jeffrey. C. Lerner and Norbert Goldfield - AJC - December 17, 2020
As deaths in Georgia from COVID-19 continue to march towards 10,000, and cases towards a half million, there is no “political vaccine” against disinformation to accompany the coming biological one. Local health professionals throughout Georgia will have to administer both to reverse the trend.
National attention is focused on whether and how government officials, including the victors in Georgia’s Senatorial race, will work to create a political vaccine. Will they be the allies of Georgia’s health professionals in prioritizing and conveying the legitimacy of science and urgency of evidence-based medical care?
Local action is now our best hope of setting examples for following good public measures and providing guidance for protecting one another and ensuring schools and businesses operate as safely as possible until both the vaccines and better treatments help stem the rising tide of illness.
Public bodies are, increasingly, taking public stances. The American Medical Association, the American Nurses Association, and the American Hospital Association, representing healthcare professionals from both Democratic and Republican parties, are united in pleading with the public to adhere to scientific guidance by wearing masks, maintaining social distance, and washing hands frequently. But their efforts have not proved to be enough to get the needed results.
Overcoming resistance to science-based approaches will need local leaders - people who deliver the messages and provide the advice that stands a better chance of being followed by more local citizens. That’s where health professionals, especially, come in, accepting that they need to redefine what it means to provide “frontline care.” Public health is the new frontline care because it is the most effective means we currently have to spare people unnecessary illness, misery, and death.
People living in smaller cities, towns and rural areas of Georgia, as well as poorer residents in the most densely populated big cities, have an especially high proportion of residents at high risk for the worst outcomes from the virus because of obesity, diabetes, hypertension, and smoking. The issues here are more challenging than in some other areas of the state.
Sixty-eight percent of the public trust Dr. Fauci from the National Institutes of Health, and nurses are the nation’s most-trusted profession for their honesty and ethics according to a recent Gallup poll, as they have been for the last 18 years of the survey. Engineers and doctors are second and third .
While many people, including those reading this op-ed, have their own physician or health care professional that they work with for personal health, they may still need to know more about the evolving research in science behind vaccines and other public health practices. Health professionals can translate uncertainties and controversies publicly in ways outside the clinic through writing opinion pieces or speaking at community events.
The task shouldn’t be left solely to media commentators, even if they are sometimes reliable medical professionals. Local engagement is key to success. Medical terms and reasoning can be obscure to many people and need to be conveyed by trusted health professionals that people may meet in their everyday lives. This more-public role is an unaccustomed one for most professionals working in healthcare, but it is a necessity now.
Health professionals in Georgia can speak to and on behalf of their patients on issues that go beyond direct virus ones, such as measles, flu and shingles vaccinations and attention to substance abuse prevention.
Health professionals can help Georgians understand the positions of the senatorial candidates and in future local elections. For those who want to work more politically, there are organizations such as Ask Nurses and Doctors that provides guidance for responsible political expression of a broader view on health system reform.
But now is the moment for every health professional to widely distribute the “political vaccine” against unreliable health information on the frontline because it is a duty both for ourselves and our patients.
When I, Dr. Goldfield, speak to my patients about the flu vaccine, they often broaden the conversation, saying they do not want the COVID vaccine. I reassure them that I and many others will be evaluating information on the virus vaccine(s) safety. As these vaccines are made more available, they will become an important addition to masks, distancing, handwashing, and, yes, taking the flu vaccine too.
Issues of who gets earliest access to the vaccines will also be an issue, in part because much of the decision-making will rest with local entities like health systems and regional health departments. Trust in the process will be linked to who delivers and explains the rationale, and whether it is seen as reasonably fair, even if it is imperfect.
The only true way to honor the dead and sick COVID-19 victims and their families is to help stop adding to their numbers. So let’s do this together, fellow health professionals and citizens.
Wrongfully denied: Minnesotans fighting mental illness denied coverage from insurance providers
by Kirsten Swanson - Minnesota Eyewitness News - May 5, 2019
Her insurance company refused to cover the cost of the visit because Mischler only needed "hydration," according to a lawsuit filed by her family.
Max Tillitt was court-ordered into treatment for his heroin addiction. He was forced to leave residential treatment early after his insurance cut off funding, according to a class action lawsuit. Tillitt died months later from an overdose his family says could have been prevented had his insurance not been wrongfully denied.
A 5 INVESTIGATES review of medical, state and court records found that health insurance companies have repeatedly denied coverage to patients who are seeking treatment for mental health-related disorders.
While federal privacy laws make it difficult to know exactly how many patients in Minnesota have been denied coverage, the practice became so problematic at one point that it led to a landmark lawsuit by the state's then Attorney General, a multi-million dollar settlement and widespread reform that led to a drastic decrease in complaints.
Currently, attorneys say the number of patients being denied coverage is once again trending in the wrong direction. As proof that the problem is ongoing, they point to a recent class-action lawsuit in which a federal judge said a Minnesota-based insurance company's guidelines—which determine which patients receive coverage—are "fundamentally flawed" and "tainted by financial interests."
"I really question how many people are out there, not getting the help that they need," said Jeannie Uhlenkamp, Sophia's mother.
Eating disorder coverage denied
After her diagnosis, Sophia Uhlenkamp, now 14, was in and out of residential treatment for anorexia nervosa. Her mother said their health insurance provider, Blue Cross Blue Shield of Minnesota, stopped covering the more extensive type of care after six months even though Sophia was still struggling to maintain her weight.
"All of a sudden, things weren't automatically covered," Jeannie Uhlenkamp said.
In 2017, Blue Cross suggested the teen should go instead to an "intensive outpatient treatment" program.
However, the Uhlenkamps live in Redwood Falls, more than two hours from any specialist or treatment center.
In a statement to 5 INVESTIGATES, Blue Cross said its criteria "didn't account for geographic distance" in the Uhlenkamp case.
The company's decision was later overturned by the Minnesota Department of Commerce, which can review insurance denials in certain cases.
Yet just months later, when Sophia relapsed, Blue Cross again denied to cover the cost of her treatment.
"We couldn't believe it," Jeannie Uhlenkamp said.
Blue Cross said it's since changed its policies based on the Uhlenkamp's experience and is taking steps "to prevent this type of issue from reoccurring."
Another family was forced to sue their insurance provider after exhausting their appeals.
OptumHealth, a subsidiary of Minnesota-based United Healthcare, repeatedly refused to cover Brooke Mischler's eating disorder treatment, including one instance in which her symptoms were so bad that she was sent to the ER by her psychiatrist, according to court records.
"I needed that visit," Mischler said. "If I didn't, I don't think I would be here."
Yet, OptumHealth determined that Mischler was "not in immediate danger of hurting herself" and only needed "hydration," according to the lawsuit, which was later settled out of court.
Elizabeth Wrobel, who represented the Mischlers, specializes in health insurance benefit disputes and said she finds the practice of denying mental health disorders is not limited to a single company.
"It's an ongoing problem," Wrobel said.
No incentive to comply
Minnesota recognized the magnitude of the problem in the late 1990s, when the Attorney General's office began receiving a large number of health-related complaints against insurance companies.
In response, then-attorney general Mike Hatch sued Blue Cross Blue Shield of Minnesota, claiming the provider had a pattern and practice of improperly denying coverage to adolescent patients.
Hatch negotiated a settlement in 2002 in which Blue Cross paid more than $8-million and agreed to have every denied claim reviewed by an external panel within one business day.
"We then turned to Medica and Health Partners and said, 'You know, you're up next,'" Hatch said. "Complaint levels went down to zero."
The settlement is lauded by patients, advocates and attorneys as a landmark moment in the fight for mental health coverage.
However, in 2007, the deal expired and the review panel dissolved.
Today, Hatch said he believes companies have reverted back to denying coverage because "there's no incentive for them to comply."
Elizabeth Wrobel, the attorney who specializes in such cases, said, "Instead of moving forward, we're probably moving backward."
Financially 'tainted' practice puts profits over patients
Wrobel says denying coverage for mental health disorders has once again become a common practice because health insurance providers often operate on their own set of internal guidelines instead of relying on industry-adopted standards.
"So often, the guidelines don't match the disease," Wrobel said.
In March, a federal judge in California condemned United Healthcare's guidelines for being based "as much or more on its own bottom line" instead of with the interests of patients in mind.
Chief Magistrate Judge Joseph C. Spero found the company's process was "fundamentally flawed" because it was tainted by "financial interests."
In response to the ruling, United Healthcare told 5 INVESTIGATES that the issue "underscores the pressing need to establish and gain widespread adoption of clear, evidence-based treatment standards" for mental health-related disorders.
The provider also said it is "committed to ensuring our members have access" to treatment.
Deadly consequences
DeeDee Tillitt, of Eden Prairie, argues that access was not given to her son, Max, who died in 2015 of a heroin overdose after struggling with substance abuse and addiction.
Tillitt, who was a named plaintiff in the class action lawsuit, said months before his death, Max was court-ordered into treatment at Beauterre Recovery Institute in Owatonna. He made it only 20 days.
"United Healthcare cut off funding saying basically, well he hasn't used in 20 days, so he's OK to leave residential and go to outpatient," Tillitt said.
In a statement to 5 INVESTIGATES, United Healthcare said it has since changed its guidelines for substance use disorders.
Tillitt said she believes if Max could have stayed in residential treatment, he would be alive today.
"He was so motivated Tillitt said. "Max had a treatable disease. But he wasn't treated for it."
Minnesota-based health insurer ordered into court supervision for mental health coverage denials
by Kirsten Swanson - Minnesota Eyewitness News - December 18, 2020
A special court-appointed master will monitor the company over the next 10 years, the November ruling from Chief Magistrate Judge Joseph C. Spero said.
This comes after a landmark ruling in the mental health parity case. In 2019, Judge Spero found UnitedHealth Group liable for wrongfully denying coverage, stating the insurer used its own internal guidelines that were "tainted by... financial interests..." and benefited the company financially.
"I can't think of another case, another recent case, where a managed behavioral health organization was essentially found of such pervasive misconduct," said attorney Meiram Bendat of Psych Appeal, the California-based law firm leading the class-action.
Bendat called this a watershed moment that exposes a loophole in the federal mental health parity law and said that the decision should serve as a stern warning to other health insurance companies.
"UBH is not the only company that engages in these kinds of practices," he said.
In 2019, 5 INVESTIGATES found families in Minnesota fighting mental treatment denials from other insurers, according to medical, state and court records.
"I believe that any insurer looking at this case is going to be well served to re-evaluate its conduct," Bendat said.
Dee Dee Tillitt, who lives in Minneapolis, joined the class-action lawsuit as a named plaintiff after her son, Max, died of an overdose.
After being arrested in 2015, a judge ordered Max into treatment for heroin addiction. Tillitt says her son spent 20 days at Beauterre Recovery Institute in Owatonna until United Healthcare cut funding for Max's treatment.
"You don't have to be a clinician to know 20 days of in-patient is not enough to cure a three-year heroin habit," Tillitt said in a recent interview.
Tillitt said she was thrilled with the court's ruling.
"We basically got everything we were seeking," she said. "Having a special master in there watching them, they won't be able to slip back into doing the bad practices."
In a statement to 5 INVESTIGATES, a UnitedHealth Group spokesperson said the company has taken "concrete steps to improve access to quality care," that includes expanding its provider network and increasing access to telehealth.
"We are focused on ensuring our members get the quality, compassionate care they need, and will continue working closely with people across the behavioral health community on this important issue," the statement read.
Glancing at a photograph of Max on her fireplace mantle, Tillitt thinks what he would say about the ruling.
"Oh, he would love this," she said. "Max always wanted to help people. I didn't want any other family to go through what I went through."
‘Obamacare’ enrollment rising as COVID-19 pandemic deepens
The Centers for Medicaid and Medicaid Services said more than 8.2 million people had signed up through the close of open enrollment Dec. 15.
The Centers for Medicaid and Medicaid Services said more than 8.2 million people had signed up through the close of open enrollment Dec. 15.
WASHINGTON — Sign-ups for “Obamacare” health insurance plans are trending more than 6 percent higher amid surging coronavirus cases and deepening economic misery, according to preliminary figures released Friday by the government.
The Centers for Medicaid and Medicaid Services, or CMS, said more than 8.2 million people had signed up through the close of open enrollment Dec. 15 in the 36 states served by the federal HealthCare.gov website.
An apples-to-apples comparison with last year’s sign-ups translates to a 6.6 percent gain, the agency said. Unlike last year, two populous states that had used the federal website are now running their own. Numbers from New Jersey and Pennsylvania were not counted in Friday’s tally from HealthCare.gov states. They’ll be reported in coming weeks, along with those from other remaining states.
Created by former President Barack Obama’s health law, the insurance markets offer taxpayer-subsidized private plans to more than 11 million people who don’t have job-based coverage. Insurers cannot turn away customers with pre-existing medical conditions. Medicaid expansion, another component of the Affordable Care Act, covers about 12 million people.
President Trump failed to repeal “Obamacare” his first year in office, an early defeat he never forgot. Although Trump has been trying to convince a skeptical Supreme Court to overturn the law in its entirety, his administration took credit Friday for what officials called a successful enrollment season.
“We’ve opened more pathways to enroll by taking advantage of private sector and people are clearly finding the coverage they need at this critical time,” CMS Administrator Seema Verma said in a statement. Nonetheless, the Trump administration ignored calls to provide a special sign-up period related to the pandemic, something President-elect Joe Biden has said he will do.
Former Obama administration officials who keep a close eye on the health law celebrated.
“This is the largest increase in HealthCare.gov enrollment since 2016 and it’s the only increase during the Trump administration,” said Joshua Peck, who once served as marketing chief for the program. It’s “a testament to the role the ACA is playing in creating a strong safety net.”
Some states that run their own enrollment campaigns are also reporting stronger numbers. Maryland said this week it signed up more than 166,000 people, a record.
Final numbers for HealthCare.gov, expected soon, will include people who started their applications before the Dec. 15 deadline but weren’t able to finish. Those usually track close to the preliminary results reported Friday. The official national enrollment report will be released sometime early next year, counting big states like California and New York that run their own sign-up efforts.
Of some 28 million uninsured Americans before the pandemic, the nonpartisan Kaiser Family Foundation estimates more than 16 million were eligible for some form of subsidized coverage through the health law.
With coronavirus shutdowns leaving even more people uninsured, Biden has pledged to build on the ACA to provide coverage to all Americans. His path forward doesn’t look that easy, since he will come into office with a closely divided Congress and most Republicans still opposed to “Obamacare.”
ACA coverage starts Jan. 1 for those who signed up this year.
https://www.pressherald.com/2020/12/18/obamacare-enrollment-rising-as-covid-19-pandemic-deepens/
Surprise Medical Bills Cost Americans Millions. Congress Is Finally Set to Ban Most of Them.
Efforts to solve the common consumer problem had been stalled by lobbying pressure and legislative squabbles.
by Sarah Kliff and Margot Sanger-Katz - NYT - December 21, 2020
After years of being stymied by well-funded interests, Congress has agreed to ban one of the most costly and exasperating practices in medicine: surprise medical bills.
Surprise bills happen when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to a hospital that accepts their insurance, for example, but get treated there by an emergency room physician who doesn’t. Such doctors often bill those patients for large fees, far higher than what health plans typically pay.
Language included in the $900 billion spending deal reached Sunday night and headed for final passage on Monday will make those bills illegal. Instead of charging patients, health providers will now have to work with insurers to settle on a fair price. The new changes will take effect in 2022, and will apply to doctors, hospitals and air ambulances, though not ground ambulances.
Academic researchers have found that millions of Americans receive these types of surprise bills each year, with as many as one in five emergency room visits resulting in such a charge. The bills most commonly come from health providers that patients are not able to select, such as emergency room physicians, anesthesiologists and ambulances. The average surprise charge for an emergency room visit is just above $600, but patients have received bills larger than $100,000 from out-of-network providers they did not select.
Some private-equity firms have turned this kind of billing into a robust business model, buying emergency room doctor groups and moving the providers out of network so they could bill larger fees.
Among the major consumer problems in the fiendishly complex health system, surprise billing was the rare Washington issue that both parties could get behind. Health committee leaders have been engaged on the issue for years, as has the White House. President-elect Joe Biden included the proposal in his campaign health care agenda. It had the backing of many prominent and powerful legislators, including Senator Lamar Alexander, Republican of Tennessee and the retiring chairman of the Senate health committee.
A survey published Friday by the Kaiser Family Foundation found that 80 percent of adults want the practice banned. More than a dozen states, including Texas and California, have passed bans of their own on surprise billing.
Even so, the issue struggled to move through Congress as each policy proposal faced an outcry from some faction of the health care industry.
“There were a lot of things working in the legislation’s favor — it’s a relatively targeted problem, it resonates very well with voters, and it’s not a hyperpartisan issue among voters or Congress — and it was still tough,” said Benedic Ippolito, a resident scholar at the American Enterprise Institute, who helped explain the issue to lawmakers early in the process. “It has almost everything going for it, and yet it was still this complete slog.”
Hospitals and doctors, who tend to benefit from the current system, fought to defeat solutions that would lower their pay. Insurance companies and large insurers groups, on the other hand, have wanted a stronger ability to negotiate lower payments to the types of medical providers who can currently send patients surprise bills.
Dealbook: An examination of the major business and policy headlines and the power brokers who shape them.
Legislation nearly passed last December, but was scuttled at the 11th hour after health providers lobbied aggressively against the deal. Private-equity firms, which own many of the medical providers that deliver surprise bills, poured tens of millions into advertisements opposing the plan. Committee chairs squabbled over jurisdictional issues and postponed the issue.
This year, many of the same legislators behind last year’s failed effort tried again, softening several provisions that had been most objectionable to influential doctor and hospital lobbies. The current version will probably not do as much to lower health care spending as the previous version, but will still protect patients.
After years of defeats, consumer advocacy groups cheered the new legislation.
“This was a real victory for American people against moneyed interests,” said Frederick Isasi, executive director of Families USA. “This really was about Congress recognizing in a bipartisan way the obscenity of families who were paying insurance still having financial bombs going off.”
The final compromise would require insurers and medical providers who cannot agree on a payment rate to use an outside arbiter to decide. The arbiter would determine a fair amount based, in part, on what other doctors and hospitals are typically paid for similar services. Patients could be charged the kind of cost sharing they would pay for in-network services, but nothing more.
This type of policy is generally seen as more advantageous to health care providers than the other proposal Congress considered, which would have minimized the role of arbiters and instead set benchmark reimbursement rates. Several states have set up their own arbitration systems, and have found that most price disputes are negotiated before an arbiter is involved.
“If this bill will force them to come to the table and negotiate a solution, it will be a definite win for everybody,” said Christopher Garmon, an assistant professor of health administration at the University of Missouri, Kansas City, who has measured the scope of the problem.
The new law will bar air ambulances from giving patients surprise bills. These bills are infrequent but, when they do happen, tend to be very large. This summer, a Pennsylvania coronavirus patient received a surprise air ambulance bill that was over $52,000 for a flight between two hospitals that happened while she was unconscious. States that ban surprise bills have been prevented from tackling these cases because federal law bars them from regulating air transit fees.
Ground ambulances, which generate a significant number of surprise bills, are excluded from the new law.
The Congressional Budget Office found that an earlier version of the plan would cause small reductions to affected providers including emergency room doctors and anesthesiologists. This would happen to providers that both do and do not send surprise bills, because taking away the option would reduce their leverage in negotiating contracts with health insurers.
Health insurers tend to be disappointed with the new legislation, while hospitals and doctors have offered a more mixed response. Some have cited the coronavirus pandemic as a reason to delay new rules.
The American Medical Association sent a letter to congressional leaders on Tuesday saying it was “deeply concerned” about the possibility of lower reimbursement rates, “especially in light of the significant financial pressures practices have faced in the last 10 months.”
TeamHealth, a large private-equity-owned physician staffing firm that has previously engaged in surprise billing, called the agreement “a significant improvement over the catastrophic proposals advanced by major insurance companies over the past two years.”
The American Hospital Association, the country’s largest hospital group, opposed a recent version of the new rules, while the Federation of American Hospitals, which represents private hospitals, supported it.https://www.nytimes.com/2020/12/20/upshot/surprise-medical-bills-congress-ban.html?
This Is the Health System That Biden Inherits From Trump
With medical spending down for the first time in decades, gains in care for the poor and vulnerable are under threat.
by Sarah Kliff - NYT - December 18, 2020
President-elect Joe Biden will inherit a health system that is trying to care for a population made sicker by both coronavirus and skipped preventive care, all while trying to make up for money lost in 2020.
But he’ll face another immediate challenge: Hospitals that tend to care for the poor and the vulnerable are facing major financial pressure, while wealthier hospital systems expect to emerge slightly bruised but not broken.
“This is all going to push inequality up,” said Alan Morgan, president of the National Rural Health Association. “There is no way around that.”
The policies that Mr. Biden decides to pursue in his first months as president — for example, how to pay for telemedicine visits as the pandemic continues, or whether to pursue additional stimulus for health providers — will be crucial in shaping the long-term future of the health system.
“Any crisis produces change, and this one will clearly produce big change,” said David Cutler, a health economist at Harvard who served as a health care adviser in the Obama administration. “We don’t know yet if it will be good or bad.”
For decades, American doctors and hospitals have been accustomed to constant spending growth. But 2020 has been on track to be the only year in this era when health care spending goes down. Even with the pandemic overwhelming some providers’ capacity, they seem set to lose money because of the scores of profitable elective procedures canceled this spring.
For Mr. Biden, this is likely to mean fights between hospitals, insurers and patient advocates, who fear that the gains in equality made from the Affordable Care Act have been eroded. Health providers that typically care for vulnerable populations may face tough choices between closing or selling to a larger competitor.
“The health care system lost a ton of money when people didn’t show up in March and April,” Mr. Cutler said. “It’s not clear it’s going to get that money back. I fully expect we’ll see a wave of providers go under, demand higher prices, and demand bailouts.”
Pick nearly any metric, and it will show the American health system’s tremendous growth in recent years. Overall health spending rose to $3.6 trillion this year from $2.9 trillion in 2010, buoyed by medical prices that increased faster than inflation. Health care jobs grew in tandem, peaking at 16.5 million workers this February.
Insurance enrollment increased significantly during the 2010s, largely a result of the Affordable Care Act’s coverage expansion. Even with some backsliding under President Trump, the uninsured rate is still lower than it was at the start of the decade, about 9 percent last year versus 16 percent in 2010.
This past decade’s growth didn’t just mean more dollars flowing into hospitals and doctor’s offices. It also appears to have made access to health care, and certain health outcomes, more equal.
The health law’s coverage expansion, for example, had an outsize impact in providing insurance to Black Americans and Latinos, and reducing disparities in uninsured rates. In 2013, there was a gap of 25.7 percentage points between the uninsured rates for Hispanic and white Americans. By 2018, that figure had fallen to 16.3 percentage points, a study from the nonprofit Commonwealth Fund showed.
The Medicaid expansion in many states is credited with keeping rural hospitals up and running. Some research has found that the expansion has reduced unequal outcomes in areas like maternal and infant mortality.
Now experts see those gains eroding. The change started under the Trump administration, which cut health law advertising and allowed states to impose new restrictions on Medicaid enrollment. One million Americans lost coverage between 2017 and 2019; experts were especially alarmed by declining public coverage among children.
The trend accelerated with the pandemic and a sharp decline this spring in medical revenue. Across the country, hospitals lost billions as patients canceled lucrative procedures like hip replacements and cataract surgery. Primary care doctors struggled to stay open as preventive care appointments plunged. Federal aid offset some but not all of those losses. Experts who study the health system now think much of the care canceled this spring will not be rescheduled.
Safety-net health systems, which by mission or mandate give care regardless of people’s ability to pay, say they’re already starting to see richer hospitals pulling further ahead. Employment in the health sector is recovering: About two-thirds of the 1.5 million jobs lost during the recession have come back. But there’s some evidence those gains aren’t being distributed equally.
Mr. Morgan, of the rural health association, hears from members who say they’re struggling to retain nurses. Some workers are getting better-paying offers from wealthier health systems in need of traveling nurses to help fight the pandemic.
“Two weeks ago, I heard from a hospital chief executive saying he was losing his clinical staff because they can make more money elsewhere,” he said. “His clinical staff is getting knocked offline in the middle of a pandemic. It’s a work force crunch.”
Margaret Mary Health System, which operates a 90-year-old nonprofit hospital in rural Indiana, expects to run a 4 percent deficit this year even after accounting for federal aid payments. The hospital has treated hundreds of coronavirus patients, who have sometimes occupied 23 of the hospital’s 25 beds.
“The thing that makes this all so difficult is how hard we’ve worked this year,” said Tim Putnam, the hospital’s chief executive. “We’ve put in so much to serve our community, and it’s tough to face a loss as the financial outcome.”
Before the pandemic, Margaret Mary executives felt it was on solid financial footing. The hospital received a boost from Indiana’s Medicaid expansion in 2015. Things looked so good last year that it decided to buy a new electronic medical record system.
Now, Margaret Mary is bracing for even heavier financial losses after Indiana announced Thursday it would once again suspend elective health care procedures.
“It’s hard to determine where this ends up until we figure out how the pandemic ends,” Mr. Putnam said. “To remain viable, to continue to serve our community, we’ve got to do better than break even, and we’ve got to find a way to do it in 2021.”
North Oaks Medical Center in Hammond, La., is a public hospital that serves predominantly low-income patients. It was projecting its “best financial year in the hospital’s history” before the pandemic struck, said the chief executive officer, Michele Sutton.
Instead, it ended up furloughing many workers this spring in an effort to break even. North Oaks ran into problems that a hospital with wealthier patients wouldn’t face — like the fact many of its patients did not have access to internet reliable enough to support video doctor visits.
“Because of our parish being poor, we didn’t have a lot of access to telemedicine,” Ms. Sutton said. “We didn’t have the fiber-optic capacity.”
Her hospital had to do extra work to set up stations where doctors could video-chat with their patients, a cost other health systems didn’t have to bear. Now, it’s bracing for another difficult year treating sicker patients.
“We’re seeing an increase in suicide, a lot more stroke, a lot more heart attack,” Ms. Sutton said, “and a decline in routine maintenance for fear of contracting Covid.”
Some of the early decisions facing the Biden team are small, practical ones: Should Medicare continue paying the high but temporary reimbursement rates it offered for telemedicine visits this year, a signal that would encourage private plans to do the same?
“Imagine I’m a primary care practice, I’ve taken a big financial hit already, and I’m trying to decide: Do I make a big investment in telemedicine or not?” said Dr. Ateev Mehrotra, a Harvard health researcher. “It’s tough for a clinical practice to not know what you’ll get paid in a week or two.”
Other decisions are bigger, like whether to provide additional stimulus funding for health providers and how to allocate it.
Doctors know patients have been putting off some kinds of care and are bracing for the consequences. Dr. Mehrotra and his colleagues published research this week finding that fewer patients are starting opioid addiction treatment during the pandemic, as some providers feel uncomfortable prescribing a new drug without an in-person meeting.
The Biden administration’s policies will help determine how providers care for this sicker population while health insurance coverage is declining. To increase sign-ups, the administration could use waivers expanding Medicaid coverage or restore the Affordable Care Act’s advertising budget. Bigger coverage expansions, like a public option that would allow all Americans to sign up for Medicare, would require congressional approval.
“There’s a big population I’m really worried about that has diabetes, hypertension and heart failure, and deferred all this care,” Dr. Mehrotra said. “The accumulation of not getting care will result in complications. But at this point it’s unclear what exactly those complications of illness will look like.”
https://www.nytimes.com/2020/12/16/upshot/biden-trump-health-pandemic.html?
US healthcare workers protest chaos in hospitals' vaccine rollout
- Key personnel miss out on first wave of life-saving shots
- Stanford doctors speak out on behalf of frontline staff
by Allexandra Real - The Guardian - December 20, 2020
Frontline healthcare workers saw their hopes dashed last week when a botched algorithm, crashing scheduling platforms and other logistical mishaps thwarted their efforts to be among the first in the US to receive a long-awaited coronavirus vaccine.
Amid a surge in infections overwhelming hospitals around the US, doctors were incensed by administrative failures that denied access to the potentially life-saving shots, even as they volunteered to work in intensive care units or looked after the critically ill.
Christine Santiago is an internal medicine resident with Stanford Health Care in California, where ICU availability is at 2% statewide.
“I think that there’s a sense of disappointment in not really being considered,” she said, “despite sort of being held up as like, you know, ‘healthcare heroes’, and being on the frontlines.
“Maybe it was just words.”
More than 100 Stanford doctors protested on Friday, standing up for respiratory therapists, environmental services workers, nursing staff, residents and fellows who interact with patients. They were unable to lay claim to initial doses of the vaccine, even as they learned that employees doing telehealth from home had nabbed slots.
“Healthcare heroes, support is zero,” the protesters chanted.
Residents – doctors completing their training after medical school – were especially frustrated because they were being asked to volunteer for the Covid ICU but Stanford’s algorithm was not prioritizing them for vaccination.
Ronald Witteles, program director at Stanford’s internal medicine residency program, tweeted that the vaccine rollout “was an absolute mess” and “one of the most upsetting 24 hours I have ever experienced”.
Stanford Medicine said it took “complete responsibility for the errors in the execution of our vaccine distribution plan”, which it was “immediately revising”.
“Our intent was to develop an ethical and equitable process for distribution of the vaccine,” the statement said. “We apologize to our entire community, including our residents, fellows, and other frontline care providers, who have performed heroically during our pandemic response.”
On the east coast, doctors in Boston’s Mass General Brigham system were also distraught. After the online scheduling platform crashed, employees filed into a long line on Thursday morning to sign up for shots in-person. But staff in emergency departments couldn’t abandon their patients. Once appointments came back online, availability vanished in minutes, a rush one physician likened to buying tickets to see Taylor Swift.
“It has converted it [into] almost like a parking spot, you know?” said the doctor, who spoke on condition of anonymity. “It’s almost become an employee perk that everyone’s rushing to get as soon as they can.”
In an email to leadership that was ultimately not sent, the physician described how “employee was pitted against employee in a dystopian race” and how “what should have been a moment of triumph for medicine and the healthcare system writ large was instead clouded by the dysfunction that hospitals are known for only too well”.
Other disappointed healthcare professionals posted screenshots on social media, showing error messages received instead of appointments.
“In attempting to prove I am not a robot repeatedly, I watched every date and time slip away,” tweeted George Alba, a pulmonary and critical care physician at Massachusetts General Hospital.
He added: “We got crushed by a boulder of operational failure.”
A spokesman said Mass General Brigham was following priorities set by the commonwealth of Massachusetts with guidance from the federal Centers for Disease Control and Prevention, and that “the first group is deliberately inclusive of the role groups who are involved in the care of Covid patients”.
“While we have now scheduled as many appointments as our initial supply allows, we expect to receive a significant shipment of vaccine in the coming days,” he said.
Tufts Medical Center experienced similar issues with online signup, the Boston Globe reported.
As the US mounts a historic vaccination campaign, such hiccups could prove a harbinger of problems affecting Americans at large, Santiago warned.
“It’s more [about] lessons learned for when this really is gonna be distributed on a large scale for the rest of the population,” she said.
The troubles were yet another blow to frontline workers enduring a year in which more than 317,000 in the US have died from the coronavirus.
“I’m going to try to focus on being happy for everyone who managed to get a vaccine slot, and not on my personal inability to do the same,” tweeted Yuval Raz, a doctor at Mass General. “I mean, I’m probably going to fail and thr
The vaccine will be covered for people with private insurance, according to guidelines released by the Centers for Medicare and Medicaid Services (CMS).
“Health insurers whose plans are subjected to the coverage of preventive services without cost-sharing requirement under the Public Health Service Act are not allowed to bill patients for the administration of the COVID-19 vaccine,” said Anh Nguyen, PhD, a health economics expert and assistant professor of economics at Carnegie Mellon University’s Tepper School of Business.
Nguyen noted that this applies to both in-network and out-of-network providers.
Private insurers such as Blue Cross Blue Shield (BCBS) and Oscar Health confirmed members will pay $0 for the vaccine.
“If the primary purpose of a patient’s visit is to receive the COVID-19 vaccine, BCBS companies will cover the vaccine, administration services, and the office visit at no cost-share to the patient, even if the appointment is out-of-network, per regulations issued by CMS,” a BCBS spokesperson told Healthline.
If the doctor’s visit includes health services unrelated to COVID-19, the person may be charged.
“If a patient receives additional, non-COVID-19 care at the same appointment, patients will be covered for those services in accordance with their health plan,” the BCBS spokesperson said.
Oscar Health, too, has committed to providing the vaccine for free to its members. There will be no charge for the vaccine itself or for the doctor’s visit associated with the immunization, Oscar Health confirmed.
“People receiving the COVID-19 vaccine will not be billed with copays or unexpected administrative fees,” an Oscar Health spokesperson said. “Based on guidance so far from the federal government, plans and issuers must cover COVID vaccines without cost sharing.”
According to Nguyen, this coverage benefit doesn’t apply to certain alternative healthcare plans, such as short-term limited duration insurance. Individuals on alternative plans may be subjected to copay or administration costs related to the vaccine.
Some states may require these plans to cover costs related to COVID-19 similarly to how they did with testing for the disease.
The CMS also states there will be no vaccine costs, administration fees, or deductibles for people on Medicare.
Any COVID-19 vaccine that receives Food and Drug Administration (FDA) authorization “will be covered under Medicare as a preventive vaccine at no cost to beneficiaries,” the CMS states on its website.
COVID-19CMS released a set of toolkits for providers, states and insurers to help the health care system prepare to swiftly administer the vaccine once it is available. These resources are designed to increase the number of providers that can administer the vaccine and ensure adequate reimbursement for administering the vaccine in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover the vaccine at no charge to beneficiaries. In addition, CMS is taking action to increase reimbursement for any new COVID treatments that are approved by the FDA.
Health care providers will play an important role when a COVID-19 vaccine(s) becomes available. CMS is committed to ensuring you have the necessary tools to respond to the COVID-19 public health emergency. In anticipation of safe and effective COVID-19 vaccines being available in the future, we’re issuing this toolkit to help health care providers prepare to administer vaccines. Because the initial supply of COVID-19 vaccines will be federally purchased, this toolkit primarily focuses on coverage of vaccine administration. Vaccine doses purchased with U.S. taxpayer dollars will be given to the American people at no cost. Providers that participate in the CDC COVID-19 Vaccination Program contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and regardless of their coverage status, and also may not seek any reimbursement, including through balance billing, from a vaccine recipient. Providers who have questions about billing or reimbursement of vaccine administration for patients covered by private insurance or Medicaid should contact the respective health plan or state Medicaid agency. People without health insurance or whose insurance does not provide coverage of the vaccine can also get COVID-19 vaccine at no cost. Providers administering the vaccine to people without health insurance or whose insurance does not provide coverage of the vaccine can request reimbursement for the administration of the COVID-19 vaccine through the Provider Relief Fund.
We’ll update this toolkit as new information becomes available.
This toolkit includes information to describe:
- How health care providers can enroll in Medicare to bill for administering COVID-19 vaccines when available
- The COVID-19 Vaccine Medicare coding structure
- The Medicare reimbursement strategy for COVID-19 vaccine administration
- How health care providers can bill correctly for administering vaccines, including roster and centralized billing
*Updated* Additionally, you can find information about a monoclonal antibody infusion for treating COVID-19. During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA)
https://www.cms.gov/covidvax-provider
Black Men Have the Shortest Lifespans of Any Americans. This Theory Helps Explain Why.
The unrelenting stress of fighting systemic racism can alter a body’s normal functioning until it starts to wear down. The theory, known as John Henryism, helps explain racial health disparities.
The reality, however, is more complex.
AARP asked me to explore the business of nursing homes and the culpability of their owners for what has transpired. Clearly most operators reacted to the pandemic as best they could. But what I found was that the industry’s complex and murky financial structure fails to safeguard the health of residents and staff.
While the overall profits reaped by owners are secret, COVID-19 is clearly hurting nursing homes financially. Fully 55 percent of them claim to be losing money, and 72 percent say they may not be able to sustain operations for another year, according to an August survey by the American Health Care Association and the National Center for Assisted Living.
Even the nation’s largest nursing home chain, Genesis HealthCare, says it’s in jeopardy. Genesis, with 360 facilities in 25 states, said in August there was “substantial doubt” about its ability to survive for the next 12 months.
“If there isn’t more money coming in, many members will face decisions about shrinking the number of beds or even closing their doors,” says Katie Smith Sloan, CEO of LeadingAge, an organization that represents nonprofit nursing homes.
Here is what you need to know to understand the business of nursing homes, and to what extent they caused the mess they are in.
The nation’s 15,600 nursing homes generated about $166
billion in revenue in 2017—a little more than what U.S. hotels took in
by renting out their rooms. And nursing homes receive about the same
amount for most of their residents as nice hotels get for a night’s
stay.
But the similarities end there. For example, roughly 30 percent of nursing homes are owned by nonprofit organizations predominantly affiliated with religious groups, ethnic aid societies and social service agencies. They strive to maximize revenue and efficiency, but any unspent revenue is used to improve and expand their facilities and services.
The remaining 70 percent of homes are for-profit — free to pay out income to owners once they cover operating expenses and other obligations. Owners include national chains, regional chains and stand-alone facilities. About 1 in 7 for-profit homes are controlled by private equity investors — something that can be problematic, as I’ll explain shortly.
To understand nursing homes’ finances, you have to start with their
revenue. Three-fifths of the nation’s 1.3 million nursing home
residents’ fees are paid by Medicaid,
the federal-state insurance program for low-income Americans. These
older adults (and people with disabilities) often spend their remaining
years in a nursing home, at taxpayers’ expense.
How profitable is the Medicaid business? It depends on whom you ask. The average Medicaid payment, which varies by state, is around $200 per resident per day. But unlike a hotel charging that price, nursing homes have to provide hands-on care that many residents need with their daily activities. They also must provide meals, medical services and more.
Nursing home operators consistently say that $200 doesn’t cover their
costs. Industry critics aren’t so quick to agree, citing owners’ opaque
finances and multiple income sources (more on that later). “We don’t
know whether Medicaid rates are too low or not,” says
Charlene Harrington, a University of California, San Francisco, professor emerita who has studied nursing homes for decades.
What is clear is that the share of this revenue spent on paying and training personnel isn’t enough. The industry’s staff turnover is high, and there’s a critical shortage of people qualified to provide patient care. This detracts from residents’ well-being at any time, but it’s proven especially dangerous in 2020.
And $200 a day isn’t enough to fund a deep well of supplies or to have private rooms available that might reduce the spread of infection. It has been especially inadequate this year, when facilities faced suddenly skyrocketing costs for infection-control supplies and tests.
Well before the coronavirus blindsided the industry, the numbers were bleak. Consider the most recent report of the government’s Medicare Payment Advisory Commission. In 2018, MedPAC found, nursing homes had an operating profit margin of negative 3 percent on patients paid for by Medicaid and other non-Medicare sources. In other words, for every $100 they took in for these residents, they spent $103 on their care — clearly a losing proposition. During the pandemic, no doubt the math got worse.
A Lopsided Model
Medicare pays for relatively few nursing home residents, but provides a major portion of the home’s revenue. These figures show 2019 inpatient revenue for Genesis Health Care, the nation’s largest chain.
If caring for Medicaid residents is such a poor business, how have
nursing homes stayed afloat all these years? The answer is, chiefly,
Medicare. While Medicare doesn’t pay for long-term nursing home care, it does cover skilled services
and therapy for up to 100 days after a patient is discharged from a
hospital. And it pays very well. In 2019, for example, Genesis
HealthCare received $535 per resident per day from Medicare — about 2½
times the $215 it got for Medicaid patients.
Yes, Medicare residents usually need more care than Medicaid residents. Even so, Medicare is more profitable: For every $100 that nursing homes receive on behalf of these patients, an average of $10 is left over after subtracting the cost of the care — not a loss of $3.
The upshot is that nursing homes rely on a relatively small number of well-paying residents to make up for the money they say they lose on the rest. “It’s not a structure anyone would have designed from the outset,” says R. Tamara Konetzka, a professor of health services research at the University of Chicago.
Not surprisingly, nursing homes strive to admit more Medicare patients to offset what they say are losses on Medicaid. But that can lead to bad care decisions, Konetzka says, such as encouraging nursing homes to send Medicaid residents to the hospital so they can return as higher-paying Medicare patients.
This year, some nursing homes evicted Medicaid residents in favor of COVID-19
patients receiving care at the higher Medicare rate, according to The New York Times and other news outlets. Inappropriate discharges have long been a top complaint to long-term care ombudsmen nationwide; AARP Foundation has fought the practice in the courts.
This dependence on Medicare patients has proven hazardous for nursing homes this year. Starting in March, hospitals and patients canceled or delayed many elective procedures, and roughly 10 percent fewer Medicare patients were sent to skilled nursing facilities for rehabilitation, according to MedPAC. Overall nursing home occupancy dropped from 83.4 percent to 74.8 percent from March through June, according to the National Investment Center for Seniors Housing & Care, a research group that compiles nursing home data for investors.
Between May and October, the federal government pumped more than $21 billion into the industry in the form of grants, loans and advance Medicare payments. Only $2.5 billion of that had usage stipulations; it’s unknown how much of the aid went to stop the spread of COVID-19. “Nursing homes can use it to shore up their bottom lines if they want to,” says Elaine Ryan, AARP’s vice president of government affairs for state advocacy. “We might never know where the money went.”
Profits and Private Equity Can Eat Into Care
Beyond the problematic payment system, researchers and policymakers question whether the for-profit ownership structure of most nursing homes is the best model for delivering care.
A number of research studies have found that for-profit nursing homes generally have significantly lower staffing levels and quality of care than nonprofit facilities, as measured by the Nursing Home Compare quality star rating system run by the government’s Centers for Medicare & Medicaid Services (CMS).
Of particular concern to industry followers are the estimated 10 percent of America’s nursing homes owned by private equity (PE) investment groups. Bankrolled by institutional investors and wealthy individuals, these PE firms typically buy businesses, make efficiency and/or cost-cutting changes to increase their apparent value, then sell them within three to five years. PE firms often borrow money against the businesses’ assets and receive management fees as well as a share of profits when the enterprises are sold.
Here’s their usual practice as it pertains to nursing homes, according to Harvard University professor of health care policy David Grabowski and other researchers: A firm will buy a nursing home, then place its buildings and other real estate — nursing homes’ most valuable asset— in a separate holding company. Other companies also owned by the investors will start providing management, laundry, supplies and other services to the nursing home. These ownership structures make it hard to figure out who is responsible for the quality of care and how to recover damages if a resident is injured, says Ashvin Gandhi, a health economist at UCLA who has studied private equity and nursing homes.
Once a nursing home starts paying these related companies, says Grabowski, the home may appear to be struggling, while at the same time the owners are making money from their other entities. The nursing home itself ends up saddled with debts incurred to pay off lenders who financed the PE firm’s purchase.
“The main reason these for-profit companies are in the nursing home business is to extract money through management contracts and lease agreements,” UCSF’s Harrington says. “They scream they have no money, but they’ve legally taken money out through all these related-party transactions.”
Deals like these have been going on for more than 20 years. Other for-profit firms have engaged in similar practices, separating out their real estate holdings and striking management and supply deals with related firms.
“Every dollar they squeeze out of a nursing home for profit is a dollar that isn’t going to the care of the residents,” says Patrick Woodall, a senior researcher at Americans for Financial Reform, a national coalition of consumer and civil rights groups.
Solutions, sadly, seem far off. “People get concerned when stories of poor nursing home care come out,” Konetzka says. “But politicians never run for office on a platform of raising taxes to improve Medicaid reimbursement.”
The industry itself isn’t always eager for change; it often lobbies at both the federal and state levels to oppose long-term care reforms.
Ultimately, a group effort will be necessary, says Bob Kramer, founder of the National Investment Center for Seniors Housing & Care: “It will take partnerships between the federal government, states, the long-term care industry and insurers to change the system and ensure that people can afford the care they need.”
https://www.aarp.org/caregiving/health/info-2020/covid-19-nursing-homes-failing-business-model.html
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