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Thursday, June 18, 2020

Health Care Reform Articles - June 18, 2020

“The path to becoming homeless can start with a large medical bill that causes someone to fall behind on their rent payments, which leads to eventual eviction.”
 
  Where does California’s Homeless Population Come From? by Inyoung Kang, 6-17-2020 New York Times California Today

At A Time Of Great Need, Public Health Lacks ‘Lobbying Muscle’

by Angela Hart - KHN - June 15, 2020

SACRAMENTO — If there were ever a time for more public health funding, health experts say, it’s now.
Yet California Gov. Gavin Newsom and the state’s Democratic-controlled legislature are expected to reject a plea from local public health officials for an additional $150 million a year to battle the COVID-19 pandemic and protect against future public health threats.
“I’m not holding my breath,” said Riverside County Public Health Director Kim Saruwatari. “Right now, more than ever, the gaps that we have in our public health infrastructure have been exposed.”
Public health officials vow to continue making their case. But persuading lawmakers to increase spending in a time of cuts will be even more difficult because public health doesn’t carry the same political clout in the Capitol as other power players such as hospitals, doctors or public employee unions, which plow millions of dollars into lobbying each year.
“I’ve not met anybody who is a lobbyist for public health,” said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee. “The organizations that wear the whitest of hats have the least resources. Consequently, it’s easier to say ‘No.’”
The novel coronavirus has decimated California’s economy and, like local and state governments around the country, the state faces unprecedented budget challenges. Newsom is projecting a $54 billion deficit for the 2020-21 fiscal year, and says the state must make painful decisions before his July 1 deadline to sign a balanced budget into law.
The budget lawmakers are poised to send to Newsom on Monday does not include the additional public health funding.
Similar funding battles are taking place elsewhere, such as in Wisconsin, where the state faces budget cuts and officials are asking for more public health money.
“We need to have a plan to build up public health,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “We have to figure out how to afford it, otherwise we’re going to have the same kind of economic consequences the next time something like this happens.”
California’s 61 local health departments are the backbone of the state’s public health system, and the two leading public health organizations representing local health officials have spent pennies on the dollar to lobby the governor, lawmakers and state agencies compared with big-name groups.
The Health Officers Association of California spent almost $7,000 on lobbying from January 2019, the start of the current legislative session, through March 2020, according to lobbying disclosures from the California Secretary of State office. The County Health Executives Association of California spent $191,000 over the same period. And while other groups employ in-house lobbyists to influence Capitol decision-makers full time, the public health organizations’ executive directors pull double duty, serving as head lobbyists when they can fit it in.
Among the top spenders on lobbying were the powerful California Teachers Association, at $7.4 million, and the Service Employees International Union California, at $5.3 million.
Deep-pocketed health industry groups have also outspent public health interests. DaVita Inc. and Fresenius Medical Care, the two dominant dialysis companies operating in the U.S., spent $5.3 million on lobbying during that period. The California Hospital Association spent $3.4 million and the California Medical Association, representing doctors, spent $2.7 million. The groups collectively employ at least 15 in-house lobbyists.
In addition to paying for lobbyists, the money is used to curry favor with the governor, lawmakers and agency officials. California lobbyists are allowed to give gifts, and to wine and dine officials.
In October, for example, the California Medical Association hosted a “legislative reception” and dinner that included lawmakers, with the tab at the Napa Rose restaurant at the Disneyland Resort totaling more than $22,500.
Although political spending doesn’t always get big industry groups everything they want, it has gained them more access to the governor and other state leaders steering pandemic response plans. It has also enabled moneyed health industry groups to continue working on other legislative priorities, such as relaxing hospital seismic safety standards and opposing a proposal granting nurse practitioners the ability to work without doctor oversight.
By comparison, lobbying by public health groups consists primarily of visiting lawmakers’ offices, often accompanied by health officials from the lawmakers’ jurisdictions.
Public health leaders are regularly invited to testify at legislative hearings tackling issues like measles outbreaks, the opioid epidemic or teen vaping, but they don’t have anywhere near the “lobbying muscle” that major health industry groups have cultivated, said Kat DeBurgh, executive director of the Health Officers Association of California.
“We have no money; we advocate with our ideas,” DeBurgh said. “We don’t have millions of dollars to spend on billboards, and we can’t call in a hundred people to stand up at a hearing and say ‘I didn’t get sick because of public health measures.’”
State spending for state and county public health programs has declined over the past decade. The governor’s budget proposal for 2020-21 would continue that trend, reducing the current $3.4 billion public health budget to $3.2 billion.
Counties also are confronting a $1.7 billion loss in public health dollars due to pandemic-related declines in sales tax revenue and vehicle license fees, county health officials said, and they have asked Newsom to provide $1 billion from the state’s general fund to help make up for it.
Newsom has said the state may not be able to afford to do that given other financial demands.
Health officials say the additional $150 million they’re requesting would help them hire public health nurses and disease investigators, fund public health labs and purchase protective gear. They say addressing the underfunding of public health is especially critical now because counties are primarily responsible for providing adequate testing and contact tracing before easing stay-at-home restrictions.
“That $150 million, that doesn’t even get anywhere close to where we need to be because so much of our funding has eroded away,” said Mimi Hall, president of the County Health Executives Association of California, who is also the director of the Santa Cruz County health department.
State Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee, is also a pediatrician. Pan has consistently pushed for public health funding during his time in the legislature, and Capitol insiders view him as a de facto lobbyist for public health.
Pan said he plans to continue to advocate for the additional public health funding — despite the economic turmoil.
“It’s hard because what public health does is invisible and you have to move people’s hearts,” Pan said.
Other lawmakers acknowledged concerns about public health shortfalls but said it would be difficult to increase spending this year. However, organizations that can afford to hire high-priced lobbying firms “will probably do OK in this budget,” said Wood, the Santa Rosa Assembly member.
He is among the lawmakers considered most friendly to public health and said he supports more money, but wants to understand how it would be spent before deciding.
“They have been underfunded for years,” Wood said. “But some of that happens at the local level, too.”
Last year, public health officials sought $50 million a year from state lawmakers to help rebuild public health infrastructure following years of recession-era budget cuts. Newsom denied their request.
County health directors say chronic underfunding has forced them to make difficult decisions to curtail spending and cut programs like public health labs — 11 of 40 have shuttered in the past two decades.
And for years, they have warned California leaders that the state would be quickly overwhelmed should a public health crisis strike. Their pleas have gone largely ignored.
The impact of the relentless cuts has been felt across the state, including in Riverside County, which has slashed its public health staff by about 60% over the past decade, leaving just 30 disease investigators, contact tracers and public health nurses to serve the sprawling region of 2.5 million people, said Saruwatari, its public health director.
“Had we had the ability to test earlier, I think we would have been able to get out in front of this a little bit more,” she said.
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
https://khn.org/news/at-a-time-of-great-need-public-health-lacks-lobbying-muscle/ 


Coronavirus survival comes with a $1.1 million, 181-page price tag 

by Danny Westneat - Seattle Times - June 12, 2020

Remember Michael Flor, the longest-hospitalized COVID-19 patient who, when he unexpectedly did not die, was jokingly dubbed “the miracle child?”
Now they can also call him the million-dollar baby.
Flor, 70, who came so close to death in the spring that a night-shift nurse held a phone to his ear while his wife and kids said their final goodbyes, is recovering nicely these days at his home in West Seattle. But he says his heart almost failed a second time when he got the bill from his health care odyssey the other day.
“I opened it and said ‘holy [bleep]!’ “ Flor says.
The total tab for his bout with the coronavirus: $1.1 million. $1,122,501.04, to be exact. All in one bill that’s more like a book because it runs to 181 pages.
Michael Flor battled with coronavirus for 62 days at Swedish Issaquah. His stay makes him the longest coronavirus patient at a Swedish hospital. (Ramon Dompor / The Seattle Times)
The bill is technically an explanation of charges, and because Flor has insurance including Medicare, he won’t have to pay the vast majority of it. In fact because he had COVID-19, and not a different disease, he might not have to pay anything — a quirk of this situation I’ll get to in a minute.
But for now it’s got him and his family and friends marveling at the extreme expense, and bizarre economics, of American health care.
Flor was in Swedish Medical Center in Issaquah with COVID-19 for 62 days, so he knew the bill would be a doozy. He was unconscious for much of his stay, but once near the beginning his wife Elisa Del Rosario remembers him waking up and saying: “You gotta get me out of here, we can’t afford this.”
Just the charge for his room in the intensive care unit was billed at $9,736 per day. Due to the contagious nature of the virus, the room was sealed and could only be entered by medical workers wearing plastic suits and headgear. For 42 days he was in this isolation chamber, for a total charged cost of $408,912.
He also was on a mechanical ventilator for 29 days, with the use of the machine billed at $2,835 per day, for a total of $82,215. About a quarter of the bill is drug costs.
The list of charges indirectly tells the story of Flor’s battle. For the two days when his heart, kidneys and lungs were all failing and he was nearest death, the bill runs for 20 pages and totals nearly $100,000 as doctors “were throwing everything at me they could think of,” Flor says.
In all, there are nearly 3,000 itemized charges, about 50 per day. Usually hospitals get paid only a portion of the amount they bill, as most have negotiated discounts with insurance companies. The charges don’t include the two weeks of recuperating he did in a rehab facility.
Going through it all, Flor said he was surprised at his own reaction. Which was guilt.
“I feel guilty about surviving,” he says. “There’s a sense of ‘why me?’ Why did I deserve all this? Looking at the incredible cost of it all definitely adds to that survivor’s guilt.”
There also are special financial rules that apply only to COVID-19. Congress set aside more than $100 billion to help hospitals and insurance companies defray the costs of the pandemic, in part to encourage people to seek testing and treatment (including those with no insurance). As a result, Flor probably won’t have to pay even his Medicare Advantage policy’s out-of-pocket charges, which could have amounted to $6,000.
The insurance industry has estimated treatment costs just for COVID-19 could top $500 billion, however, so Congress is being asked to step up with more money.
The writer David Lat got a $320,000 bill for his COVID-19 treatment, and also ended up paying nothing. Yet he heard from dozens of cancer and leukemia patients who have been hit with big bills or co-pays during this same time period.
It’s like we’re doing an experiment for what universal health coverage might be like, but confining it to only this one illness.
“Suffering from the novel coronavirus as opposed to cancer shouldn’t make a difference in terms of your financial burden,” Lat wrote, in Slate. “What you pay as a patient shouldn’t depend, in essence, on whether your disease has a good publicist.”
Flor said he’s hyper-aware that somebody is paying his million-dollar bill —  taxpayers, other insurance customers and so on. “Fears of socialism” have always stopped us from guaranteeing full health care for everyone, he said. But there’s also the gold-plated costs here, twice as expensive per capita as anywhere else in the world.
“It was a million bucks to save my life, and of course I’d say that’s money well-spent,” he says. “But I also know I might be the only one saying that.”
https://www.seattletimes.com/seattle-news/inspiring-story-of-seattle-mans-coronavirus-survival-comes-with-a-1-1-million-dollar-hospital-bill/

A $1.1m hospital bill after surviving the coronavirus? That's America for you

After he nearly died from Covid-19, Michael Flor probably thought he couldn’t be shocked by much else. He had survived a battle with a deadly virus that had killed more than 100,000 people across America.
But Flor, a 70-year-old from Seattle, was hit with an incomprehensible hospital bill for his stay: $1.1m, the Seattle Times reported.
The bill included $9,736 per day for the intensive care room, nearly $409,000 for its transformation into a sterile room for 42 days, $82,000 for the use of a ventilator for 29 days, and nearly $100,000 for two days when he appeared to be on his deathbed.
Luckily for Flor, Medicare will pick up the bill. For other Americans, medical debt could follow them for the rest of their lives.
When Janet Mendez, a 33-year-old New Yorker, also nearly died from Covid-19, she learned that surviving a deadly virus wasn’t going to be her only life-altering challenge. Soon after she left the hospital and returned to her mother’s home, her medicals bills started to pile up.
First, a bill for $31,165, the New York Times reported. Then an invoice for an absurd $401,885.57, though the hospital, Mount Sinai Morningside, said it would reduce the bill by $326,851.63 as a “financial assistance benefit”. That still left a tab of more than $75,000.
Mendez was unable to walk, let alone find work. She told the New York Times she was optimistic that her insurance company would cover a large part of the costs, though she had already been on the receiving end of harassing phone calls from the hospital.
She was yet another victim of America’s immoral and Kafkaesque healthcare system.
Federal funding is supposed to cover the vast majority of medical bills Americans incur from Covid-19, which has killed more than 100,000 nationwide and almost 30,000 in New York. It was a rare gesture toward socialism for a nation that has mostly known predatory capitalism when it comes to the business of staying alive; private, for-profit healthcare amounts to an American religion.
In New York City, hospitals received more than $3bn in federal funds last month from an early round of bailout payments. The money is supposed to compensate hospitals and healthcare providers for the expense of treating coronavirus patients and make up for the revenue hospitals lost from canceling elective procedures.
Though the federal money comes with some conditions that are intended to protect patients from medical debt, loopholes remain. Doctors who treat patients can send their own bills to patient directly. The doctors who treated Mendez individually charged between $300 and $1,800 for each day, according to the New York Times.
And depending on their insurance plan, patients may still be stuck with paying co-payments, deductibles and a percentage of the bill. This can still amount to many thousands of dollars. For those without insurance entirely, still possible even in a world with the Affordable Care Act, the consequences are even more dire.
Coronavirus, momentarily, turned even the most jaded conservatives into socialists, as a broad consensus emerged that the federal government needed to spend trillions of dollars to save people’s lives. Tea Party Republicans called for coronavirus testing to be free. Josh Hawley, a Republican senator who hopes to be an heir to Donald Trump, has argued that the federal government should subsidize businesses to keep workers on their payrolls, mirroring the kind of programs carried out in nations like Germany, where the social safety net is far more robust.
In no civil or sane society should anyone experience what Mendez had to endure: astronomical medical bills and threatening, harassing calls from a hospital that is supposed to only care about sustaining life. But that is what happens when the profit motive is so directly tied to healthcare. Instead of a single-payer system that covers everyone and eliminates medical debt, we are left with a patchwork of private insurance companies that price gouge the sick and vulnerable.
The fallout from coronavirus, even in a world with a vaccine, promises to be more painful for Americans than Europeans who have health plans subsidized by their national governments. For Americans with shoddy health insurance or no insurance at all, the hospital bills may be staggering. No serious economic recovery is possible if thousands of people are choosing between paying a healthcare bill or buying groceries.
More importantly, it shouldn’t take a once-in-a-century pandemic to make policymakers understand the tragic absurdity of healthcare in the United States of America. Every day, people encounter medical crises that alter the trajectories of their lives. If it’s not coronavirus, it’s cancer or diabetes or a broken bone. Every person in pain deserves the dignity of life without medical bills.
 
https://www.theguardian.com/commentisfree/2020/jun/16/coronavirus-hospital-bill-healthcare-america 
 

She Survived the Coronavirus. Then She Got a $400,000 Medical Bill.

Patients who were treated for the virus are largely supposed to be exempt from receiving large bills.
by Joseph Goldstein - NYT - June 14, 2020

Janet Mendez started receiving bills soon after returning in April to her mother’s home from Mount Sinai Morningside hospital, where she nearly died of Covid-19. First, there was one for $31,165. Unable to work and finding it difficult to walk, Ms. Mendez decided to put the bill out of her mind and focus on her recovery.
The next one was impossible to ignore: an invoice for $401,885.57, although it noted that the hospital would reduce the bill by $326,851.63 as a “financial assistance benefit.” But that still left a tab of more than $75,000.
“Oh my God, how am I going to pay all this money?” Ms. Mendez, 33, recalled thinking. The answer came to her in about a second: “I’m not going to be able to pay all this.”
Ms. Mendez is optimistic that her insurance company will cover a large part of the costs, but only after receiving a series of harassing phone calls from the hospital about payment.

A spokesman for the hospital told The Times that Ms. Mendez erroneously received a bill that should have gone directly to her insurance company or the government. Coronavirus patients, through a series of federal aid packages, are supposed to be largely exempt from paying for the bulk of their care.
But mistakes are likely to occur, particularly given the number of people who have recently lost their health insurance amid an economic downturn and widespread job loss. And when they do happen, patients like Ms. Mendez will be the ones to have to sort out the complicated billing process at a time when they are still recovering from Covid-19.
“We’re looking at a tsunami,” said Elisabeth Benjamin, a vice president at the Community Service Society of New York, which is trying to help Ms. Mendez get her bill reduced. “The earthquake has struck, and now we’re waiting for the bills to roll on in.”
When Ms. Mendez got over the initial shock and examined her bill more closely, she was struck by how vague and arbitrary the charges seemed. She was billed $3,550 for “inpatient charges” and another $42,714.52 for “pharmacy,” but without any breakdown of what medicines she received or how much each cost.
Ms. Mendez said the bill should have at least been itemized, listing each drug she was being charged for — and the price. She was, after all, unconscious for much of her hospitalization.
“I don’t know what medicines they put in me,” she said. “I can’t say they did this, or they didn’t do this.”
Most of the line items on her hospital bill are vague. Some of the most expensive are four entries that simply read “Medical — Cardiac Care.” Each one ranges from $41,000 to $82,000.
Part of the confusion was that Ms. Mendez had recently changed health insurers, and she had arrived at the hospital struggling to breathe and without her new insurance information. The hospital billing department concluded she was uninsured and sent her a bill directly.
“To be clear, neither this patient nor any Mount Sinai patient should receive a bill or be expected to directly pay for their Covid-19 care,” a spokesman for Mount Sinai Health System, Jason Kaplan, wrote in an email, describing it as an isolated error.
While eye-popping medical bills are nothing new, Covid-19 patients are supposed to be largely exempt. During Ms. Mendez’s hospitalization, a huge bailout of hospitals was taking shape.
In New York City, hospitals received more than $3 billion in federal payments last month from an early round of bailout payments. The hospital where Ms. Mendez was treated, Mount Sinai Morningside (formerly Mount Sinai St. Luke’s) received at least $63.7 million.
The federal dollars are intended to help compensate hospitals and health care providers for the expense of treating Covid-19 patients like Ms. Mendez. The money is also meant to help make up for the revenue hospitals lost as elective procedures were canceled and non-Covid patients dwindled.
The money comes with some conditions that are intended to protect patients from medical debt. For instance, health care providers are not permitted to seek extra payment from patients with health insurance who received care at an out-of-network hospital. Nor can they “balance-bill” — that is, bill the patient for the difference between what the insurer will pay and the hospital’s charges.
But the protections do not fully insulate patients. Even if a hospital takes federal money, some of the doctors who treat patients there can send their own bills to patients directly.
Ms. Mendez received a bill separate from the hospital. The doctors who cared for her individually charged between $300 and $1,800 for each day. Some days, four different doctors billed her for treatment.
Depending on their insurance plan, patients may still be stuck with paying co-payments, deductibles and a percentage of the bill — which can amount to thousands of dollars, although some plans may limit out-of-pocket costs, said Jack Hoadley, a health policy researcher at Georgetown University.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
And significantly, some of the conditions imposed with the bailout funds only apply to patients with insurance.Hospitals can seek reimbursement from the government for treating uninsured patients through a different process. But it may turn out that uninsured patients still receive bills.
Ms. Mendez has submitted the bill to Cigna, her new insurer, and said that she was led to believe her share of it will be under $10,000.
Like thousands of other gravely ill Covid-19 patients in New York City, Ms. Mendez, an office administrator for a Domino’s Pizza franchise, had been deeply sedated and placed on a ventilator to keep her breathing soon after arriving at the hospital on March 25. She was in the hospital for 19 nights.
When she awoke, she could not remember her own name or where she was, she said in an interview.
It was a day or two before her memory returned and her confusion receded.
When she was discharged, an ambulance took her to her mother’s home.
At first her mother tried to keep the bills from her. But then Ms. Mendez said began to get phone calls from Mount Sinai asking her how she intended to pay.
She is hopeful that insurance will cover the vast majority of the charges. But she is also worried that more bills will arrive.
“I haven’t seen anything that says ‘ambulance’ on it,” she said, wondering if she was going to be charged for the ride to the hospital. Then she remembered that she left the hospital by ambulance as well. “Maybe I’ll be charged for both of them.”
https://www.nytimes.com/2020/06/14/nyregion/coronavirus-billing-nyc.html?referringSource=articleShare

How Rich Investors, Not Doctors, Profit From Marking Up ER Bills

TeamHealth, a medical staffing firm owned by private-equity giant Blackstone, charges multiples more than the cost of ER care. All the money left over after covering costs goes to the company, not the doctors who treated the patients.

by Isaac Armsdorf - Pro Publica - June 12 2020

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In 2017, TeamHealth, the nation’s largest staffing firm for ER doctors, sued a small insurance company in Texas over a few million dollars of disputed bills.
Over 2 1/2 years of litigation, the case has provided a rare look inside TeamHealth’s own operations at a time when the company, owned by private-equity giant Blackstone, is under scrutiny for soaking patients with surprise medical bills and cutting doctors’ pay amid the coronavirus pandemic.
Hundreds of pages of tax returns, depositions and other filings in state court in Houston show how TeamHealth marks up medical bills in order to boost profits for investors. (Some of the court records were marked confidential but were available for download on the public docket; they were subsequently sealed.)
TeamHealth declined to provide an interview with any of its executives. In a statement for this story, the company says it’s fighting for doctors against insurance companies that are trying to underpay: “We work hard to negotiate with insurance companies on behalf of patients even as they unilaterally cancel contracts and attempt to drive physician compensation downward.”
But the Texas court records contradict TeamHealth’s claims that the point of its aggressive pricing is to protect doctors’ pay. In fact, none of the additional money that TeamHealth wrings out of a bill goes back to the doctor who treated the patient.
Instead, the court records show, all the profit goes to TeamHealth.



Anatomy of an ER Bill

Two TeamHealth affiliates in Texas billed 7.7 times more than their actual costs of paying for clinicians and support services. The bulk of the charges were discounted or written off. About 10% of the money actually collected went to corporate profits.
Source: Tax returns filed in Texas state court (Isaac Arnsdorf/ProPublica)

“These companies put a white coat on and cloak themselves in the goodwill we rightly have toward medical professionals, but in practice, they behave like almost any other private equity-backed firm: Their desire is to make profit,” said Zack Cooper, a Yale professor of health policy and economics who has researched TeamHealth’s billing practices and isn’t involved in the Texas lawsuit.
“In the market for emergency medicine, where patients can’t choose where they go in advance of care, there’s a real opportunity to take advantage of patients, and I think we’re seeing that that’s almost precisely what TeamHealth is doing, and it’s wildly lucrative for the firm itself and its private equity investors.”
Some of TeamHealth’s own physicians say they’re uncomfortable with the company’s business practices.
“As an emergency medicine physician, I have absolutely no idea to whom or how much is billed in my name. I have no idea what is collected in my name,” said a doctor working for TeamHealth who isn’t involved in the Texas lawsuit and spoke to ProPublica on the condition of anonymity because the company prohibits its doctors from speaking publicly without permission.
“This is not what I signed up for and this isn’t what most other ER docs signed up for. I went into medicine to lessen suffering, but as I understand more clearly my role as an employee of TeamHealth, I realize that I’m unintentionally worsening some patients’ suffering.”
Most ER doctors aren’t employees of the hospital where they work. Historically they belonged to doctors’ practice groups. In recent years, wealthy private investors have bought out those practice groups and consolidated them into massive nationwide staffing firms like TeamHealth and its largest competitor, KKR-owned Envision Healthcare.
These takeovers have affected patients, too, because the groups have gotten into payment disputes with their insurers. As a result, patients can receive huge medical bills even when they pick a hospital within their insurance plan’s network, because the individual doctor working for a contractor like TeamHealth could be out of network. This practice, known as surprise billing, caught the attention of lawmakers who have spent months working on legislation.
TeamHealth said surprise bills are “rare and unintended,” but with millions of patients, it has happened tens of thousands of times. The company has called surprise billing a “source of contracting negotiating leverage” to demand higher payments from insurers.
“Underneath this are patients who may well be charged outrageous amounts of money, but that’s just not a core consideration,” said Joshua Sharfstein, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. “The situation a lot of patients feel like they’re in is they’re collateral in this financial tug of war.”
TeamHealth and Envision Healthcare have poured millions into political ads attacking surprise billing legislation. The companies have said they want to settle out-of-network bills through arbitration instead of using average local rates, as some lawmakers have proposed.
As an alternative to going after patients themselves, TeamHealth said it sues insurers to demand higher payments for out-of-network charges. The company has filed 38 such lawsuits since 2018.
In the Texas case, two TeamHealth affiliates that provide doctors and nurses to emergency rooms in the Houston and El Paso areas sued a small insurance company called Molina Healthcare. TeamHealth identified almost 5,000 out-of-network claims in 2016 and 2017 for which it billed $6.6 million and Molina paid $760,000. TeamHealth sent a letter demanding that Molina pay $2.3 million. Molina’s lawyers viewed this as an admission that the original bill was far higher than even TeamHealth thought was fair.
The actual costs of medical services are not a factor in setting TeamHealth’s prices, according to the deposition of Kent Bristow, a TeamHealth executive in charge of revenue. At some locations, TeamHealth’s prices were higher than those of 95% of other providers and eight or nine times more than what Medicare would pay, according to Bristow’s deposition.
Most of the two TeamHealth affiliates’ charges were never actually collected, according to their tax returns and a deposition of the accountant who prepared them. For the years 2016 and 2017, the two affiliates billed a combined $1.9 billion, the tax returns show. But $1.1 billion, or 58%, was discounted according to negotiated deals with insurers. An additional $528 million was written off as bad debt that would never get repaid. So the combined revenue that the two affiliates actually received across the two years was $274.5 million, or about 14% of the amount initially billed, according to the tax returns.
The amount that TeamHealth charges doesn’t determine how much TeamHealth pays its doctors who perform those services, the company’s chief financial officer, David Jones, said in an October 2019 deposition. Instead, the doctors are paid a base compensation plus an incentive tied to how much work they do (which is not the same as the price billed for their services). For the two TeamHealth affiliates in the Molina case in 2016 and 2017, the company paid doctors a total of $170.5 million, or 62% of the net revenue, according to the tax returns. Other health care providers such as nurse practitioners and scribes received another $48.4 million.
The administrative services that TeamHealth provides — such as billing, printing and malpractice insurance — added up to $29.5 million, according to the tax returns.
After covering all those expenses, the amount of money left over — commonly called profit — was $26.1 million, about 10% of the two affiliates’ net revenue in 2016 and 2017. (The accounting method that TeamHealth uses for its tax returns is different from how it prepares financial statements regulated by the Securities and Exchange Commission. Under the latter method, the tax returns note a total of $36.8 million for the two affiliates in 2016 and 2017. Because of these accounting variations, it’s impossible to compare the figures on the TeamHealth affiliates’ tax returns to profits reported by publicly traded health care companies.)
The TeamHealth executive in charge of the two affiliates said he assumed the profit would be shared with the doctors who did the work. “It would most likely go back to the providers,” the executive, Lance Williams, said in a deposition. Under further questioning, he admitted, “Yeah, I’m not sure.”
In fact, the entire leftover $26.1 million went to TeamHealth’s “management fee.” The management fee is not a fixed rate but rather everything that remains after covering costs, regardless of the amount, according to the CFO’s deposition. “If the revenues exceed the expenses, that is essentially the management fee,” Jones said.
In other words, out of the $1.6 billion that was originally billed but not collected, any additional dollar that TeamHealth managed to recover would be passed through to the corporate parent. The doctors would not see it.
Jones said doctors benefit from increasing collections because their incentive-based pay is adjusted over time. In addition, Bristow said the management fee is not the same as profit because there may be additional expenses at the corporate level.
“The economic benefits created by these practices, any profit, if you will, ultimately flows up to the TeamHealth entity,” Ron Luke, a health economics expert hired by Molina, said in a deposition.
To establish this business model, TeamHealth had to find a way to deal with long-standing state laws that were specifically designed to protect the medical profession from becoming beholden to profit motives. These laws, known as the corporate practice of medicine doctrine, require doctors to work for themselves or other doctors, not lay people or corporations like TeamHealth. Court records in the Molina case show how TeamHealth’s lawyers use shell entities to avoid directly employing doctors.
“TeamHealth monetizes this process by unilaterally setting charges and then billing patients and payors for those amounts and retaining all of the profits of the enterprise,” Robert McNamara, a former president of the American Academy of Emergency Medicine, wrote in a memo as an expert witness against TeamHealth in the lawsuit. “The fees generated, billed, and retained by TeamHealth reflect the type of overt commercialization of the medical profession that the prohibition on the [corporate practice of medicine] is designed to prevent.”
TeamHealth said its business arrangements comply with all laws and no court or agency has ever found otherwise. “TeamHealth’s clinicians are supported by a world-class operating team that provides them with comprehensive practice management services that allow our clinicians to focus on the practice of medicine,” the company said. Envision Healthcare also said it follows all local, state and federal laws and regulations.
State laws against the corporate practice of medicine date as far back as the 19th century, as doctors strove to distinguish themselves from quacks and snake oil salesmen. According to the American Medical Association, the laws are meant to prevent profit motives from influencing medical judgments — a recognition that corporations’ devotion to shareholder value shouldn’t mix with doctors’ Hippocratic oath.
Another way to think about it is: Practicing medicine requires a license, and only a real human being can possibly have the education, training and character qualifications that licensing boards require.
Courts have scrutinized these arrangements for decades. No judge has ever ruled that TeamHealth or Envision Healthcare specifically violate state licensing rules. But such allegations have repeatedly cropped up in lawsuits involving the companies, some of which settled favorably to the other side, according to McNamara, who was consulted on many of the cases.
TeamHealth and Envision have themselves acknowledged that they operate on questionable legal ground. During periods when the companies were publicly traded, their investor disclosures highlighted the controversy surrounding their compliance with state licensing regimes. TeamHealth and Envision said they believed their business models were legal but recognized that prosecutors, regulators and judges could conclude otherwise. TeamHealth specifically cited “laws prohibiting general business corporations, such as us, from practicing medicine.”
“While we believe that our operations and arrangements comply substantially with existing applicable laws relating to the corporate practice of medicine and fee splitting, we cannot assure you that our existing contractual arrangements, including restrictive covenant agreements with physicians, professional corporations and hospitals, will not be successfully challenged in certain states as unenforceable or as constituting the unlicensed practice of medicine or prohibited fee splitting,” the company said in its 2015 annual report. “In this event, we could be subject to adverse judicial or administrative interpretations or to civil or criminal penalties, our contracts could be found to be legally invalid and unenforceable or we could be required to restructure our contractual arrangements with our affiliated provider groups.”
TeamHealth says the laws are outdated and unnecessary — as one of the company’s senior lawyers called it in a deposition, “this arcane law we call the corporate practice of medicine that nobody needs.”
Not all states have such laws. In Florida, for instance, TeamHealth employs doctors directly. In states that have laws against the corporate practice of medicine, TeamHealth has a workaround depending on the specific requirements in that state. Here’s how it works for the affiliates involved in the Molina litigation, just two out of hundreds of equivalent arrangements around the country.
Doctors working for TeamHealth are technically independent contractors to a “professional association,” or P.A. In order to comply with Texas law, the professional association is owned by a licensed physician. The professional association then contracts with TeamHealth subsidiaries to provide administrative services — such as billing, payroll and malpractice insurance — in exchange for payment.
These professional associations, however, are hardly independent. They’re “owned” by an executive at TeamHealth, and the company has the power to remove and replace him at any time. For the two professional associations involved in the Molina case, when a new executive took over as “owner” in 2019, he said in a deposition that he couldn’t remember how he “bought” the entities or if he ever paid anyone the $2 nominal price of their shares.
“Everything about your right to own, operate, and manage ACS and EST [the two professional associations] is dependent upon you staying in the good graces of the TeamHealth organization, correct?” Molina’s lawyer asked in the deposition.
“Correct,” the owner/executive, Lance Williams, said.
“And if you were fired for any reason, you would lose ownership of ACS and EST, lose the right to manage ACS and EST, correct?”
“Correct.”
Williams also said there’s no “black and white” separation between clinical and financial issues.
In sum, the contract between TeamHealth and the professional associations gives investors more control of the business than doctors, according to Chuck Pine, a financial investigator who specializes in examining shell companies to determine the real beneficial owners. Pine isn’t involved in the Molina litigation.
Molina’s lawyers called the arrangement “a sham to permit TeamHealth to unlawfully practice medicine by allowing it to in effect employ physicians in violation of state law.”
TeamHealth countered that whether or not Molina’s claims are right, they aren’t enforceable through private litigation; only the state’s attorney general could prosecute a corporation for practicing medicine without a license.
The judge rejected Molina’s claims in an order that didn’t explain her rationale. Other parts of the case are still pending.
TeamHealth has used the same argument to defeat other lawsuits. It puts opponents in a Catch-22: State licensing boards have no control over a corporation that might be practicing medicine without a license because the boards don’t license corporations. The boards could theoretically punish the “owners” of the professional associations, but those doctors are not always licensed in the same state as the practice, and TeamHealth could always replace them with someone else.
The Texas attorney general’s office didn’t respond to requests for comment. McNamara said he’s brought several cases to the attention of various state attorneys general, to no avail.

Rooks: How to get to ‘Medicare for All’

By Douglas Rooks - Seacoastline.comJun 13,  - June 13, 2020
 
 
For the first time in years, countless Americans are going through their daily lives with a pervasive sense of dread. That it comes amid new evidence that the nation’s super-high priced health care system is inadequate for dealing with a pandemic only increases the worry.
Even before the coronavirus, the beachhead established by the Affordable Care Act was receding, not primarily through the Republican assault on it in Congress and the courts, but the inevitable erosion produced by a system that rewards waste and punishes thrift.
The ACA tried to square the circle by expanding access to both public and private systems. The former, through Medicaid expansion, worked pretty well, as least where governors cooperated.
The private expansion, however, has failed. Tens of millions of Americans have discovered their previous employer-paid health insurance is now paid, in increasing amounts, by themselves.
Consumer payments, through premiums and especially through co-pays and deductibles, are the fastest growing part of the payment pie, and employers increasingly provide inadequate lump sums, while instructing employees to buy their own insurance.
And that doesn’t include the tens of millions who’ve lost their jobs. For them, dread of “The Bill,” surprise or not, has become overwhelming.
Yet polls indicate there’s still one aspect of Medicare for All, the most promising reform initiative since Medicare itself, in 1965, that hasn’t quite registered. Despite the evidence that the private insurance system, declining since the 1980s, has now failed, many fear losing it.
The obvious answer: that you’re not losing your private insurance, you’re gaining much more reliable and affordable public insurance, hasn’t yet become real.
So we need this time not only to shore up support for the switch to a public system – the only way to overcome the perverse financial incentives of American health care – but to reform Medicare itself, which needs it.
It’s heartening that at least one Maine candidate, Betsy Sweet, running for U.S. Sen. Susan Collins’ seat, is rising to the challenge. Sweet, unlike many Medicare-for-All enthusiasts, recognizes that Medicare, despite its universal coverage for those over 65, has systemic problems, too.
Most were introduced by the “reform” package backed by Republican President George W. Bush, and enacted in 2003 with too-credulous support from Democrats. For the first time, Medicare fully covered most prescription drug costs, but it did so in an unfortunate manner.
The program was never adequately funded, and immediately went further into the red through an irresponsible clause, at GOP insistence, that Medicare couldn’t “negotiate” with drug companies, but must pay whatever they asked.
Another regrettable provision was the inclusion of private insurance within Medicare, the so-called “Advantage plans.” These supplements do provide valuable benefits, but they’re largely funded by the taxpayers, and insurance companies make still more profit.
Sweet is calling for true reform by using the government’s formidable buying power to drive down prescription prices, and to remove the private offerings and replace them with public alternatives with the same benefits.
There was never any reason for privatized Medicare. From the beginning, the insurance companies have been the benefit managers – one reason why Medicare’s stated administrative costs are so low – and do a reasonably good job, though that role, too, should get more scrutiny.
Privatization was the Republicans’ major goal, amply rewarded by a steady flow of campaign contributions, and abetted by Democrats who simply wanted to expand Medicare benefits without understanding they were undermining its future as a public program.
If all this seems a bit complicated, it isn’t, really. All the other advanced nations on the globe have public insurance systems, or private ones so tightly regulated they could never function here.
Returning Medicare to its public purposes is a necessary first step to gradually expanding eligibility to more Americans – lowering the age of enrollment to 60, and then 55. Yes, it would seem expensive, but far less expensive than sticking with the current failed methods.
And the savings – yes, savings – could be reinvested so the gap between Medicare and Medicaid, in eligibility and income levels, could eventually disappear, with Medicare for All finally achieved.
Some activists will be disappointed that universal coverage through public programs can’t be achieved sooner, but the problem of soaring costs and failing access took 50 years to develop, and it’s not going to be solved overnight.
The good news is that it is achievable, and can overcome any lingering doubts voters might still have. And the best way to start is by electing the right candidates to Congress.
Douglas Rooks, a Maine editor, reporter, opinion writer and author for 35 years, has published books about George Mitchell, and the Maine Democratic Party. He welcomes comment at drooks@tds.net.
https://www.seacoastonline.com/opinion/20200613/rooks-how-to-get-to-medicare-for-all

Pandemic takes staggering financial toll on Maine hospitals

They have lost $250 million a month since the pandemic hit the state. The federal bailout has covered about a month's losses. 
by Penelope Overton - Maine Sunday Telegram - June 14, 2020

Federal bailout funds intended to help the U.S. health care system survive the COVID-19 pandemic have covered a little less than one-third of the financial losses suffered by Maine’s three dozen hospitals since mid-March, when the deadly virus forced them to stop treating all but the sickest patients.
Maine hospitals began losing about $250 million a month after suspending elective and preventative care, said Steven Michaud, president of the Maine Hospital Association. Patient volumes fell to half their normal levels. Yet the hospitals have received only $225 million from the federal Provider Relief Fund to date, federal records show.
Maine hospitals are hoping more bailout funds and a resumption of traditional care will help make them whole. Patient volumes are back up to 75 percent, a good sign, but most Maine hospitals can’t afford to wait. They’re dipping into their financial reserves, delaying building projects, laying off workers and taking out loans against future Medicare payments to stay afloat.
“We are in big trouble,” Michaud said. “The losses are staggering. They are frightening. Things are starting to get better, but very slowly. People are skittish about coming back. … I think we are only starting to see the financial consequences of this. I don’t know how we come back from it. I don’t know if that’s even possible.”
Some worry a big chunk of the commercially insured care that enables Maine’s nonprofit hospitals to break even has been lost for good. After all, while a faulty hip must eventually get replaced, no one gets two annual physicals. Some patients who have had to use telehealth or urgent care to get medical care during the pandemic may not return to hospitals, either.
Congress created a $175 billion Provider Relief Fund within the CARES Act to help U.S. hospitals, clinics and doctors survive the financial losses of deferred care, as well as respond to the pandemic itself, but it has not been enough. Michaud estimates Maine hospitals have received enough Provider Relief Fund money to cover a month’s worth of their losses.
That’s just the revenue side of the books, he notes. Nobody has even had time to track how much COVID-19 has driven up costs.
The Maine Hospital Association has joined a national chorus of health care groups calling on Congress to distribute the Provider Relief Fund to ailing health care providers as quickly as possible. The U.S. Health and Human Services Department has awarded $125 billion of it so far, sending out money in allocation waves targeting different aid to different groups.
Maine has received about $323 million from the Provider Relief Fund to date, distributed among 963 providers that range from rural ambulance services to well-heeled private practices to urban hospitals that employ thousands and operated COVID-19-only intensive care units. The first payment of $146 million to Maine went out in early April.
The first round was distributed using Medicare reimbursement rates – a formula readily available to federal agencies – to get the money into the hands of providers as quickly as possible. With Maine’s demographics, local hospitals did well in that first round. According to Michaud, Medicare accounts for about half of all revenues for Maine hospitals.
So far, Maine’s 36 hospitals have received about $225 million of that $323 million, or 70 percent, according to the latest federal statistics. Awards varied from hospital to hospital, from less than $500,000 for a 25-bed facility such as Rumford Hospital to as much as $69.8 million for MaineHealth, a nine-hospital network that includes the state’s largest medical center.
While bailout amounts vary by hospital, the ratio of what that bailout covers – about a month’s worth of lost revenue – is universal, Michaud said. The MaineHealth network, including its New Hampshire hospital, has been losing $100 million a month since the pandemic hit, and to date the network has received $98 million in Provider Relief Funds.
Follow-up disbursement rounds have targeted COVID-19 hot spots, rural providers and nursing homes. No Maine hospital treated enough COVID-19 patients to qualify for hot spot money, but 121 Maine health care providers, including hospitals, received $131 million in rural provider subsidies and 65 nursing homes have received $17 million.
And just last week HHS announced that its latest round of Provider Relief Fund disbursements would go to so-called safety net hospitals that treat mostly Medicaid-dependent patients. The agency said it will deposit another $52.2 million into bank accounts of eight Maine hospitals soon, if it has not already showed up, but it would not say which ones.
An HHS spokesman said the next round of Provider Relief Fund money will likely go to dentists, but didn’t give any more details.
To cover what the bailout does not, Maine hospitals are turning to advance Medicare payments for reimbursable services they are likely to perform in the future. These are essentially short-term, zero-interest loans that act like the health care world’s version of a payday loan. The amount they get is based on past Medicare reimbursements.
So far, Maine hospitals have accepted $580 million of these advances. Hospital finance officials fear their long-term impact – at best, repayment dulls the financial impact of returning patient volumes, and at worst, volume doesn’t rebound fast enough to pay the advance back before interest kicks i
St. Joseph Hospital in Bangor has received $2.7 million in grants so far from the Provider Relief Fund, but that wasn’t enough to cover its losses at the height of the shutdown, when patient revenues were down 53 percent, so it had no choice but to tap into its future Medicare payments – about six months’ worth, or $15.4 million.
“It was about our cash flow, which is the problem most hospitals are facing right now,” said hospital president Mary Prybylo. “We won’t be getting a payment now even if our volume goes up, and it’s really going to have to go up to where it was before if we want to survive this. … But we have a responsibility to our community, at this time more than ever.”
Net patient revenue fell 53 percent during the pandemic, and is only now starting to creep back up, but it’s nowhere near the level needed to operate in the black, much less repay its Medicare advance, according to Mike Hendrix, St. Joe’s chief financial officer. That does not count the increased costs of COVID-19 prep and care, which clocked in at more than $700,000 in the first 90 days.
Only Calais and Penobscot Valley are not receiving any advances, but neither is eligible – both are mired in bankruptcy court. But that hasn’t stopped either one of these small hospitals from applying for another form of federal COVID-19 bailout assistance, the Paycheck Protection Program. The government tried to exclude them, but a judge is allowing both to participate.
Hospitals are taking other steps to close the revenue gap, including employee layoffs and furloughs in the midst of a public health crisis, reviewing community programs with an eye toward reducing those that are not considered essential to the community, and delaying some long-awaited building projects.
Houlton Regional Hospital has reduced pay to salaried employees, including doctors, by 2 to 10 percent, and hourly workers must take one furlough day a month to stay afloat during the height of the pandemic, a strategy that officials there say impacted close to 400 people.
Central Maine Medical Center in Lewiston implemented a voluntary furlough plan that allowed employees to maintain health care while applying for unemployment, redeployed the remaining staff to parts of the system that remained operational, and deferred executive compensation by 10 percent.
MaineHealth, the largest private employer in the state, has promised to protect its 23,000 jobs and current pay rates through the end of the fiscal year ending Sept. 30, said Katie Harris, the network’s senior vice president of government affairs. But it needs its patient volumes to return to pre-COVID levels or more bailout relief to keep staffing levels and wages safe beyond that.
“We worked together to flatten the curve of COVID-19 infections here in Maine and were able to avoid the worst of it, but it wasn’t without consequences,” Harris said. “With help from the federal government, we were able to smooth out our financial losses, too, but the losses haven’t gone away. … Without more help, something has to give.”
The network is likely to delay part of its planned $525 million, five-year expansion plan, Harris said. Ironically, the part that may get put on hold would be plans to fit out a wing of 32 new single-occupancy rooms – a hospital feature whose value is made clearly apparent during a pandemic, when hospitals are scrambling to isolate infected patients, Harris said.
While MaineHealth has the ability to absorb losses, many of Maine’s hospitals, especially its rural ones, were barely staying afloat before the pandemic hit, according to Michaud. Almost half – 17 out of 36 – of Maine hospitals finished last year with a negative operating margin. The average Maine hospital ended the year with a 1.4 percent operating margin.
https://www.pressherald.com/2020/06/14/pandemic-takes-staggering-financial-toll-on-maine-hospitals/ 
 

Insurance status linked to survival benefit in cancer treatment trials

by John DeRosier - Practice Management - June 12, 2020 

Patients with cancer who either had Medicaid or no health insurance derived smaller benefits from experimental therapies than standard therapies in clinical trials, according to results of a meta-analysis published in JAMA Network Open.
Better understanding of the quality of survivorship care — including supportive and post-treatment care — received by patients with suboptimal insurance could help explain how external factors may affect outcomes, researchers noted.
“A patient’s insurance coverage seems to be related to the extent to which they benefit from new experimental treatments tested in trials,” Joseph M. Unger, PhD, Southwest Oncology Group (SWOG) health services researcher and biostatistician at Fred Hutchinson Cancer Research Center, said in a press release. “Our findings highlight the importance of policies that would provide more Americans insurance coverage and underline the importance of improving that coverage.”
Few new treatments tested in randomized phase 3 cancer trials improve OS. Understanding whether treatment benefits are consistent across patient groups is necessary to inform guideline care. However, individual trials are designed to assess the benefits of experimental treatments among all patients and can be too small to determine whether the benefits apply to demographic or insurance subgroups, according to study background.
Unger and colleagues analyzed pooled patient-level data of 10,804 patients with cancer in 19 SWOG Cancer Research Network trials to examine whether positive treatment effects in randomized clinical cancer trials apply to specific demographic or insurance subgroups.
The majority of patients were aged younger than 65 years (67.3%) and female (66.3%). Additionally, 11.4% of patients were black and 5.7% were Hispanic.
Enrollment for the trials occurred from 1984 to 2012, and each trial followed patients for up to 5 years after treatment. All trials reported an OS benefit for patients randomly assigned to the experimental treatment.
Researchers used interaction tests to assess whether the association of treatment with survival differed according to age (65 years or older vs. younger than 65 years), race/ethnicity (minority vs. nonminority populations), sex, or insurance status among patients aged younger than 65 years.
Investigators also examined PFS and RFS.
Results showed no significant added survival benefit associated with experimental therapy for patients with Medicaid or no insurance (HR = 1.23; 95% CI, 0.97-1.56) compared with patients with private insurance (HR = 1.66; 95% CI, 1.44-1.92).
Receipt of experimental treatment appeared associated with reduced added OS benefits among patients aged 65 years or older (HR = 1.21; 95% CI, 1.11-1.32) compared with patients aged younger than 65 years (HR = 1.41; 95% CI, 1.3-1.53). Both groups, however, benefited greatly from the experimental treatments.
HRs for PFS and RFS did not differ by age, sex or race/ethnicity but did differ between patients who had private insurance (HR = 1.74; 95% CI, 1.54-1.97) and those who had Medicaid or no insurance (HR = 1.32; 95% CI, 1.06-1.64).
Most trials were completed before the implementation of insurance exchanges and Medicaid expansion under the Affordable Care Act, which served as a limitation to this study.
“People with fewer financial resources have access to fewer health care resources, which can have a persistent, negative influence on their health,” Unger said in a press release. “Patients in trials having no or limited insurance may not have the financial means to pay for the extra supportive treatments or post-trial cancer treatments that help people live longer. This could be especially meaningful for understanding treatment benefits if experimental therapy requires more supportive care or is more difficult to adhere to than standard treatment.”
https://www.healio.com/news/hematology-oncology/20200611/insurance-status-linked-to-survival-benefit-in-cancer-treatment-trials?


 

Why People Are Still Avoiding the Doctor (It’s Not the Virus)

At first, people delayed medical care for fear of catching Covid. But as the pandemic caused staggering unemployNYT  - ment, medical care has become unaffordable for many.
by Reed Abolson - June 16, 2020  

At first, people delayed medical care for fear of catching Covid. But as the pandemic caused staggering unemployment, medical care has become unaffordable for many.
Kristina Hartman of North Garland, Tex., was recently laid off from her job, forcing her to cut back on some health appointments.Credit...Allison V. Smith for The New York Times
At first, Kristina Hartman put off getting medical care out of concern about the coronavirus. But then she lost her job as an administrator at a truck manufacturer in McKinney, Texas.
While she still has health insurance, she worries about whether she will have coverage beyond July, when her unemployment is expected to run out.
“It started out as a total fear of going to the doctor,” she said.
“I definitely am avoiding appointments.”
Ms. Hartman, who is 58, skipped a regular visit with her kidney doctor, and has delayed going to the endocrinologist to follow up on some abnormal lab results.
While hospitals and doctors across the country say many patients are still shunning their services out of fear of contagion — especially with new cases spiking — Americans who lost their jobs or have a significant drop in income during the pandemic are now citing costs as the overriding reason they do not seek the health care they need.
“We are seeing the financial pressure hit,” said Dr. Bijoy Telivala, a cancer specialist in Jacksonville, Fla. “This is a real worry,” he added, explaining that people are weighing putting food on the table against their need for care. “You don’t want a 5-year-old going hungry.”
Among those delaying care, he said, was a patient with metastatic cancer who was laid off while undergoing chemotherapy. He plans to stop treatments while he sorts out what to do when his health insurance coverage ends in a month.
The twin risks in this crisis — potential infection and the cost of medical care — have become daunting realities for the millions of workers who were furloughed, laid off or caught in the economic downturn. It echoes the scenarios that played out after the 2008 recession, when millions of Americans were unemployed and unable to afford even routine visits to the doctor for themselves or their children.
Almon Castor’s hours were cut at the steel distribution warehouse in Houston where he works about a month ago. Worried that a dentist might not take all the precautions necessary, he had been avoiding a root canal.
But the expense has become more pressing. He also works as a musician. “It’s not feasible to be able to pay for procedures with the lack of hours,” he said.
Nearly half of all Americans say they or someone they live with has delayed care since the onslaught of coronavirus, according to a survey last month from the Kaiser Family Foundation. While most of those individuals expected to receive care within the next three months, about a third said they planned to wait longer or not seek it at all.
While the survey didn’t ask people why they were putting off care, there is ample evidence that medical bills can be a powerful deterrent. “We know historically we have always seen large shares of people who have put off care for cost reasons,” said Liz Hamel, the director of public opinion and survey research at Kaiser.
And, just as the Great Recession led people to seek less hospital care, the current downturn is likely to have a significant impact, said Sara Collins, an executive at the Commonwealth Fund, who studies access to care. “This is a major economic recession,” she said. “It’s going to have an effect on people’s demand for health care.”
The inability to afford care is “going to be a bigger and bigger issue moving forward,” said Chas Roades, the co-founder of Gist Healthcare, which advises hospitals and doctors. Hospital executives say their patient volumes will remain at about 20 percent lower than before the pandemic.
“It’s going to be a jerky start back,” said Dr. Gary LeRoy, a physician in Dayton, Ohio, who is the president of the American Academy of Family Physicians. While some of his patients have returned, others are staying away.
But the consequences of these delays can be troubling. In a recent analysis of the sharp decline in emergency room visits during the pandemic, officials from the Centers for Disease Control and Prevention said there were worrisome signs that people who had heart attacks waited until their conditions worsened before going to the hospital.
Without income, many people feel they have no choice. Thomas Chapman stopped getting paid in March and ultimately lost his job as a director of sales. Even though he has high blood pressure and diabetes, Mr. Chapman, 64, didn’t refill any prescriptions for two months. “I stopped taking everything when I just couldn’t pay anymore,” he said.
After his legs began to swell, and he felt “very, very lethargic,” he contacted his doctor at Catalyst Health Network, a Texas group of primary care doctors, to ask about less expensive alternatives. A pharmacist helped, but Mr. Chapman no longer has insurance, and is not sure what he will do until he is eligible for Medicare later this year.

  • What is pandemic paid leave?

    The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.

  • Does asymptomatic transmission of Covid-19 happen?

    So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

  • What’s the risk of catching coronavirus from a surface?

    Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

  • How does blood type influence coronavirus?

    A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

  • How many people have lost their jobs due to coronavirus in the U.S.?

    The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

  • Will protests set off a second viral wave of coronavirus?

    Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

  • My state is reopening. Is it safe to go out?

    States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

  • What are the symptoms of coronavirus?

    Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

  • How can I protect myself while flying?

    If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

  • Should I wear a mask?

    The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

  • What should I do if I feel sick?

    If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
“We’re all having those conversations on a daily basis,” said Dr. Christopher Crow, the president of Catalyst, who said it was particularly tough in states, like Texas, that did not expand Medicaid. While some of those who are unemployed qualify for coverage under the Affordable Care Act, they may fall in the coverage gap where they do not receive subsidies to help them afford coverage.
Even those who are not concerned about losing their insurance are fearful of large medical bills, given how aggressively hospitals and doctors pursue people through debt collections, said Elisabeth Benjamin, a vice president at Community Service Society of New York, which works with people to get care.
“Americans are really very aware that their health care coverage is not as comprehensive as it should be, and it’s gotten worse over the past decade,” Ms. Benjamin said. After the last recession, they learned to forgo care rather than incur bills they can’t pay.
Geralyn Cerveny, who runs a day care in Kansas City, Mo., said she had Covid-19 in early April and is recovering. But her income has dropped as some families withdrew their children. Although her daughter is urging her to get some follow-up testing because she has some lingering symptoms from the virus, she is holding off because she does not want to end up with more medical bills if her health plan will not cover all of the care she needs. She said she would dread “a fight with the insurance company if you don’t meet their guidelines.”
Others are weighing what illness or condition merits the expense of a doctor or tests and other services. Eli Fels, a swim instructor and personal trainer who is pregnant, has been careful to stay up-to-date with her prenatal appointments in Cambridge, Mass. She and her doctor have relied on telemedicine appointments to reduce the risk of infection.
But Ms. Fels, who also lost her jobs but remains insured, has chosen not to receive care for her injured wrist in spite of concern over lasting damage. “I’ve put off medical care that doesn’t involve the baby,” she said, no
ting that her out-of-pocket cost for an M.R.I. to find out what was wrong “is not insubstantial.”
At Maimonides Medical Center in Brooklyn, doctors have already seen the impact of delaying care. During the height of the pandemic, people who had heart attacks and serious fractures avoided the emergency room. “It was as if they disappeared, but they didn’t disappear,” said Dr. Jack Choueka, the chair of orthopedics. “People were dying in home; they just weren’t coming into the hospital.”
In recent weeks, people have begun to return, but with conditions worsened because of the time they had avoided care. A baby with a club foot will now need a more complicated treatment because it was not addressed immediately after birth.
Another child who did not have imaging promptly was found to have a tumor. “That tumor may have been growing for months unchecked,” Dr. Choueka said.
https://www.nytimes.com/2020/06/16/health/coronavirus-insurance-healthcare.html?referringSource=articleShare

Why the Sickest Workers May Be Among the First Back on the Job

Since most people in the U.S. get health insurance through work, many with pre-existing conditions fear unemployment more than they fear coronavirus.
Last month, Patti Hanks faced a wrenching decision: go back to her job, or lose her health insurance.
Ms. Hanks, 62, recently had ovarian cancer treatment. With her immunity low, she was nervous about returning to her workplace, a store where she would be drawing up financing plans and taking cash payments from customers buying furniture and large appliances.
But she was even more worried about losing her health coverage if she didn’t go back. Finding a job with health benefits that allowed her to work from home felt like a pipe dream in the midst of an economic downturn.
“I just got over chemo,” she said. “Now is not the time for me to lose my insurance."
So, despite her reservations, she returned to work. She wears a mask and makes sure customers sit a good distance away at an L-shaped desk.
“It’s a scary thing to go back and know you have low immunity,” she said in mid-May, after two days back at her job. “But when it all boils down to it, I don’t think Covid-19 is going away any time soon. I don’t think you can hide from it. You’ve got to trust God and go back.”
Ms. Hanks’s experience illustrates how America’s employment-based health insurance system could become another liability in the country’s fight to contain coronavirus. It could push workers at highest risk of serious illness from coronavirus back to work the fastest. Those people need coverage to treat the pre-existing conditions that make them vulnerable in the first place.
About one-quarter of American workers — 37.7 million people in total — are estimated to be at high risk of serious illness from coronavirus, according to a Kaiser Family Foundation study published this week.
Some are at increased risk because of age, and some have health problems like diabetes or asthma that the Centers for Disease Control and Prevention has identified as risk factors.
“It is one of the many ways the U.S. health care system has made us so much more vulnerable to the effects of the pandemic than other countries,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation and a co-author of the new study. “In other countries, you don’t hear about people losing health insurance when they lose their jobs.”
When it comes to health care, the United States is rarely like the other countries Mr. Levitt mentions. In Canada and Britain, workers get their health coverage through the government. In many European countries, like Germany and the Netherlands, workers buy subsidized coverage individually in tightly regulated markets.
In the United States, 61 percent of working-age adults get health insurance through work. This system of employer-sponsored insurance dates to World War II-era policy decisions that encouraged companies to provide workers with medical benefits.
The federal government’s most consequential decision, in the mid-1940s, was to not tax health insurance benefits. An employer’s dollar spent on health benefits suddenly stretched much further than one spent on wages. This laid the groundwork for what we see today: Most companies, large and small, offer health benefits to workers.
The Affordable Care Act did provide new ways for Americans to get health insurance outside of work. It expanded Medicaid to cover millions more low-income adults. It also created new private insurance marketplaces where middle-income Americans could buy subsidized coverage (and health plans could not discriminate against those with pre-existing conditions).
But that new safety net has some holes. Fourteen states, including large ones like Florida and Texas, declined to participate in the health law’s Medicaid expansion. Workers who lose employer-sponsored coverage in those places may have less access to affordable coverage options.
Others may find the coverage options on the health law marketplaces prohibitively expensive, particularly those earning slightly too much to receive coverage subsidies. What’s more, the most affordable marketplace plans tend to provide less robust coverage than what employers typically offer. They require patients to pick up a greater share of their treatment costs with co-payments and deductibles.
Those shortfalls in the safety net may push vulnerable workers to do what Ms. Hanks did: go back to work before feeling entirely comfortable with the risks.
Ms. Hanks lives in Virginia, a state that expanded Medicaid, but she expects that she earns too much from other income sources to be able to sign up for the program. She and her husband (who is a few years older and covered by Medicare) own a few rental properties as well as a herd of Black Angus cattle, which they sometimes sell to meat producers or other farmers.
When the couple bought their own health coverage about a decade ago, before Obamacare, they could find only expensive options shopping on their own. Access to employer-sponsored coverage was one of the reasons Ms. Hanks took her job at the furniture store in the first place.
A month after returning to work, she generally feels safe. She and other employers sanitize their chairs and desks frequently. Ms. Hanks is careful to wipe down the pens her customers use to sign contracts.
She recently got some good news from her doctor: Her immune system seems to be recovering from the chemotherapy treatment, returning closer to normal.
Still, the store has been pretty busy since Virginia began lifting stay-at-home restrictions last month (demand for freezers appears to be especially high, possibly a sign of families stocking up on groceries). There was one episode that scared her, when a worker from a local nursing home entered the store to shop.
“She didn’t look like she felt good, like she was kind of sweaty on the forehead,” she said. “She had a mask on, but I was sitting there, looking at her, thinking this is not good.
“But you can’t crawl into a hole. I think we’ve done everything we can to protect ourselves. I know I try to. So I’ll just keep going. That’s just the way it is.”
https://www.nytimes.com/2020/06/18/upshot/coronavirus-health-insurance-sickest-workers-return.html?

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