Why Aren’t More People Comparison Shopping for Health Plans?
Most Medicare beneficiaries don’t compare plans during open enrollment season, and may be paying more, or accepting more restrictions, than they should.
by Paula Span - NYT - October 30, 2021
One morning last month, Eunice Korsah, a retired nurse in Burke, Va., spent about half an hour on the phone being guided through the complexities of various plans for Medicare Part D, which covers prescription drugs.
Her current drug plan was being discontinued and the insurer wanted to move her into one with sharply higher premiums. “I decided, ‘No way,’” she said. But what to replace it with? She looked at the Medicare website for Part D plans available in Fairfax County and found 23, with monthly premiums ranging from $7.10 to $97.30. “There are so many choices, so I wanted someone to clarify them for me,” she said.
Jack Hoadley, a health policy researcher at Georgetown University, was on the other end of the call with Ms. Korsah. He has for two years volunteered with the State Health Insurance Assistance Program, or SHIP, the federally funded, free counseling service that helps Medicare beneficiaries find the coverage that’s best for them.
“Some very smart people just don’t know how Medicare works and get confused,” Dr. Hoadley said. For example, “it can make a $1,000-a-year difference if you’re willing to try several different pharmacies.”
Ms. Korsah, 74, and her son had already compiled a list of her eight medications — for blood pressure, cholesterol, acid reflux and glaucoma — and their doses. Using the online Medicare Plan Finder, Dr. Hoadley narrowed the field to three suitable selections.
With the cheapest plan, from Wellcare, Ms. Korsah’s estimated total yearly drug and premium costs (“the magic number,” he said) would be $301 a year if she used a CVS or Giant pharmacy — but $1,125 if she took the same prescriptions to a Walmart. Conversely, a Humana plan would cost $525 a year through a Walmart pharmacy, but more than twice that at CVS. With a Cigna plan, the best deal involved a mail-order pharmacy.
In theory, all beneficiaries who have traditional Medicare with Part D coverage, or who are interested in or enrolled in Medicare Advantage programs (an “all-in-one” alternative offered through private insurers), should be making similar calculations during this annual open enrollment period, from Oct. 15 until Dec. 7. It’s the reason that insurers’ pitches for plans are showing up in their mailboxes and inboxes, and on TV ads featuring Joe Namath and Jimmie “Dyn-o-mite” Walker.
“The idea is that consumers can re-evaluate what coverage is best for them,” said Tricia Neuman, the executive director of the Program on Medicare Policy at the Kaiser Family Foundation. Since each year brings changes to Part D and Medicare Advantage — in premiums, benefits, co-payments and provider networks — shopping around makes sense.
But that’s not what happens.
For 2019, 71 percent of beneficiaries said they didn’t compare plans during the open enrollment period, according to a Kaiser study published last month. The rate was even higher among Black and Hispanic beneficiaries, people over 85 and those with lower income and fewer years of education — precisely the groups most likely to require more medical services and drugs, and least able to pay high costs.
Roughly half of respondents had never visited the official Medicare website, used its 1-800-MEDICARE help line or read the “Medicare & You” handbook that annually arrives by mail.
Accordingly, “there’s not a lot of switching,” Dr. Neuman said. Kaiser found that in 2019, only eight to 10 percent of beneficiaries voluntarily changed their Medicare Advantage or stand-alone Part D plans.
Some of that inertia may reflect people’s satisfaction with their coverage; it might also indicate an overwhelming amount of choice. For 2022, beneficiaries face an average of 33 Medicare Advantage plans to select from (but 56 in Philadelphia and 63 in Cincinnati) and 30 stand-alone Part D plans.
“It is hopelessly, needlessly complicated and it continues to get more complicated,” said David Lipschutz, associate director of the Center for Medicare Advocacy. “The entire system relies on savvy actors maximizing their choices, and that just does not happen.”
Even those who are motivated to comparison shop can have trouble finding reliable information. Most overtures and ads come from brokers or agents with financial incentives, though the offers may mimic official Medicare communications.
Moreover, “brokers typically only market a portion of plans,” sometimes excluding the most advantageous, a fact they’re not required to disclose, said Gretchen Jacobson, a vice president of Medicare at the Commonwealth Fund, a foundation which supports health research.
The Center for Medicare Advocacy, a nonprofit group, has charged that Medicare itself has shown bias toward private Medicare Advantage plans in its promotional materials, starting in 2017. “They started overplaying some of the benefits and downplaying some of the negatives,” said Mr. Lipschutz. “I think they wanted private health insurers to thrive.”
Medicare has since resumed a more neutral stance, but “they still have a way to go,” Mr. Lipschutz said.
As for the star ratings that Medicare awards, critics have begun to invoke “the Lake Woebegon” effect (after the radio personality Garrison Keillor’s fictional town where “the children are all above average”). Medicare gave four stars or higher to 68 percent of 2022 Medicare Advantage plans with drug coverage, making the rankings less than useful for comparisons.
How much does all this matter? With Part D, choosing the most cost-effective plan goes beyond a financial issue, because skipping unaffordable medications can have health consequences. And choosing between traditional Medicare and Medicare Advantage involves substantial differences in the health care experience.
Medicare Advantage plans, so increasingly popular that 42 percent of Medicare beneficiaries are now enrolled in one, offer one-stop shopping. They include a Part D benefit, and don’t require a supplemental Medigap policy to cover co-payments and deductibles.
They put a cap on out-of-pocket expenses ($7,550 for in-network coverage in 2021). They also promote “extra benefits” like dental, hearing and vision coverage, and transportation — though “they may not be very generous,” Dr. Jacobson said. However, some services aren’t available to everyone in the plan, and beneficiaries can’t learn if they’ll qualify until after they’ve enrolled.
Medicare Advantage also restricts full coverage only to doctors, hospitals and pharmacies within their networks; if patients go outside the network, they face higher costs or may have to pay entirely out of pocket. In-network providers change frequently, and it can be challenging to ascertain which ones a plan includes.
Except for emergency or urgent care, Medicare Advantage coverage may not extend outside beneficiaries’ county or state. “If you’re in Albany, you may not be able to get care in New York City,” Dr. Jacobson said. Advantage plans also often require preauthorization from the insurer for services and drugs.
With traditional Medicare, “you can see any provider you want to at any time, without getting prior approval,” Dr. Jacobson said. It’s accepted nationally. But factoring in a private Medigap policy and a separate Part D plan sometimes pushes overall costs higher.
Still, a recent Commonwealth Fund analysis found that traditional Medicare and Advantage plans (excluding special needs plans) now attract similar populations in terms of demographics and health, with high rates of satisfaction in both groups (though both reported waiting more than a month for a doctor’s appointment).
Advantage beneficiaries are more likely to receive some care management services, such as a review of their medications, the study found. But when it comes to patients’ health, “it doesn’t seem to change the outcomes much,” Dr. Jacobson said, because hospitalization and emergency room use were roughly the same for both groups.
That raises the question of whether the federal government should continue paying Advantage plans 4 percent more per beneficiary than it pays for those in traditional Medicare. Everyone who pays a Part B premium, which is almost every beneficiary, winds up subsidizing that higher cost.
But for now, it’s open enrollment season. SHIP programs in every state, with 12,500 trained team members, represent the best source of unbiased information and work with more than 2.5 million people each year.
Ms. Korsah, who opted for traditional Medicare because she wants to be able to choose her doctors, signed up with the low-cost Wellcare Part D plan and will probably pay less for drugs than she did last year.
So she appreciated Dr. Hoadley’s counsel. “He was a great help,” she said.
https://www.nytimes.com/2021/10/30/health/open-enrollment-health-insurance-medicare.html?
https://www.pbs.org/wnet/amanpour-and-company/video/hospitals-crisis-why-nurses-are-burned-out-and-quitting-zxyf/
The Rotten Core of the Republican Party
by Binyamin Appelbaum - NYT - October 24, 2021
Representative Kevin McCarthy of California, the top House Republican, recently took to social media to warn that Democrats have hatched a dastardly plot. “Democrats,” he said, “want to track every penny you earn so they can then tax you and your family at the maximum possible amount.”
Well, yes. Democrats want Americans to pay the full amount they owe in taxes.
What doesn’t get enough attention is that many Republicans seem not to agree.
Resistance to taxation is the rotten core of the modern Republican Party. Republicans in recent decades have sharply reduced the federal income tax rates imposed on wealthy people and big companies, but their opposition to taxation goes beyond that. They are aiding and abetting tax evasion.
Republicans have hacked away at funding for the Internal Revenue Service over the past decade, enfeebling the agency. When the rich and powerful open loopholes in the tax code, Republicans reliably fight to keep the loopholes open. Indeed, they valorize Americans who find ways to pay less, a normalization of antisocial behavior that may be even more damaging than the efforts at bureaucratic sabotage.
Former President Donald Trump’s loud and proud declaration that paying very little in taxes “makes me smart” was just a more brazen articulation of what has become party orthodoxy.
The Democratic proposal targeted by Mr. McCarthy — in the video he posted online, he calls it “un-American” — would make it harder for wealthy people to cheat on their taxes.
The I.R.S. estimated in 2019 that Americans conceal from taxation more than half of income that is not subject to some form of third-party verification like a W-2, the form that the government uses to verify ordinary wage income. This blind spot costs the federal government hundreds of billions of dollars in unpaid taxes. In comparison, more than 95 percent of wage income is reported.
Under the current version of the Democrats’ plan, which is part of the Biden administration’s sweeping “Build Back Better” legislation, banks would be required to submit annual reports on accounts with total inflows and outflows exceeding $10,000, excluding paychecks and government benefits. The banks would report the total amount deposited in the account and the total amount withdrawn. There would be no reporting of individual transactions. The information would give the I.R.S. a better chance to catch cheaters — and it would provide a salutary reminder for people to pay what they owe.
The Biden administration recently cemented an international agreement to establish a 15 percent global minimum tax on corporate income. The long-sought deal would reduce the incentive for American firms to evade taxation by pretending to generate revenue in low-tax havens like Ireland and roughly half the islands in the Caribbean — a practice that has become all but business as usual in industries with intangible products, like finance, technology and pharmaceutical research.
The minimum corporate tax, like the bank reporting requirement, is not aimed at increasing what is owed. It is aimed at collecting what is owed already.
Improving tax collection has another important benefit. Democracy — and capitalism — rest on a lacework of mutual obligation. People fulfill their own responsibilities because they are confident others will, too. Collecting taxes, especially from the rich and powerful, is an affirmation of that faith.
Felicia Wong, the president of the Roosevelt Institute, a progressive think tank based in New York, said that the corporate tax agreement, which includes 136 countries, is valuable as a demonstration that governments have the ability to impose their will on multinational corporations in the service of the public interest — a hopeful model for confronting other problems, like climate change.
“It can and should create more faith in governance,” she said.
Both plans, however, must overcome the united opposition of congressional Republicans.
The Republican Party was reborn in the 1970s under the banner of resistance to taxation, led by anti-tax men like Jack Kemp and Ronald Reagan. It remains the party’s fixation, the one major area of policy on which congressional Republicans were able to agree during the Trump administration.
By way of ideological justification, Republicans like to talk about liberty, by which they mean a narrow and negative kind of freedom from civic duty and mutual obligation.
But the fervent opposition to taxation has always found its deeper wellsprings of motivation in concern about how the money will be spent. In the bellwether case of California, the rise of anti-tax activism was inextricably intertwined with the decline of a white electoral majority. It wasn’t a question of whether Americans should ever be required to help one another. The real question was who would be helped.
Opposition to progressive income taxation also draws strength from an imagined democratic ideal in which the people who vote for taxation, pay the taxes and get the benefits are all one and the same.
History tells a different story. From the outset, taxation in the United States was designed as an antidote to inequality. The government initially chose to raise revenue through tariffs collected from wealthy merchants. The introduction of a federal income tax in the early 20th century was a different means to the same end. In a historical analysis published last year, a pair of German political scientists, Laura Seelkopf and Hanna Lierse, showed that progressive taxation is a hallmark of democratic governance.
Political philosophers have long fretted that democracy allows the poor to plunder the rich. The opposite has proved more nearly true. Progressive taxation is not a threat to the wealthy. It is a small price to pay for prosperity.
Cutting taxes to starve social programs is, by itself, a threat to the sustainability of the American experiment in multicultural democracy. In enabling resistance to lawful taxation, Republicans are engaged in an even more direct assault.
Having failed to constrain government spending through the democratic process, they are seeking to undermine government.
Mr. McCarthy is right to frame a fairly technical change in tax rules as an issue that goes to the heart of American democracy. Democracies impose higher taxes than other forms of government because democracies are communities of common purpose. We create and maintain our society through our contributions.
Or we don’t. And things fall apart.
https://www.nytimes.com/2021/10/24/opinion/republicans-tax-evasion.html?
Why I Ask More of America Than We Can Get
by Jamelie Boule - NYT - October 29, 2021
As flawed and incomplete as the American Revolution was, there is no question that it unleashed an impulse toward democracy and political equality that has shaped our history and continues into the present. That impulse, however, is in tension with the Constitution, which not only structures American democracy but arguably was written to constrain it.
I write, on occasion, about the need to reform the structures of American government, from the Electoral College to the Senate itself. The immediate (and obvious) response from readers is often to ask “why?”
After all, the barrier to constitutional amendment is impossibly high. There is almost no chance that a two-thirds majority of Congress (and a three-fourths majority of the states) would, for example, vote to require direct popular election of the president and vice president. And the final clause of Article 5 of the Constitution — “no State, without its Consent, shall be deprived of its equal Suffrage in the Senate” — is an insurmountable obstacle to ending the distortions caused by equal state representation in that chamber.
It is equally difficult, if not impossible, to imagine much in the way of reform to the unwritten parts of the American political order. The Supreme Court’s power of judicial review — which does not exist in the Constitution — is virtually untouchable. The two-party system is similarly resistant to change, for the simple reason that incumbent lawmakers would have to vote to radically transform the landscape in which they operate.
Yes, the odds of serious reform are low to the point of nonexistent, right now and for the foreseeable future. And yet I still think it’s worth it to make the case.
I should say that I am inspired here by the political scientist Robert Dahl, whose illustrious and influential career spanned most of the 20th century. Dahl was preoccupied with the democratic ideal, the actual mechanics of democracy and the profound distance between the two in even the most mature democratic states. Or, as he wrote in his 1998 book “On Democracy,” “In almost all, perhaps all, organizations everywhere there is some room for some democracy; and in almost all democratic countries there is considerable room for more democracy.”
An American, Dahl applied this maxim to his own country, writing, at the start of the new millennium, a book-length critique of our political institutions called “How Democratic is the American Constitution?”
Dahl, who was then in his late 80s, did not think that constitutional change of any kind was on the horizon. “My reflections lead me to a measured pessimism about the prospects for greater democratization of the American Constitution,” he wrote. “Changes … that would be desirable from a democratic point of view seem to me to have very little chance of coming about in the indefinite future.”
Still, Dahl made the argument. Not for the sake of change to the Constitution as much as for the sake of “changes in the way we think about our constitution.”
Most Americans revere the Constitution. Some even believe that it is divinely inspired. Few want fundamental change. But despite the way we often talk about it, the Constitution was not actually chiseled on stone tablets. “The Framers were not philosophers searching for a description of an ideal system,” wrote Dahl. “Nor — and we may be forever grateful to them for this — were they philosopher kings entrusted with the power to rule. They were practical men, eager to achieve a stronger national government, and as practical men they made compromises.”
To think about the framers as practical men making practical choices should lead us to think of their Constitution in practical terms. Does it serve us well? Does it meet the democratic standards of the present day? Does it, Dahl asks, help us “maintain the democratic system; protect fundamental democratic rights; ensure democratic fairness among citizens; encourage the formation of democratic consensus; and provide a democratic government that is effective in solving problems?”
Now the usual, and frankly facile, response to these kinds of questions is that the United States is a “republic” and not a “democracy.” This, I’ve argued before, is nonsense. When James Madison critiqued “pure democracy” in Federalist No. 10, he meant direct democracy, “a society consisting of a small number of persons, who assemble and administer the government in person.” A republic, by contrast, was government by representation. “The two great points of difference between a democracy and a republic,” wrote Madison, “are first, the delegation of the government, in the latter, to a small number of citizens elected by the rest; second, the greater number of citizens, and greater sphere of the country, over which the latter may be extended.”
To say that the present-day United States should be “more democratic” is to say that it should have greater representation and political equality, not that it should refashion itself into an Athenian-style assembly. Madison, for his part, would become an important figure in the democratization of American politics as the founder, with Thomas Jefferson, of the Republican (or Democratic-Republican) Party.
It is not for nothing that, toward the end of his long career as a practical politician, Madison defended in no uncertain terms the concept of political equality. Here he is, in 1821, criticizing the views of his younger self as they had been expressed at the Philadelphia Convention 34 years earlier.
Under every view of the subject, it seems indispensable that the Mass of Citizens not be without a voice, in making the laws which they are to obey, & in chusing the Magistrates, who are to administer them, and if the only alternative be between an equal & universal right of suffrage for each branch of the Govt. and a confinement of the entire right to a part of the Citizens, it is better that those having the greater interest at stake namely that of property & persons both, should be deprived of half their share in the Govt. than, that those having the lesser interest, that of personal rights only, should be deprived of the whole.
All of this is to say that I do not write about structural reform because I believe it will happen in my lifetime, although, of course, no one knows what the future will bring. I write about structural reform because, like Dahl, I want to think expansively about (and readers to think expansively about) American democracy, to understand that it is, and has always been, bigger than the Constitution.
If there is anything else useful in these arguments, it’s in how they make the lines of political conflict as clear as possible. There are, we cannot forget, Americans who do not believe in political equality and the democratic ideal, Americans with a narrow and circumscribed vision of “freedom” and “liberty.” A debate over reform can, in the course of the argument, drag those views out of the shadows and into the open.
I am fond of the expression, from the Gospel of Mark, that “The Sabbath was made for man, not man for the Sabbath.” I think it captures a basic truth: that our rules and institutions exist for us and our flourishing, not for their own sake. And if those rules and institutions do not work, if they constrain our aspirations or violate our sense of justice, then it is the role of people like me to agitate for at least a little change.
https://www.nytimes.com/2021/10/29/opinion/democracy-madison-robert-dahl.html
Let the Games End!
Don McCanne - Health Justice Monitor - October 28, 2021
Summary: Two unrelated news stories highlight ways that powerful actors in our healthcare system manipulate complex reimbursement rules and procedures, approaching and crossing legal boundaries. Detecting and stopping abuse in our complex profit-focused system is impossible. We need to end this gaming, with a simple fair payment system.
5 things about DOJ’s upcoding allegations against Kaiser
By Alex Kacik - Modern Healthcare - October 26, 2021
Kaiser Permanente allegedly coerced employees to upcode claims for Medicare Advantage beneficiaries, resulting in an estimated 75% error rate, according to a new complaint from the U.S. Justice Department.
The federal government intervened in six related lawsuits in July and filed a complaint Monday, outlining how Kaiser physicians allegedly changed medical records often months after care was provided to boost the Oakland, California-based integrated health system’s Medicare Advantage reimbursement. More than half of Kaiser physicians said they were forced to add diagnoses they did not consider, evaluate or treat, according to one of the whistleblowers and former Kaiser medical coder, Randi Osinek.
…
5. Some of the diagnoses that Kaiser allegedly added via the chart reviews did not even exist; many allegedly did not require or affect patient care or treatment. These chart reviews were often added months or even a year or more after the visit so that Kaiser could get risk adjusted payments for the newly added diagnoses, according to the complaint.
Wall Street Is Pressing ER Docs To Fleece PatientsBy Maureen Tkacik - Daily Poster - October 27, 2021
Robert McNamara, a Temple University medical school professor who has been working for decades to galvanize ER doctors in opposition to the “corporate practice of medicine,” had proposed a resolution that would essentially force all ER staffing companies seeking to do business with ACEP [American College of Emergency Physicians] to periodically furnish their physicians with data on the services and procedures the company had billed for under their license numbers.
… Unsurprisingly, the ACEP Board expressed extreme reluctance to adopting the proposal, noting that four separate attorneys it had consulted believed there was “substantial risk” ….
“ACEP engaged outside counsel to advise on whether securing regular reporting of billing in a physician’s name could inadvertently subject that physician to potential liability under the False Claims Act [emphasis added], since provision of this information could now leave them considered to be ‘knowing,’” they wrote.
In other words: emergency room doctors are better off not knowing what their private equity overlords are billing under their license numbers, because they are less likely to go to jail for Medicare fraud if they didn’t actually know they were committing it.
Comment by: Jim Kahn
Our health system’s arcane payment rules + big-profit corporate mentality = the perfect medium for intensive gaming, both legal and illegal. These two stories illustrate different manifestations of the problem — albeit just the tip of the iceberg quantitatively, a faint hint of the true scale of abuse.
Kaiser Permanente is considered by many an admirable actor in the HMO world, with a history of innovative care models. Yet, in this article in Modern Healthcare, we learn that the US Department of Justice is taking KP to court for orchestrated efforts to increase physician disease severity coding – even to add false diagnoses – to bump Medicare Advantage revenues by tens of millions of dollars. HJM has covered “risk adjustment” exploitation before. The money at stake with exaggerated coding is astronomical, eliciting the worst behaviors among corporate actors in health.
Organizations like ACEP were founded to represent the interests of doctors, which should include fair and transparent billing. But the Daily Poster describes that ACEP has increasingly focused on preserving ER profit, including for private equity investments. It abets a corporate model that hides potentially fraudulent billing. HJM recently addressed the hazards of private equity. The new article describes deep ties that two former heads of ACEP have to PE. One even dismissed the problem of surprise billing – rampant in ERs staffed by private equity-funded companies which seek to profit from out-of-network charges. The doctors are coerced into being complicit, with plausible deniability.
How can we end this gaming, abuse, and extraction of resources from the health system? Single payer would use simple, fair rules. For example: annual global budgets for hospitals and their ERs. Ambulatory care doctors would typically be paid fee-for-service, with no need for exploitable risk adjustment data. If capitation is permitted (a discussion), it would rely on a standard clinically-focused electronic health record containing legitimate, consistent diagnostic information.
Let the billing games end!
Opinion | Health Care Employment Is Rising. Is That a Good Thing?
There are places in America where factories have closed, mines have shut and farms have reverted to forest but hospitals and clinics are continuing to open. Health care services in such places perform two vital functions: not just caring for the sick and old but also supplying much-needed jobs. Case in point: Breathitt County in the coal fields of eastern Kentucky.
There are other places in America where the economy is strong, living standards are high and a large health care sector attracts consumer dollars from far away. Case in point: Olmsted County in southeastern Minnesota, home of the famous Mayo Clinic.
I found both types of places when I created a spreadsheet of the counties in the United States most dependent on private health care employment, using regional data from the Commerce Department’s Bureau of Economic Analysis. (I couldn’t easily add public-sector employment so the picture is incomplete.)
The health care and social assistance sector is already the biggest private employer in the United States, according to the Census Bureau, with 20 million employees and more than $1 trillion in payroll as of 2018.
This sector’s share of employment is projected to keep growing as the population ages. Last month the Bureau of Labor Statistics projected that health care employment would grow 16 percent from 2020 to 2030, adding 2.6 million jobs, more than any other occupation.
In a way, looking at the counties in this table is like peering into the future, because they are already dependent on health care jobs in a way that other places will soon be.
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I did some reporting on the top three counties in the table. Each has a different story. Montour County in central Pennsylvania leads the list because it’s a small, mostly rural county that happens to be the home of a big hospital — Geisinger Medical Center in Danville — that treats traumatic injuries and other serious health problems. The Geisinger Health System employs nearly 10,000 people in Montour County, according to economic development officials.
Geisinger helps the community in other ways too. It contributed $300,000 for a wireless broadband system for Montour County, according to Timothy Hippensteel, a project manager of a local development agency called Drive. Geisinger also makes payments to the county in lieu of property taxes, which it doesn’t owe because it’s a nonprofit. “Without Geisinger, this county would not be what it is,” says Ken Holdren, the chairman of the county commissioners, who worked for Geisinger in finance for 30 years before retiring. (Not everything is perfect, though, he says: The county has to pay a coroner every time someone dies in the hospital, and Covid-19 has pushed the annual cost of that to more than $100,000.)
The biggest success story in the table is No. 2, Minnesota’s Olmsted County, where the Mayo Clinic in Rochester draws patients from across the upper Midwest, as well as elsewhere in the United States and abroad. Mayo has become even more important to the city in recent years because IBM has reduced jobs there at what was once one of its bigger computer factories. “It is a true blessing to have a world-renowned health care institution based in our county,” says John Wade, the president of Rochester Area Economic Development Inc.
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Every county that is dependent on the health care industry must decide whether to double down on its specialty or to diversify so it doesn’t have all its economic eggs in one basket. Olmsted County is open to all kinds of employers, but it’s emphasizing health care, says Patrick Seeb, the executive director of Destination Medical Center, which, despite its name, is not a hospital but an economic development agency responsible for doling out infrastructure funds from the State of Minnesota.
Seeb is trying to get people to call Rochester America’s Med City. Google and Epic Systems have opened offices there to work with Mayo on, respectively, data mining and electronic medical records, he says. And now other companies are arriving because of Google and Epic. “It’s concentric circles,” he says.
The third county on the list is a less happy story. Kentucky’s Breathitt County is in a part of Appalachia that has suffered from declining employment, dwindling population and poor health. “Health care is one of our biggest employers,” says Sue Clair, who has a real estate development company in the county seat, Jackson. “We don’t have any other kind of employment but that.” A 40,000-square-foot industrial building was put up more than 20 years ago with public funds but has never attracted a commercial tenant. “Right now it has the Breathitt County Water District in it,” she says.
Breathitt County is not alone on the list in being hard-pressed. Three of the top 10 counties are in eastern Kentucky, and another, Cumberland, is in south-central Kentucky, all of which are struggling economically. That’s no coincidence. When the local economy falters, total employment dwindles, and the need for health care services increases, both of which push counties upward on the list. Kentucky has the nation’s third-highest mortality rate, after West Virginia and Mississippi, according to the National Center for Health Statistics.
Kosali Simon, a health care economist who is the associate vice provost for health sciences at Indiana University in Bloomington, ran some calculations for me using her own set of data and found that the share of a county’s population in poverty is a predictor of the share of its employment from health care and social assistance.
Many economists view rising health care employment nationally as a mixed blessing. “Every person employed in health care is one less person available to work in other industries,” David Cutler, a health care economist at Harvard University, wrote in a 2018 article for The JAMA Forum, a publication of the American Medical Association. “Thus, people should work in health care only if the extra care is more valuable than the output would be in some other industry.”
However, it’s hard to argue that small towns and cities that are dependent on health care have too many health care jobs. If anything, they may not have enough to meet demand. “As the United States struggles with health care provider shortages, an uneven distribution of workers means that shortages are often more profound in rural areas,” says the Rural Health Information Hub, a federally funded clearinghouse.
https://www.nytimes.com/2021/10/22/opinion/health-care-jobs.html
Our View: Health care hiring needs state’s help
Gov. Mills is rightly working with the industry to beat longstanding national workforce trends.
by The Editorial Board - Portland Press Herald - October 26, 2021
Gov. Mills is rightly working with the industry to beat longstanding national workforce trends.
Some people are surprised to hear that Maine’s largest industry isn’t fishing, forest products or even tourism. It’s health care.
Nearly one in five Mainers draws a paycheck from a health care job, including people who work for some of the state’s largest employers – our regional medical centers – and some of the smallest – including home health agencies.
One thing they all have in common is difficulty hiring and retaining the staff they need to meet their obligations.
It’s a problem that has been exacerbated by a 19-month pandemic that has demanded more of everyone throughout the system, but workforce challenges were an issue in Maine’s health care sector long before COVID appeared, and they won’t go away if the virus were to suddenly disappear.
On Monday, Gov. Mills rolled out the details of a health care workforce plan that uses federal COVID aid to launch programs designed to help hire, retain and promote a generation of health care workers who will not only fill the gaps that exist today but also replace the thousands of people in health care who are retiring or leaving the field for other reasons.
It’s a complex problem that won’t be fixed with a single remedy. On Monday, Mills explained how her administration was going to put resources behind a number of proposals.
They include:
• $4 million for scholarships and debt relief for students in health care fields.
• $8.5 million to help people in health care jobs to attain higher-level credentials so they can move up in their field.
• $1.5 million to encourage young people to consider health care careers, with $500,000 earmarked for recruiting direct-care service jobs, such as home health aides.
Programs like these will probably be the first steps, if Maine is going to buck the national trends in health care employment. A report released last month by Mercer, a New York-based asset management firm, forecasts millions of vacancies in lower-paid health care jobs in the next five years, including nursing assistants, who are critical to staffing nursing homes.
Mercer also predicts a national shortage of nurses and primary care doctors, which may change the way health care is delivered in the places that don’t meet the workforce challenge.
The national scope of these trends should rebut the notion that the labor shortage in Maine’s health care sector was caused by the Mills administration’s COVID vaccine requirement for health care workers. Retaining the very small number of employees who will give up their jobs because they refuse to be vaccinated would not have any meaningful effect on the employment numbers – not in the short term and certainly not in the long term.
The only way to fill those jobs is to bring more Mainers into the health care professions and to bring more people who want to work in health care to Maine. Mills’ plan moves Maine in the right direction.
https://www.pressherald.com/2021/10/26/our-view-health-care-hiring-needs-states-help/
Editor's Note:
The following is a link to a segment of the PBS show "Amanpour and Company" about the impending national nursing crisis, and a Portland Press-Herald article about how that shortage is playing out in Maine.
- SPC
Diagnosis burnout: Acute staffing shortages weigh on Maine nurses who stay on the job
Many employed at assisted-living and long-term care facilities point to relentless stress, and the toll it takes on those who need their care.
by Eric Russell - Portland Press Herald - October 24, 2021
Most days when he gets home from work, after he sheds his personal protective equipment and washes his hands one last time, Rich Gilbert finds himself reflexively retreating from his family.
Not because he’s worried about spreading COVID-19, necessarily, but because he doesn’t want to transfer the stress of his job to his loved ones.
“I’m exhausted, and a little angry, I guess,” said Gilbert, 57, who works as a nurse and unit manager at a Portland-area long-term care facility. “And I try not to take it out at home, but boy it’s getting hard. So I tend to isolate. … Now, I feel like I don’t have much of a home life anymore.”
Eighteen-plus months of pandemic has created a situation that can only be characterized as untenable for many nursing home workers like Gilbert, and those in other health care fields as well. Some nursing homes have closed in recent weeks or have threatened to do so because of staffing shortages. Some have cut back on the number of residents they can serve or halted new admissions. And some have piled on work, out of sheer necessity, to the employees who have stayed.
For Gilbert, his biggest fear is that continued loss of staff will jeopardize care for the 60 or so residents who live there. Thankfully, that hasn’t happened yet, although a new COVID-19 outbreak that is ravaging the facility has added another layer of stress. He’s coming in early to handle all the blood draws that used to be done by an outside agency, and he’s staying late to help dispense medication and even deliver laundry to the machines. He dreads the weekends because he fears he’ll be called in to help and doesn’t want to live with the guilt of saying no.
“We’re all doing things that are not our jobs,” he said. “We’re trying to make things work as best we can, but I do worry that the health of residents is being compromised.”
Gilbert spoke candidly about the stress of being a health care worker in a long-term care facility on the condition that his employer not be identified. He said he doesn’t want his facility unfairly targeted for challenges that exist industry-wide and he also wants to protect the privacy of residents there.
The Portland Press Herald/Maine Sunday Telegram verified his employment and the details he shared from other employees and a supervisor. The facility is highly rated by the U.S. Centers for Medicare and Medicaid Services and had no serious deficiencies in its most recent federal inspections.
One of Gilbert’s co-workers, Nikki Mowatt, said most people she knows in the field are like Gilbert, carrying some level of stress and wondering if they’d be better off in another field.
Some nursing home administrators have warned that the state’s COVID-19 vaccine mandate for all health care workers to be vaccinated by Oct. 29 or they could be fired is contributing to employee shortages, although that’s hardly the only factor. Meanwhile, older residents who might be thinking about moving to a long-term care facility are having to wait.
“In 20 years of working in Maine, this is the first time I’ve seen facilities limit their admissions,” said Dr. Jabbar Fazeli, medical director of Durgin Pines Nursing Homes in York County.
The Mills administration announced last month that it will distribute $146 million in funding to congregate living facilities and hospitals to support both workforce recruitment and retention. It’s a recognition that the problem has reached a crisis level, but the money has not had an immediate impact.
“I think it’s really important that we acknowledge the toll of the pandemic on caregivers,” said Angela Westhoff, executive director of the Maine Health Care Association, which represents nursing homes and other long-term care facilities. “I think by nature, these workers are selfless and giving of their time, but it has been both physically and emotionally draining.”
John Orestis, president and CEO of North Country Associates, which owns or manages 26 facilities and is the state’s largest long-term care provider, said workforce challenges have been growing for years and that has added stress to those who are still left.
The jobs are hard, and the pay hasn’t always been commensurate, especially in places that rely heavily on Medicare and Medicaid reimbursement, which many do. With many other employment fields also seeing massive shortages, prospective workers can be selective.
“I wouldn’t put it all on the pandemic,” Orestis said. “But it’s certainly more difficult now. It feels like we’re competing against ourselves.”
HIGH LEVEL OF BURNOUT
Gilbert has a thick frame and slightly overgrown goatee that doesn’t quite match his gentle personality. He’s been a nurse for 10 years and has worked at his current job for the last three.
His facility avoided any major COVID-19 outbreaks last year, in part he said because it shut down weeks before the virus reached Maine due to a norovirus scare. Most workers were committed to staying in their jobs.
By the spring of 2021, though, he started to notice a shift.
“People were just leaving, and there was nobody applying for jobs to replace them,” Gilbert said. “Since then, it’s only gotten worse.”
Pandemic fatigue has touched everyone, but the relentlessness of working in health care and the life-or-death stakes have created a high level of burnout. A national survey of 1,000 health care workers last month by Morning Consult revealed that 18 percent have left their job during the COVID-19 pandemic and another 12 percent were fired. Among those who have stayed, 31 percent of those surveyed said they have considered leaving.
And a recent survey by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) found that 86 percent of nursing homes and 77 percent of assisted living providers say their workforce situation has gotten worse in just a few months.
Fazeli said the workforce shortage isn’t confined to nurses. It’s CNAs, housekeepers, kitchen staff.
He said one thing that isn’t often mentioned is the impact of foreign workers, who have been restricted from coming to Maine during much of the pandemic. Those workers often worked in hospitality, and those jobs are now being filled by locals. That means more jobs in health care facilities are going unfilled.
“This has boiled under the surface for a while,” Fazeli said. “I remember last year when I brought up staffing issues, no one wanted to talk about it. Now it has kind of tipped over.”
It’s not just nursing homes either. Central Maine Medical Center in Lewiston recently took the extraordinary step of suspending pediatric and trauma admissions due to “acute nursing staffing shortages in key areas.” York Hospital also announced last week that it was temporarily halting emergency care because of staffing problems.
Agencies that provide care for adults with intellectual disabilities and substance use disorder have also said the workforce shortage is at a critical point and it’s affecting the level of care for vulnerable populations.
Gilbert said many of his co-workers who have stayed are older and have their own physical limitations. Not only are people leaving because of burnout and stress, some are just aging into retirement. There really isn’t that much time between when these employees leave the workforce and when some of them might need beds in the facilities where they once worked.
Many homes are relying on temporary or traveling nurses and certified nursing assistants just to get by, but even that has limitations.
So Gilbert keeps showing up each day.
Most mornings, he’s there early drawing blood because he’s one of the staff members who can do it. They used to have an outside agency come in, but that’s no longer the case.
At mealtimes, many of the residents – especially those with dementia – need help eating. That task, which used to be carried out by CNAs, is now left to folks like Gilbert.
He said he and his co-workers try hard to hide their stress from residents. Some cry in the breakroom.
“The residents can sense it, though,” he said. “They are all isolated in their rooms. Activities have been canceled. There is limited visitation. A lot of depression has settled in.”
Kelley Gilbert, Rich’s wife, said she’s seen the stress mount in her husband in recent months.
“There are days when he comes home, has dinner, and goes to bed because he is so mentally exhausted he has to rest,” she said. “There was a period of time when it felt like the pandemic was getting better and cases were down, and my husband could start to relax at home. We started projects to improve our home and fix up our backyard and life felt more normal. That changed with the delta variant.”
Kelley Gilbert said their family sacrificed a lot when her husband attended nursing school and she’d hate to see him leave because he worked so hard and because he’s good at it.
“So many health care workers are just burnt out with everything they have had to deal with throughout this pandemic,” she said. “The fatigue they feel is not only physical but mental and emotional as well.”
SOBER REALIZATION
Westhoff, with the Maine Health Care Association, said many workers were “drowning in COVID-19” over the winter and spring.
“Then vaccines became available and that was the big pillar of hope that we might get on the other side of this,” she said. “What we’re seeing now is the realization that this is endemic. There isn’t some switch we can flip for this to be over.”
The vaccine mandate has been cited by some who have left health care-related fields, and others could be terminated by the end of this month if they fail to comply.
According to the most recent data from the Maine Center for Disease Control and Prevention, 92 percent of hospital workers are fully vaccinated, while 86 percent of nursing home employees have gotten their shots.
The facility Gilbert works in had a vaccination rate of 94 percent as of last month, up from 60 percent in May.
Gilbert said he understand how some workers might balk at a mandate. He wasn’t first in line either.
“I was eligible in January but didn’t get mine until May,” he said, crediting his wife for persuading him.
Mowatt said she, too, knows staff members who left because of the vaccine mandate but doesn’t know if they would have left anyway.
She was late to get the vaccine herself because she was pregnant and then because she was breastfeeding and was wary. Experts have said the vaccine poses no risk to pregnant mothers. But when it came time to choose being getting vaccinated or getting fired, she took the shot.
Mowatt, who just returned from 12 weeks of maternity leave, admitted she looked for other jobs during that time. In the end, though, she doesn’t want to leave.
“I’ve been there since 2002. I love it there. I love everything about it,” she said. “I just have such a strong connection to the staff members who have stayed and to the residents. They are like family.”
Officials have said the vaccine mandate is a small contributing factor. Workers who were already nearing their breaking point may see it as a final straw.
“Ours is a profession that calls out to people who make the decision to work with us with their heart as much as anything else,” said Orestis, the nursing home administrator. “But they have to live. They have to support their family.”
At Gilbert’s facility, nurses make between $26 and $30 per hour, while CNAs make $16 to $20 an hour.
Just as workers have to weigh the financial aspects of staying or leaving, so too do the facilities themselves. The only way for them to make more money is to bring in more residents, but they can’t do that if they can’t care for them.
Fazeli, the medical director at Durgin Pines, said because new admissions have been halted, many older Mainers are being released from hospitals to their homes, rather than to a rehab facility.
“What that means is: People are staying in an unsafe environment longer. The burden on families increases, as does the risk for elder abuse or neglect,” he said.
There are some signs of hope that things may improve.
Nationally, enrollment in nursing programs increased 5.6 percent in 2020 over the previous year, to just over 250,000 students, according to the American Association of Colleges of Nursing. Figures for the current 2021-22 school year won’t be available until January, but administrators expect that trend to continue.
And the additional money announced last month by the Mills administration has started to funnel down to long-term care facilities.
“Most of it is aimed at staff retention and recruitment and that’s how we’ll use it,” Orestis said. “And we’re happy to have it. Money is never the only solution, but it certainly can help.”
Gilbert said his facility is offering pay differential for staff who work certain shifts or with COVID patients.
“Honestly, I would rather give that $5 an hour to a new staff person and have that time with my family,” he said. “And to not see people suffering or not come in the next day and find out about all the things that got missed the night before.”
Lately, Gilbert measures his days by one somber metric.
“If you go home and nobody died, then you had a good day,” he said.
