Health Care Reform Articles - October 10, 2022

 Editor's Note: 

I have occasionally described the American healthcare system as "the largest and most successful extortion racket ever invented" - much of it perfectly legal, and have been criticized for being hyperbolic.  Read the following NYT story about the profit-maximizing behaviour of Medicare Advantage plans (and soon Traditional Medicare as Designated Contractual Entities take over some of their management), and see whether or not you agree with me,  or agree with my critics.

But where does the fault lie? When you put the fox in charge of the chicken coop and the chickens begin to disappear, it seems a little misplaced to blame the fox for behaving like a fox.  

Who put the fox in charge anyway? Well - we all did - through our government.  

The Affordable Care Act put for-profit corporations, including publicly-traded and other investor-owned corporations including hedge-funds (poorly regulated private equity) in charge of much of our healthcare system, and asked them to use the tools of the market-place (such as choice of plans and competition among them) to provide accessible, affordable and high quality health care. This idea has resulted in the perfectly predictable behavior described in the following NYT clipping.

There is so much easy money sloshing around in the American healthcare system, and so many different actors in a position to be tempted to drink at the trough, that greed quickly overtakes the best of intentions. 

The fundamental mission of investor-owned corporations is to create wealth for their owners. This article rightly focuses on the insurance companies, but they are not alone. Many provider organizations are also complicit in cooperating by playing this pernicious game of up-coding - including physicians and other "providers" - many of them nominally non-profit.  Such complicit players have been described as "useful idiots".(see Kurt Andersen's excellent book "Evil Geniuses".

We need to abolish the participation of for-profit investor owned corporations from participating in our healthcare system if they are in a position to influence clinical decision-making, the documentation of those services, or the allocation of capital for the creation of the capacity to provide those services. 

Although it is true that many nominally non-profit entities behave in ways indistinguishable from their for-profit brethren, there is one important difference.  For a privately-owned company,  the amound of greed is optional.  In an investor-owned entity, including hedge funds or publicly-traded companies, it is baked into their mission - in other words, for them greed is mandatory.

I'm old enough to remember when doctors, hospitals and other providers of healthcare were overwhelmingly not for profit and motivated by putting the patient first.

It's way beyond time to put a stop to this chicanery, clean this mess up,and stop this perversion of the culture of our healthcare system. 

- SPC

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud.

by Reed Abolson and Margot Sanger-Katz - NYT - October 8, 2022

The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.

Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.

Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost. If trends hold, by next year, more than half of Medicare recipients will be in a private plan.

But a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The fifth company, CVS Health, which owns Aetna, told investors its practices were being investigated by the Department of Justice.

In statements, most of the insurers disputed the allegations in the lawsuits and said the federal audits were flawed. They said their aim in documenting more conditions was to improve care by accurately describing their patients’ health.

Many of the accusations reflect missing documentation rather than any willful attempt to inflate diagnoses, said Mark Hamelburg, an executive at AHIP, an industry trade group. “Professionals can look at the same medical record in different ways,” he said.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers. But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

For people choosing between traditional Medicare and Medicare Advantage, there are trade-offs. Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

But they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

“Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” said Senator Charles Grassley of Iowa, who has investigated the industry. The efforts to make patients look sicker and other abuses of the program have “resulted in billions of dollars in improper payments,” he said.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

“It’s an extremely high priority for us,” said Michael Granston, a deputy assistant attorney general for the civil division.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles, over the course of four presidential administrations.

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

C.M.S. officials declined interview requests. In a statement, the C.M.S. administrator, Chiquita Brooks-LaSure, said the agency recently sought feedback on how to improve the program. “We are committed to making sure that Medicare dollars are used efficiently and effectively in Medicare Advantage,” she said.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans. Nearly 80 percent of U.S. House members signed a letter this year saying they were “ready to protect the program from policies that would undermine” its stability.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,” said Representative Lloyd Doggett, a Texas Democrat who chairs the House Ways and Means Health subcommittee.

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,” said Dr. Donald Berwick, a C.M.S. administrator under the Obama administration, who recently published a series of blog posts on the industry. “When you skate to the edge of the ice, sometimes you’re going to fall in.”

The program’s promise

Congress’s first attempt to design a privatized Medicare plan paid insurers the same amount for every patient with similar demographic characteristics.

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete. Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

In one early case, a Florida medical practice was accused of falsifying diagnoses to enrich its owner and Humana. When Humana told the doctor who owned the practice that his Medicare risk adjustment, or M.R.A., scores had increased significantly, he responded by email, according to the whistle-blower lawsuit: “Good, I am trying to buy that house based on M.R.A. scores.” The case was settled for more than $3 million.

The doctor denied any wrongdoing. Humana declined to comment on the lawsuit and said it takes compliance “seriously.” The company recently told investors it had been questioned by the Justice Department about its billing practices and expected additional litigation.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

One company, Mobile Medical Examination Services, worked with Anthem and Molina, among others. Its doctors and nurses were pushed to document a range of diagnoses, including some — vertebral fractures, pneumonia and cancer — they lacked the equipment to detect, according to a whistle-blower lawsuit. According to the lawsuit, employees who drew patients’ blood often were not provided with a centrifuge or cooler; spoiled blood analyzed a day later produced strange results that could be used to justify valuable diagnoses, including kidney disease and leukemia. The company was acquired by Quest Diagnostics after the case was settled for an undisclosed amount in 2016; Quest said the company complies with all federal and state laws and regulations.

Anthem: The Justice Department suit quotes an executive describing her reluctance to change how it mined medical records for additional diagnoses. The case is continuing.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist.

According to the lawsuit, some patients were diagnosed with cancer and heart disease. Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

The company declined to comment. “We will vigorously defend our Medicare Advantage business against these allegations,” Cigna said in an earlier statement regarding the lawsuit.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

In a statement, the company, now named Elevance, said it would “vigorously defend our Medicare risk adjustment practices” and accused the government of holding it to standards “that are not grounded in formal statutory and regulatory rules.”

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

“The cash monster was insatiable,” said Dr. James Taylor, a former coding expert at Kaiser who is one of 10 whistle-blowers to accuse the organization of fraud.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

Marc T. Brown, a Kaiser spokesman, said in a statement, “We are confident in our compliance with Medicare Advantage risk-adjustment program requirements,” and added, “Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from C.M.S.”

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

A civil trial accusing UnitedHealth of fraudulent overbilling is scheduled for next year. The company’s internal audits found numerous mistakes, according to the lawsuit, which was joined by the Justice Department. Some doctors diagnosed problems like drug and alcohol dependence or severe malnutrition at three times the national rate. But UnitedHealth declined to investigate those patterns, according to the suit.

UnitedHealth Group: A whistle-blower complaint quotes an executive’s email to a firm that was helping the company review patient medical records. A trial is scheduled for next year.

Matthew Wiggin, a spokesman for the company, called the inspector general’s report “misleading.” He said the company uses diagnostic coding to improve patient care, and noted that the whistle-blower in the lawsuit had not worked for the company in nearly a decade. “Our chart review process complies with regulatory standards,” he said, adding, “Our robust compliance program also proactively seeks to identify fraud, waste and abuse in the system.”

The company countered by suing Medicare, arguing that it wasn’t required to fix inaccurate records before regulations changed in 2014. It won at first, then lost on appeal. In June, the Supreme Court declined to hear the case.

Inaction at Medicare

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments. Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Some of the agency’s top leaders have had close ties to industry. Marilyn Tavenner, a former C.M.S. administrator, left in 2015, then ran the main trade group for health insurers; she was replaced by Andy Slavitt, a former executive at UnitedHealth. Jonathan Blum, the agency’s current chief operating officer, worked for an insurer after leaving the agency in 2014, then became an industry consultant, before returning to Medicare last year.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

There are signs the problem is continuing.

“We are hearing about it more and more,” said Jacqualine Reid, a government research analyst at the Office of Inspector General who has analyzed Medicare Advantage overbilling.

Kaiser Permanente: An executive discussed punishing doctors who failed to review patient records for more diseases, according to a Justice Department lawsuit. The case is continuing.

The Justice Department has brought or joined 12 of the 21 cases that have been made public. But whistle-blower cases remain secret until the department has evaluated them. “We’re aware of other cases that are under seal,” said Mary Inman, a partner at the firm Constantine Cannon, which represents many of the whistle-blowers.

But few analysts expect major legislative or regulatory changes to the program.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html

  

Medical Debt Makes the Sick Sicker

by David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH

Most physicians have sworn an oath to "abstain from whatever is deleterious" to our patients. Yet our medical institutions harm patients daily. They dun them for medical bills they can't afford, often leaving them unable to pay their rent or mortgage, or buy enough to eat.

That accusation isn't hyperbole, it's a finding from our analysis -- published this month in JAMA Network Open -- of Census Bureau surveys on medical indebtedness. We found that more than one in 10 U.S. adults -- and nearly one in five households -- incurred a medical debt they couldn't pay. And it wasn't just the poor or uninsured who were at risk. Adults who had gone to college were just as likely to have medical debts as those who hadn't finished high school, and middle-income individuals had the same risk as the poor. While the uninsured had the highest rate (15.3%) of medical indebtedness, 10.5% of individuals with private coverage had medical debts -- presumably due to high copayments, deductibles, and coverage denials -- with Medicare Advantage enrollees having a particularly high rate. And the debts weren't trivial: they averaged $21,687 per debtor in 2018.

Our findings add to a growing litany of studies showing that medical bills are a huge problem for Americans. Back in 2001, we (together with then-Harvard law professor Elizabeth Warren and sociologist Deborah Thorne) found that illness and medical bills contributed to more than half of all personal bankruptcies, a figure that climbed to 62% in 2007. A Kaiser/NPR survey this year suggests that our estimates of medical indebtedness (based on 2017-2019 surveys) may be too conservative; Kaiser/NPR estimates that 100 million Americans are dealing with medical debt.

But whatever the number, the consequences are often grave. Because the Census Bureau repeatedly surveyed the same individuals over 3 years, we, unlike previous analysts (who used one-time surveys), could assess the consequences of newly acquiring medical debt. Among individuals with no medical debts in 2017, those who newly incurred such debt in subsequent years were more than twice as likely to newly become food insecure or unable to pay their rent, mortgage, or utility bill, and to be evicted or suffer foreclosure in subsequent years.

Moreover, the detailed income and asset data that the Census Bureau collected enabled us to isolate the effects of medical bills. It was medical bills, not lost income due to illness or depleted assets from non-medical bills, that drove people from their homes and left them struggling to afford groceries. In policy parlance, medical bills often worsened patients' Social Determinants of Health -- non-medical factors that affect health outcomes.

Medical leaders and policy makers like to blame those non-medical factors for the yawning disparities in health outcomes in our nation, and our life-expectancy that lags 3 to 4 years behind other wealthy nations. They're right. Poverty and all of the woes that come with it undermine health. But while in 80% of hospitals the "leadership is committed to establishing and developing processes to systematically address social needs as part of clinical care," they studiously avoid acknowledging that they're part of the problem. The bills they send often contribute to a downward spiral of worsening poverty that we know causes deteriorating health.

That leaves doctors trying to clean up the mess that our healthcare system creates. Our patients get sick and their medical bills too often make them sicker, or add to their trauma (as we found in another recent study led by Sam Dickman, MD).

The Dickman study examined the ED records of sexual assault victims across the nation. More than 17,000 of those survivors were uninsured; the charges for their ED care averaged $3,600. Moreover, even rape victims with private insurance are stuck paying (on average) 14% of the costs for their rape-related care -- nearly $1,000. That's a particularly steep price for the lower-income women and girls who face the greatest risk of a sexual assault. Fear of the cost is undoubtedly part of the reason that only one in five rape victims seeks medical care.

Doctors can take some small steps that might reduce patients' financial risks. We can remind veterans to check if they're eligible for VA services, help our poor patients enroll in Medicaid, or connect them to hospitals' financial assistance programs. In some practice settings, physicians can forgive copayments and deductibles that cause hardships. But those measures would still leave millions of Americans, insured and uninsured, submerged in debt once they get sick.

The hard truth is that unless you're Elon Musk, you could be only one serious illness away from financial disaster, even if you have coverage, because health insurance is a defective product.

Our healthcare system's infliction of financial (and hence medical) harm is a uniquely American policy choice. In most wealthy nations, national health insurance or a national health service protects patients from that harm; taxpayers foot the bill for everyone's care so the sick don't suffer doubly. That's an approach -- generally known as Medicare for All -- that more than half of American voters and about half of all doctors support. It would let doctors do good without worrying that they're doing harm.

David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH, are both distinguished professors at CUNY's Hunter College in New York City, lecturers in medicine at Harvard Medical School in Boston, and research associates for Public Citizen's Health Research Group.

 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796358

 

Some hospitals rake in high profits while their patients are loaded with medical debt

  By Noam Levey - Kaiser Health News - September 28, 2022 

 

PROSPER, Texas — Almost everything about the opening of the 2019 Prosper High School Eagles' football season was big.

The game in this Dallas-Fort Worth suburb began with fireworks and a four-airplane flyover. A trained eagle soared over the field. And some 12,000 fans filled the team's new stadium, a $53 million colossus with the largest video screen of any high school venue in Texas. Atop the stadium was also a big name: Children's Health.

Business has been good for the billion-dollar pediatric hospital system, which agreed to pay $2.5 million to put its name on the Prosper stadium. Other Dallas-Fort Worth medical systems have also thrived. Though exempt from taxes as nonprofit institutions, several, including Children's, notched double-digit margins in recent years, outperforming many of the area's Fortune 500 companies.

But patients aren't sharing in the good times. Of the nation's 20 most populous counties, none has a higher concentration of medical debt than Tarrant County, home to Fort Worth. Second is Dallas County, credit bureau data show.

The mismatched fortunes of hospitals and their patients reach well beyond this corner of Texas. Nationwide, many hospitals have grown wealthy, spending lavishly on advertising, team sponsorships, and even spas, while patients are squeezed by skyrocketing medical prices and rising deductibles.

A KHN review of hospital finances in the country's 306 hospital markets found that several of the most profitable markets also have some of the highest levels of patient debt.

Overall, about a third of the 100 million adults in the U.S. with health care debt owe money for a hospitalization, according to a poll conducted by KFF for this project. Close to half of those owe at least $5,000. About a quarter owe $10,000 or more.

Many are pursued by collectors when they can't pay their bills or hospitals sell the debt.

"The fact is, if you walk into a hospital today, chances are you are going to walk out with debt, even if you have insurance," said Allison Sesso, chief executive of RIP Medical Debt, a nonprofit that buys debt from hospitals and debt collectors so patients won't have to pay it.

A community shadowed by debt

Across the Dallas-Fort Worth metro area — the nation's fourth-largest — the impact has been devastating.

"Medical debt is forcing people here to make incredibly agonizing choices," said Toby Savitz, programs director at Pathfinders, a Fort Worth nonprofit that assists people with credit problems. Savitz estimated that at least half their clients have medical debt. Many are scrimping on food, neglecting rent, even ending up homeless, she said, "and this is not just low-income people."

David Zipprich, a Fort Worth businessman and grandfather, was forced out of retirement after hospitalizations left him owing more than $200,000.

Zipprich, 64, had spent a career in financial consulting. He owned a small bungalow in a historical neighborhood near the Fort Worth rail yards. His daughters, both teachers, and his four grandchildren lived nearby. He had health insurance and some savings, and he'd paid off his mortgage.

Then in early 2020, Zipprich landed in the hospital. While driving, his blood sugar dropped precipitously, causing him to black out and crash his car.

Three months later, after he was diagnosed with diabetes, another complication led to another hospitalization. In December 2020, covid-19 put him there yet again. "I look back at that year and feel lucky I even survived," Zipprich said. 

But even with insurance, Zipprich was inundated with debt notices and calls from collectors. His credit score plummeted below 600, and he had to refinance his home. "My stress was off the charts," he said, sitting in his neatly kept living room with his Shih Tzu, Murphy.

Overall in Tarrant County, 27% of residents with credit reports have medical debt on their records, credit bureau data analyzed by KHN and the nonprofit Urban Institute shows. In Dallas County, it's 22%.

That's more than five times the rate in the largest counties in New York, data shows. The Texans also owe a lot more — the median amount of medical debt on credit records in Tarrant and Dallas counties is nearly $1,000, compared with $400 or less in New York.

Last year, Zipprich returned to work, taking a job in New Jersey that required he commute back and forth to Texas. He recently quit, citing the strain of so much travel. He's now job hunting again. "I never thought this would happen to me," he said.

Who is responsible?

Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.

Johnson said the center, where she'd gone after a knee injury, initially said her visits would cost $60. "Then they billed me hundreds," she said. "I don't go to the doctor unless I absolutely have to because it's so expensive." 

Hospital industry leaders blame the patient debt on health insurers, citing the rise of high-deductible plans and other efforts that limit coverage. "The last thing that hospitals want is for their patients to face financial barriers," said Molly Smith who leads public policy at the American Hospital Association. "Hospitals are in there trying to work on behalf of patients."

Despite repeated requests from KHN, none of the medical systems around Dallas-Fort Worth would discuss their finances or the debt carried by patients.

But Smith and other hospital leaders point to billions of dollars of free or discounted care that hospitals nationwide provide every year. "Hospitals have been pretty darn generous," said Stephen Love, president of the Dallas-Fort Worth Hospital Council. "If other parts of the community did as much as hospitals, we wouldn't be in this problem."

Unlike drug companies, device makers, and many physician practices, most U.S. hospitals are nonprofit and must provide charity care as a condition of their tax-exempt status.

Regardless of tax status, medical centers in markets with high medical debt do provide more charity care, according to an analysis by KHN and the Urban Institute, a Washington think tank. That's important, said Dr. Vikas Saini, president of the Lown Institute, a nonprofit that grades hospitals on their quality and community benefits.

But Saini asked: "Is a hospital truly serving its community if it's pushing so many into debt?"

Around Dallas-Fort Worth, major medical systems frequently tout their commitment to the region and its patients.

When Texas Health Resources, a Dallas-based nonprofit system with more than $5 billion in annual revenue, opened a new hospital tower in Fort Worth earlier this year, Barclay Berdan, the system's chief executive, said the building "reinforces Texas Health's long-standing commitment to the Fort Worth community." The nine-story, $300 million tower is one of more than a half-dozen new hospitals and major expansions around the Dallas-Fort Worth area since 2018.

The big building spree has been accompanied by big bottom lines.

From 2018 to 2021, Texas Health, which owns hospitals in North Texas, had an average operating margin of almost 6%, according to a KHN analysis of publicly available financial reports.

Other major systems in the area, including Baylor, Children's Health, and HCA, the nation's largest for-profit hospital company, did even better, KHN found. Cook Children's, the region's second major pediatric system, had an average operating margin of nearly 12%.

By comparison, profits at most of the 25 Fortune 500 companies based around Dallas-Fort Worth, such as ExxonMobil, were less than 6% in 2019, according to Fortune data.

Approaching a tipping point

Hospitals have thrived in other markets with high patient debt, KHN found.

In Charlotte, N.C., where a quarter of residents have medical debt on their credit reports, hospitals recorded an average operating margin of 13.6% from 2017 to 2019.

The average margin at hospitals in and around Gainesville and Lakeland, two central Florida markets where a quarter of residents also carry medical debt, topped 9%. In Tulsa, Okla., which has the same level of debt, margins have averaged 8.5%.

Overall, U.S. hospitals recorded their most profitable year on record in 2019, with an aggregate operating margin of 6.5%, according to the federal Medicare Payment Advisory Commission. Total margins, which include income from investments, were even higher.

"You might think that hospitals in communities where patients have a lot of debt would be less profitable, but that doesn't seem to be the case," said Anuj Gangopadhyaya, a senior Urban Institute researcher who worked with KHN on an analysis of hospital finance and consumer debt data in U.S. hospital markets.

In fact, the analysis found, there is no apparent relationship between the profits of hospitals in a market and how much medical debt residents have. So while hospitals in places like Charlotte and Tulsa may be comfortably in the black, in other places with high patient debt such as Amarillo, Texas, and Columbia, S.C., hospitals are struggling, data shows.

Industry experts say the most profitable medical centers — like those around Dallas-Fort Worth — have developed business models that allow them to prosper even if their patients can't pay.

One key is prices. These hospitals maximize what they charge for everything from a complex surgery to a dose of aspirin. Most of those charges are picked up by health insurers, which still pay a much larger share of hospital bills than patients do, even those with the highest deductibles.

Across the country, many medical systems have strengthened their market power in recent years by consolidating, buying up smaller hospitals and physician practices, which enable the hospital systems to charge even more.

Dallas-Fort Worth has the highest medical prices in Texas, according to the Health Care Cost Institute, a nonprofit that tracks costs nationwide. And in a state where most markets have relatively low medical prices, in-patient care at Dallas-Fort Worth hospitals was 13% more expensive than the national median in 2020.

In addition to charging more, the most profitable hospitals frequently squeeze more savings from their operations, holding down what they pay workers, for example, and securing better contracts from suppliers. "Hospitals have had to get leaner and meaner," said Kevin Holloran, a senior director at Fitch Ratings who tracks nonprofit health systems for the bond rating firm.

It's unclear how much longer this business model can endure.

Across the country, many small and rural hospitals have closed in recent years. Even some larger systems are now losing money, as inflation and rising labor costs put new pressure on bottom lines.

As bills rise, hospitals are having a harder time collecting. Last year, nearly 1 in 5 patient bills generated by hospitals for people with insurance topped $7,500, according to an analysis of hospital billing records by Crowe LLP, a Chicago-based accounting and consulting firm. That was more than triple the rate in 2018.

"These are bills that fewer and fewer patients out there can afford," said Brian Sanderson, a senior Crowe health care consultant and former hospital executive. Indeed, hospitals manage to collect less than 17% of patient balances that exceed $7,500, according to Crowe's analysis.

"The rates at which patient balances are growing is just unsustainable for our health systems," Sanderson said, predicting that most will never be able to collect bills of this size. "It's trending to the ridiculous."

Robert Earley, a former Texas state legislator who used to head Fort Worth's public health system, compared today's hospitals to shrimpers in the Gulf Coast district he once represented.

"They wanted to pull so much shrimp out of the bay that they didn't think about whether there'd be any there long term," Earley said, recalling his constituents' struggles. "I worry that those of us in health care aren't asking ourselves enough if this system is sustainable." 

https://www.mainepublic.org/npr-news/2022-09-28/some-hospitals-rake-in-high-profits-while-their-patients-are-loaded-with

 

Physician Burnout Has Reached Distressing Levels, New Research Finds

Nearly two-thirds of doctors are experiencing at least one symptom of burnout, a huge increase from before the pandemic. But the situation is not irreparable, researchers say.

by Oliver Whang - NYT - September 29, 2022

Ten years of data from a nationwide survey of physicians confirm another trend that’s worsened through the pandemic: Burnout rates among doctors in the United States, which were already high a decade ago, have risen to alarming levels.

Results released this month and published in Mayo Clinic Proceedings, a peer-reviewed journal, show that 63 percent of physicians surveyed reported at least one symptom of burnout at the end of 2021 and the beginning of 2022, an increase from 44 percent in 2017 and 46 percent in 2011. Only 30 percent felt satisfied with their work-life balance, compared with 43 percent five years earlier.

“This is the biggest increase of emotional exhaustion that I’ve ever seen, anywhere in the literature,” said Bryan Sexton, the director of Duke University’s Center for Healthcare Safety and Quality, who was not involved in the survey efforts.

The most recent numbers also compare starkly with data from 2020, when the survey was run during the early stages of the pandemic. Then, 38 percent of doctors surveyed reported one or more symptoms of burnout while 46 percent were satisfied with their work-life balance.

“It’s just so stark how dramatically the scores have increased over the last 12 months,” said Dr. Tait Shanafelt, an oncologist at Stanford University who has led the research efforts.

Burnout among physicians has been linked to higher rates of alcohol abuse and suicidal ideation, as well as increased medical errors and worse patient outcomes. In May, the U.S. Surgeon General, Dr. Vivek Murthy, issued an advisory.

“Covid-19 has been a uniquely traumatic experience for the health work force and for their families,” he said, adding, “if we fail to act, we will place our nation’s health at risk.”

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Dr. Shanafelt noted that most of the studies on burnout among physicians and health care workers at this stage of the pandemic have been focused on certain specialties and geographic hot spots, not on the profession as a whole. With the new data set, he said, “We have, for the first time, real context.”

While the idea of burnout has become ubiquitous, the condition has a definition in medical literature. The Maslach Burnout Inventory, first published in 1981, measures burnout on three dimensions: emotional exhaustion, depersonalization from work and sense of personal accomplishment.

When the metric was first proposed, a widely held belief was that burnout could be blamed on the dispositions of individual physicians — “that these are just weaklings,” explained Dr. Colin West, a physician at the Mayo Clinic who helped conceive of the survey efforts. Over time, though, the problem persisted and that belief became outdated.

“This couldn’t just be pawned off as a handful of people who couldn’t handle the career,” Dr. West said.

In 2019, the National Academy of Medicine released a 312-page report on physician burnout, carefully laying out the current understanding of the issue and steps that people in the medical profession could take to address it. Dr. Shanafelt, who helped write the report, said that evidence suggested that many doctors’ dissatisfaction with their work could be caused by an incongruence between what they cared about and what they were incentivized to do by the health care system.

“We cared about quality of patients’ experience, building relationships with them, and then there were all these things we got paid for,” Dr. Shanafelt said. A doctor may stop looking forward to patient visits if each one is accompanied by a large amount of paperwork; they may feel as if their time is being wasted by an inefficient process.

“Even something that was once a good thing can become tarnished,” he added.

The researchers noted that the most recent survey’s broad scope has limitations. About 2,500 physicians participated by responding to a mass email, a fraction of the estimated one million practicing physicians in the United States. And the factors that might lead someone to complete a survey on burnout — such as the need for an outlet to express frustration or the lack of time to complete one — could have had complicating effects.

Doctors also exist within an ecosystem of other health workers. Dr. Sexton published a study of more than 70 hospitals this month that showed burnout is often a local phenomenon. “A lot of a person’s exhaustion score is connected to who they work with,” he said. “There’s a social contagion in burnout. If your colleagues are fried and you’re not, give it six months and you’ll look just like them.”

Doctors were unevenly affected by the early stages of the pandemic. While emergency physicians and family physicians worked around the clock, constantly exposed to Covid-19, many physicians in other specialties were able to reach their patients through telehealth appointments and spend more time with their families. Combined with a possible optimism that the worst of the pandemic was over, the rise of remote work might explain why emotional exhaustion rates actually fell among surveyed physicians in mid-2020 to the lowest point since the survey began in 2011.

But two and a half years into the pandemic, the most recent survey pointed to an overall decline in mental health.

The survey also suggested that some physicians were at higher risk of burnout, including those practicing emergency medicine, family medicine and pediatrics, as well as women physicians in general. Dr. Shanafelt said this might be because of the shortage of mental health services. “They’ve got 10 minutes to take care of their patients. There’s no psychiatrist or therapist to refer them to because our health care system is overwhelmed,” he said.

The increase in burnout is most likely a mix of new problems and exacerbated old ones, Dr. Shanafelt said. For instance, the high number of messages doctors received about patients’ electronic health records was closely linked to increased burnout before the pandemic. After the pandemic, the number of messages from patients coming into physicians’ In Baskets, a health care closed messaging system, increased by 157 percent.

And physicians pointed to the politicization of science, labor shortages and the vilification of health care workers as significant issues. In one survey published in 2021, 23 percent of physicians reported being bullied, threatened or harassed by their patients at work in the past year.

Dr. Sexton added: “On a hopeful note, we know that there are simple interventions that can have as much a positive effect on well-being as the pandemic had a negative effect. So, yes, things are worse during the pandemic, but they’re not so bad that we don’t know how to fix it.”

Dr. West, who has done research on how to combat burnout among health care workers, said that “all the solutions run through a common pathway”: They connect people with their most meaningful activities.

“What that means is it’s less important what the specific tactic is,” he said, “and more important to make sure that, whatever the solution is, it’s aligned with our basic, fundamental goals.”

But Dr. West emphasized the need for data to know the prevalence of burnout and how to combat it.

“This really provides a 30,000-foot view pulse check,” he said of the survey. “So that we’re not just guided by our feelings and our intuition.”

https://www.nytimes.com/2022/09/29/health/doctor-burnout-pandemic.html 

 

For 20-Somethings, a Confusing Rite of Passage: Finding Health Insurance

Whether you’re turning 26 and about to age out of a parent’s plan or just landing a job with benefits, finding coverage is a tricky task.

by Isabella Simonetti - NYT - September 30, 2022

Ahead of Cal Treichler’s 26th birthday in June, he faced a common challenge for 20-somethings fortunate enough to have parents with health insurance: He had to get off their plan and find his own coverage.

Mr. Treichler, who lives near Minneapolis, cannot obtain health insurance through his employer, a small financial planning firm. His company does, however, provide a stipend to pay for insurance. So Mr. Treichler considered two options: joining his wife’s plan through her teaching job or finding coverage on Minnesota’s health insurance marketplace, where residents can search for affordable plans.

Whether they are 25 and about to age out of a parent’s plan or entering the work force for the first time, young Americans are tasked with making crucial decisions about their health care at a time when they may have little understanding of how insurance works.

Luckily, Mr. Treichler’s training and knowledge as a financial planner helped him weigh his options. His wife’s plan offered advantages like lower deductibles (the amount of money you need to pay each year before coverage kicks in) and out-of-pocket maximums (the most you have to pay for covered services each year). But he calculated that her plan would be more expensive month to month than the plan he found on the marketplace.

“I typically, personally, haven’t had a lot of health care needs,” Mr. Treichler said. “I decided to go with the lower-paying option with the expectation that I wouldn’t need as much care and would likely be better off going with the lower-premium plan.” (A premium is what you pay to buy an insurance policy, separate from a deductible.)

Nearly 15 percent of Americans ages 19 to 25 were uninsured in 2021, according to data from the Census Bureau, the highest portion of any age group. That number fell from 31.4 percent in 2010, when the Affordable Care Act (nicknamed Obamacare) required insurers to cover families’ dependent children until age 26. Since then, many young people who have the benefit of insured parents have not had to research their own coverage options. Finding a suitable plan for the first time as an adult can present some pitfalls. And a lot of questions.

“You can see your 26th birthday coming,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “You know when that’s going to be. Don’t wait until a week or two before to start looking into your options.”

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What’s out there?

Depending on the situation, a young adult might weigh these choices: staying on a parent’s plan till 26, joining an employer-sponsored health insurance plan or buying coverage on their state’s marketplace. Someone with an income up to 138 percent of the federal poverty level may even qualify for Medicaid, which offers free or inexpensive health care for low-income Americans, including pregnant women and seniors. The next open enrollment period (the period when you can sign up for coverage) for marketplace plans that comply with the A.C.A. runs from Nov. 1 to Jan. 15, 2023 for most states. Many employers offer open enrollment periods, too, that are typically in the fall, but the timing varies from company to company.

The marketplace plans offer different tiered private insurance options with government subsidies for people whose income falls below a certain threshold. While the service is mainly available through Healthcare.gov, some states, including California and Pennsylvania, operate their own websites. Although the open enrollment period is fixed, those who have experienced a so-called qualifying event, like losing insurance through an employer or being forced off a parent’s insurance after a 26th birthday, have 60 days from that event to enroll in a marketplace plan. If you miss the cutoff, you will have to wait until the next enrollment period, unless there has been a major event like a natural disaster.

For those deciding whether or not to join an employer plan, it is wise to compare its cost and coverage with that of a parent’s plan. If a parent’s plan is cheaper and offers better coverage, asking your parents if they will share the cost with you might be the best solution.

Among employer plans, there may be the option to choose between a Preferred Provider Organization plan and a Health Maintenance Organization plan. A P.P.O. plan generally is more expensive on a monthly basis but may offer more out-of-network coverage, which could be necessary if you have specific medical needs. An H.M.O., though, is typically less expensive and includes a smaller group of providers.

“It’s just really a math problem,” said Robert Persichitte, a financial planner at Delagify Financial. “It’s figuring out how much would your parents pay for the insurance versus how much would you pay for the insurance, and you pick.”

Mr. Persichitte teaches a volunteer income tax assistance class at the Metropolitan State University of Denver in which accounting students help prepare tax returns for people who have annual incomes of less than $57,000. A student in the class, Deborah Son, was able to use what she learned to help prepare her father’s 2021 tax return. When they prepared the return, the family, of Aurora, Colo., got an expensive surprise.

As a college student, Ms. Son, 25, had opted to stay on her father’s plan rather than pay extra for her university health insurance. That worked for a while — until the money she earned as an intern in 2021 increased her family’s income. With the extra income, they no longer qualified for subsidized coverage through the A.C.A., requiring them to pay an unexpected additional premium of $3,000.

“We were all pretty shocked,” Ms. Son said.

Ms. Son’s case was more complicated than most, Mr. Persichitte said. Still, a multitude of varied situations can create confusion and uncertainty.

Georgia Lee Hussey, the chief executive of Modernist Financial, a planning firm in Portland, Ore., that helps clients make financial decisions aligned with their progressive values, noted that some young people who are working as independent contractors or interns may qualify for Medicaid. She said it was important for young adults to aim for financial independence, if possible.

“If you have the means, get your own health care coverage,” Ms. Hussey said.

Talking to your family

Conversations about financial decisions like health insurance can provoke tension between parents and grandparents and their children, sometimes because of generational differences. Ms. Hussey said people should focus on cultivating understanding and empathy when sensitive issues arise.

“What we don’t talk about as often as I would like is the financial realities for younger folks and the changing expectations,” Ms. Hussey said. “There’s a place for compassion between generations and understanding between generations.”

And it helps to remember that everyone has unique health needs that factor into making the right decision about insurance.

“There’s really no one size fits all, especially when it comes to something as sensitive as health care,” said Noah Damsky, a co-founder of Marina Wealth Advisors in Los Angeles.

A good place to get started, though, is educating yourself on health insurance vocabulary. Alexis Plicque, who recently went from being insured under two plans at once, to being covered by only her employer’s plan, said navigating insurance for the first time was a challenge — and it felt like a stride into adulthood.

“I really am paying for my own stuff now,” she said. “It’s kind of crazy.”

Ms. Plicque, who lives in Jacksonville, Fla., added that she leaned on her parents to teach her about terms like deductibles and co-pays (a co-pay is the fee you pay for a doctor visit or procedure after insurance). “A lot of it is very dependent on how much you want to pay per month and what your plan covers and what your employer will give you, so it’s not something you can just Google and figure it out on your own,” she said.

If like her, you have employer-sponsored coverage, Ms. Plicque offered this bit of advice: Be careful about taking on the cheapest plan an employer offers, because often that will mean having to pay a higher annual deductible before coverage kicks in.

“It is confusing, and I feel like it’s kind of confusing on purpose,” Ms. Plicque said. “And so it’s OK to ask for help and ask for other people to explain it to you, because how would you know? Because you’ve never paid for it before.”

https://www.nytimes.com/2022/09/30/business/health-insurance-obamacare-young-adults.html 

 

Medical Care Alone Won’t Halt the Spread of Diabetes, Scientists Say

Now experts are calling for walkable communities, improved housing, and access to health care and better food, particularly in minority communities.

by Roni Caryn Rabin - NYT - October 5, 2022

Over the past 50 years, medical advances have led to a more sophisticated understanding of the causes of Type 2 diabetes and to an abundance of new tools for managing it. But better treatments have done little to stem the rise of the disease.

One in seven American adults has Type 2 diabetes now, up from one in 20 in the 1970s. Many teenagers are developing what was once considered to be a disease of older people; 40 percent of young adults will be diagnosed with it at some point in their lives.

Researchers who study Type 2 diabetes have reached a stark conclusion: There is no device, no drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that are hard to navigate on foot and inequitable access to health care, particularly in minority communities.

“Our entire society is perfectly designed to create Type 2 diabetes,” said Dr. Dean Schillinger, a professor of medicine at University of California, San Francisco. “We have to disrupt that.”

Dr. Schillinger and nearly two dozen other experts laid out a road-map for doing so earlier this year in a comprehensive national report to Congress on diabetes, the first of its kind since 1975.

It calls for reframing the epidemic as a social, economic and environmental problem, and offers a series of detailed fixes, ranging from improving access to healthy food and clean water to rethinking the designs of communities, housing and transportation networks.

“It’s about massive federal subsidies that support producing ingredients that go into low-cost, energy-dense, ultra-processed and sugar-loaded foods, the unfettered marketing of junk food to children, suburban sprawl that demands driving over walking or biking — all the forces in the environment that some of us have the resources to buffer ourselves against, but people with low incomes don’t,” Dr. Schillinger said.

“We feel impotent as doctors because we don’t have the tools to tackle the social conditions people are grappling with,” he added.

The report, issued in January, calls for setting up a national policy office to roll out a far-reaching strategy to prevent and control diabetes. The document also pushes for a greater involvement of federal agencies, like those regulating housing and urban growth, that may seem to have little to do with health but could play a role in reducing the spread of the disease.

The recommendations are intended to tackle the so-called social determinants of health, said Felicia Hill-Briggs, vice president for prevention at Northwell Health.

“When we move beyond thinking of health as just biological disease, then we’re able to see that the conditions in which people are born, grow, work, live and age play a very, very key role in influencing who gets disease and what the outcomes of the disease are,” Dr. Hill-Briggs said.

“Being born into poverty should not determine whether you have access to food, or green space, or an educational system that works.”

Each patient with Type 2 diabetes faces a cascade of risks, including painful nerve damage, vision loss, kidney disease and heart disease, as well as foot and toe amputations. (Type 1 diabetes, once called juvenile diabetes, carries many of the same risks but is believed to be an autoimmune condition.)

As of 2019, more than 14 percent of Native American and Alaska Native adults had diabetes, according to the Centers for Disease Control and Prevention. The figure for Black and Hispanic adults was about 12 percent, compared with 7.4 percent for white adults.

Maria Garcia, a 58-year-old restaurant worker in San Francisco, developed Type 2 diabetes after a pregnancy almost 30 years ago. She has developed numerous complications over the years, including digestive problems, vision loss and nerve damage so severe that she has trouble walking. At night, her legs feel as if they were “on fire,” she said.

She has given up sweetened soda but said she can’t afford to purchase healthy foods like lean meat, fish and vegetables on a regular basis. It was very different in the small village in Mexico where she was born, she recalled.

“Fresh food was really cheap, and sweets and candies were expensive,” she said, adding, “We walked everywhere, even just to go to the store.”

Many of the recommendations now urged by diabetes researchers are both politically unpalatable and costly. But they could save money in the long run: One in four health care dollars goes to treat diabetes, and that costs the nation $237 billion annually (most of it paid for by government health plans), along with $90 billion in reduced productivity.

Among the proposals:

• Subsidies for farmers to grow healthy foods like fruits, vegetables and nuts in order to make them more affordable.

• Paid maternity leave for working mothers so they can breastfeed, a practice associated with a lower risk of obesity and Type 2 diabetes for both mother and child.

• Clear guidance from the government about the strong link between sugar-sweetened beverages and Type 2 diabetes. Almost one in 10 nutrition-program dollars is spent on sweetened drinks, and the researchers recommend that government programs no longer pay for them.

• Improved nutrition labels that specify the amounts of sugar in drinks in teaspoons, a measure that consumers can easily grasp, rather than grams. A 16-ounce Starbucks frappuccino contains 11 teaspoons of sugar; a 16-ounce bottle of Snapple raspberry ice tea has nine teaspoons.

The report also proposes hefty taxes of 10 percent to 20 percent on the price of sugary drinks. The beverage industry has aggressively fought similar efforts in the past.

William Dermody Jr., a spokesman for the American Beverage Association, pointed to studies showing drops in the consumption of soda and other sugary beverages, not counting tea and coffee drinks. But taxes have had little effect on consumption, he said.

Even the American Diabetes Association prefers more public education about the risks of sugary drinks to taxes or “punitive measures,” said Dr. Robert Gabbay, the association’s chief scientific and medical officer.

Healthy, unprocessed food is more costly, which has led some providers to open their own free pantries so that patients with “food prescriptions” can pick up produce, beans and items like cans of low-sodium turnip greens.

The food pantry at Nashville General Hospital helps Arleen Hicks, 59, who is unemployed and has diabetes, prepare healthy dinners. For her first two meals of the day, she eats as cheaply as possible, usually knockoff toaster pastries that are filled with sugar, which she follows with two tablespoons of peanut butter to bring her blood sugar back down.

She knows that toaster pastries are not nutritious, but they’re cheap. She lives on a monthly income of $607 and $100 in food stamps.

“I get coupons for them in the mail,” Ms. Hicks said, as she picked up zucchini, tomatoes and easy-to-follow recipes at the hospital’s food pantry. “This place has been heaven-sent.”

Some of the concerns expressed by diabetes researchers have been addressed in recent federal legislation. The Inflation Reduction Act, for example, capped the co-payments that Medicare patients shell out for insulin at $35 a month and included $50 billion to strengthen the nation’s drinking water and wastewater systems.

The report’s authors also want to make it easier for patients and people at risk for Type 2 diabetes to take in-depth courses to learn how to manage and prevent the disease. Doctors often say that managing diabetes is like having a full-time job.

Loretta Fleming, 53, who lives in New York City, didn’t know how to keep her blood sugar under control until she enrolled in peer education classes through Health People, a nonprofit, at a community center in her neighborhood in the Bronx.

“I saw dietitians and nutritionists at the hospital, but their education didn’t match what I got from the program,” Ms. Fleming said. Though the classes, she has learned to limit bread and sugary drinks and to check her feet every day for sores that could become infected. She has lost over 100 pounds and has also become a peer educator.

“I used to drink a three-liter soda every day,” she said. “It was a ritual. I had to have my soda. So I had to get rid of that. I didn’t know it was bad for me.”

https://www.nytimes.com/2022/10/05/health/diabetes-prevention-diet.html 

 

Anthem must face U.S. government lawsuit alleging Medicare Advantage fraud

by Jonathan Stempel - Reuters - October 1, 2022

NEW YORK, Oct 3 (Reuters) - A federal judge ordered Anthem Inc to face a U.S. government lawsuit claiming it submitted inaccurate diagnosis data, enabling the health insurer to fraudulently collect tens of millions of dollars in annual overpayments from Medicare.

In a decision released on Monday, U.S. District Judge Andrew Carter in Manhattan said the total alleged overpayment to Anthem appeared to be well over $100 million, making the government's financial costs "substantial and not merely administrative."

A lawyer for Anthem declined to comment. The Indianapolis-based insurer did not immediately respond to a request for comment.

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The Department of Justice lawsuit filed in March 2020 stemmed from Anthem's operation of dozens of Medicare Part C plans, also known as Medicare Advantage, a privatized system that insures Americans who opt out of traditional Medicare.

Anthem was accused of not checking the accuracy of diagnosis codes it submitted when seeking reimbursements between early 2014 and early 2018, because deleting invalid codes would have reduced revenue.

One company executive was quoted in 2016 as saying Anthem viewed its "retrospective chart review," which supplemented codes it had already collected from doctors, as a "cash cow."

The Justice Department sued Anthem under the federal False Claims Act, which prohibits submitting false payment claims, and sought civil fines and triple damages. Carter's decision is dated Sept. 30.

Anthem's case is one of multiple Justice Department civil lawsuits against companies that participate in Medicare Advantage.

The government watchdog MedPac said excess Medicare Advantage billing linked to what it calls "coding intensity" reached $12 billion in 2020.

Enrollment in Medicare Advantage has doubled since 2013 to about 28.7 million, or approximately 49% of all eligible Medicare beneficiaries, MedPac said in July.

The case is U.S. v. Anthem Inc, U.S. District Court, Southern District of New York, No. 20-02593.

https://www.reuters.com/legal/anthem-must-face-us-government-lawsuit-alleging-medicare-advantage-fraud-2022-10-03/ 

Health Care Reform Articles - September 26, 2022

 

Coronavirus Today

September 13, 2022

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Good evening. I’m Karen Kaplan, and it’s Tuesday, Sept. 13. Here’s the latest on what’s happening with the coronavirus in California and beyond. The United States accounts for a little more than 4% of the world’s population, but it’s responsible for about 16% of the world’s COVID-19 deaths. There are lots of reasons why America’s mortality rate is so high: failure to take full advantage of lifesaving vaccines; resistance to simple precautions such as wearing masks in crowded spaces; and high rates of health conditions that make people who catch the coronavirus more likely to wind up severely ill, such as coronary artery disease and obesity A recent study in the Proceedings of the National Academy of Sciences offers an additional explanation — our lack of universal healthcare. If the U.S. had a universal healthcare system like the ones in Canada, the United Kingdom, Japan, or pretty much any other high-income country, more than 1 in 4 COVID-19 deaths here could have been prevented, the study authors estimate. That added up to 338,594 avoidable deaths as of March 2022. The problem isn’t that the U.S. spends too little money on healthcare — indeed, on a per-capita basis, it spends far more than any other country. The problem is that our patchwork system of employer-based health insurance, Medicare for senior citizens and Medicaid for low-income Americans leaves a lot of gaps. In 2019, just before the pandemic hit, those gaps were so big that nearly 29 millionadults had no health insurance at all. Millions more were underinsured, meaning they had some kind of health plan but couldn’t afford the deductibles and copays they’d incur if they tried to use it. Having so many people with no easy access to health services creates a variety of issues during a pandemic. People who can’t afford to see the doctor regularly are more likely to develop a chronic health problem that makes them more vulnerable to a serious case of COVID-19. If they catch the coronavirus, they’re less likely to see a doctor or nurse right away and could miss their chance to nip their infection in the bud. Plus, while they’re getting sicker, they’re spreading the virus to others around them. To make matters worse, the ranks of uninsured and underinsured Americans grew further in the early days of the pandemic. The stay-at-home orders were designed to protect the public’s health by impeding coronavirus spread. But they also forced companies to lay off millions of workers, depriving 14.5 million Americans of employer-sponsored health insurance.

The authors of the PNAS study, led by Alison Galvani of the Yale School of Public Health, performed a series of calculations to estimate the number of lives that could have been saved if the country had a universal healthcare system.

Their starting point was the 973,459 COVID-19 deaths that had been counted in the U.S. as of March. It’s widely acknowledged that many COVID-19 deaths are never reported as such on death certificates, and other researchers had already determined that about 24% of COVID-19 deaths here were missing from official tallies. Based on that, Galvani and her colleagues figured the actual U.S. death toll as of March was 1,282,555.

Four of the study authors had previously estimated that 26.4% of COVID-19 deaths could be blamed on a lack of universal health insurance. That was based on work showing that mortality rates were higher among groups that had less insurance coverage, and that having less insurance was correlated with higher odds of getting COVID-19, especially a serious case that required hospitalization.

When Galvani and the others put it all together, they concluded that 338,594 American lives were lost as of March 2020 because of the way we pay for healthcare.

The research team also estimated that if all COVID-19 hospitalizations had been billed at roughly the same rate that’s used for people covered by Medicare and Medicaid, the country would have saved a whopping $105.6 billion from the start of the pandemic up through March.

“Universal single-payer healthcare is fundamental to pandemic preparedness,”the study authors wrote. Not only would it have saved more lives, they added, but it also “would have done so at lower cost than the current healthcare system.”

 

‘Disaster Mode’: Emergency Rooms Across Canada Close Amid Crisis

A nationwide shortage of nurses has caused dozens of emergency rooms across Canada to close temporarily and forced some patients to wait days for a bed.

by Ajosa Asai - NYT - September 14, 2022

One night in March, an understaffed hospital in Red Lake, a tiny town in northwestern Ontario, took the drastic step of shutting down its emergency department. Road signs bearing the ‘H’ symbol to guide drivers along the 60-mile route toward the hospital were covered up. The next hospital was more than two hours away.

Sue LeBeau, the chief executive of Red Lake Margaret Cochenour Memorial Hospital, took a picture of the covered hospital road sign. “This is something that moved me to tears when I saw it,” she said.

It was the first unplanned emergency room closure in Ontario since 2006, and it signaled a growing crisis, not just in one province, but across Canada. Since then, dozens of emergency rooms across the country have been forced to close, usually for a night, but sometimes for a weekend, because they don’t have enough workers.

A shortage of nurses — who have been driven away from the profession by unsafe working conditions, wage dissatisfaction, and burnout from the pandemic — has pushed Canadian hospitals to the brink.

With an underfunded public health system, Canada already has some of the longest health care wait times in the world, but now those have grown even longer, with patients reporting spending multiple days before being admitted to a hospital.

Nurses’ unions and other medical organizations are pushing for provincial governments, which administer health care in Canada, to declare the situation a “state of emergency” and direct more funding to address it.

“I don’t use those words lightly,” said Dr. Paul Parks, president of the emergency medicine section of the Alberta Medical Association, an advocacy group representing about 14,000 physicians in the western Canadian province.

“It is really a disaster mode because the definition of disaster in medicine is that the demand outstrips the ability to supply the care,” he said. “That’s what’s happening every day in our hospitals across the country.”

The United States and other countries, including England, are grappling with similar issues. Some U.S. states have tried raising nurses’ wages and Oregon called in 1,500 National Guard to help overwhelmed staff, in desperate attempts to fill the gap.

In Ontario, Canada’s most populous province, the shortage of nurses has recently forced 16 emergency departments to close, according to Ontario Health, the agency that oversees health care administration in the province.

The lack of health care workers means it takes longer for doctors to transfer acutely ill patients to hospitals with more resources and those doctors are waiting longer to find a bed, said Christine Moon, a spokeswoman for CritiCall, a 24-hour consultation line for Ontario doctors, in an email.

It’s a scene playing out across Canada. In British Columbia, a province where almost one million people do not have a family doctor, there were about a dozen emergency room closures in rural communities in August.

In Newfoundland and Labrador, the emergency room at one community hospital in a region of more than 300,000 people closed from July 1 until August 29.

In Saskatchewan, the union representing nurses in the province said the emergency room at Royal University Hospital in Saskatoon was 200 percent over capacity in late August because of the nurse shortage. The situation was much the same when Tasha Jiricka, a 24-year-old with fibromyalgia, a chronic pain condition, arrived there by ambulance earlier that month.

With intense stomach pains and unable to eat or drink, Ms. Jiricka, was assessed by nurses who thought she should be admitted, but for three days there were no open beds in the 407-bed hospital. She sat in the emergency waiting room, in pain, until one became available.

“Honestly, the only thing that got me through were the other people who were waiting,” said Ms. Jiricka in a phone interview from her hospital bed.

“We have a work force that is exhausted, demoralized, and looking at the door after toiling through the pandemic, suffering real wage cuts and working in an environment that is often unsafe for them,” Michael Hurley, president of the Ontario Council of Hospital Unions, said at a news conference in August.

To help address the crisis, the nation’s health authorities are trying to attract nurses from abroad and retain current or recently retired staff.

Jean-Yves Duclos, Canada’s health minister, announced last month that he was reinstating the position of chief nursing officer, a person who helps shape national policy, and a role that the government scrapped a decade ago.

“We need to support our nurses, make sure they are heard and that their challenges are met with solutions,” he said at a news conference alongside Leigh Chapman, a nurse and researcher who was appointed to the position.

Canada spends more on health care than all but four countries. Last year, the federal government provided 42 billion Canadian dollars for health care through a funding arrangement that increases by at least three percent per year to each of the country’s 13 provinces and territories.

But provincial leaders say that’s lower than the five percent yearly increase in the costs associated with delivering health care and are pressing the federal government to boost annual funding by at least 28 billion Canadian dollars.

Although provincial governments have ultimate control over financing for health care, including the power to raise taxes, their leaders say they can’t afford it.

In Ontario, the provincial government capped wage increases for most public sector employees in 2019, citing budget issues. Unions representing health care workers there blame the staffing shortage on the cap and the chronic underfunding of health care.

“Frankly, we need to make working in hospital better paid and safer,” Mr. Hurley, the hospitals’ union president, said, calling for financial incentives to increase the hiring and retention of experienced nurses and the addition of more full-time positions that would include insurance benefits. About 30 percent of Canada’s nursing jobs are part-time, according to data from the Canadian Institute for Health Information.

In Toronto, severe staffing shortages prompted the University Health Network, a group of five facilities that are home to some of Canada’s foremost health researchers, to issue a critical care bed alert, a warning to other emergency facilities that a hospital would not be able to readily accept transfers of critically-ill patients, said Dr. Kevin Smith, chief executive of the hospital system.

The warning typically lasts a day or so but at the health network’s Toronto General Hospital, the alert was in effect between July 22 and Sept. 2.

“Increasingly, I think many of us realize we are not going to, in the short term, train our way out of this,” said Dr. Smith. “We can’t produce nurses quickly, with the exception, possibly, of some foreign graduates.”

That’s an option that some provinces are turning to. Ontario’s health minister, Sylvia Jones, directed licensing authorities to “make every effort” to register health professionals who were internationally trained “as expeditiously as possible,” according to letters sent last month to those authorities.

Even before the pandemic, emergency departments were among the most dangerous work environments in hospitals.

Health care workers experience workplace violence at four times the rate of other workers, and half of those incidents happen in the emergency room, according to a 2021 statement by the Canadian Association of Emergency Physicians.

That violence, coupled with the increased level of risk that nurses are shouldering by serving more patients with less help even as the pandemic endures, has accelerated burnout.

“I think we’re just going to keep losing people because at a certain point, you don’t keep working in that environment,” said Dr. Carolyn Snider, the chief of emergency medicine at St. Michael’s Hospital, one of two trauma centers in downtown Toronto. “That is my biggest worry.”

In a 2019 parliamentary committee report on the issue of workplace violence, health care workers said that fewer staff led to more violence because patients and family members become frustrated with the lack of attention.

It’s something Cathryn Hoy, president of the Ontario Nurses’ Association, hears about regularly from the members of her union: punching, spitting, kicking, and two stabbings in the last six months, she said.

“Nursing is the backbone, and the heartbeat of health care,” she said. “Unless health care touches you, you don’t think about it.”

https://www.nytimes.com/2022/09/14/world/canada/nurse-shortage-emergency-rooms.html

Adequacy of Medicare Physician Fee-for-Service Payments Health Justice Monitor - September 14, 2022

Summary: A survey of California physicians finds that Medicare fee-for-service payments, not keeping pace with inflation, don’t cover their costs to provide care. Big caveat: biased sampling -- 88% of respondents don’t participate in FFS Medicare. Under single payer, payment rates would be negotiated with physicians, and fair for them.

Medicare/ PHYSICIAN PAYMENT AND ACCESS TO CARE SURVEY California Medical Association August 29, 2022   Deeply alarmed about the growing financial instability of the Medicare physician payment system, the California Medical Association (CMA) recently surveyed physicians about the financial health of their practices and how Medicare payment rates are impacting access to care in their communities.   Since 2001, inflation has increased by 40%, yet physician Medicare payments have only increased by 7%. Today’s Medicare payments on average lag 40% behind the cost of providing care, while hospital and nursing home payments are indexed to inflation (and as a result have increased by 60% since 2001).   According to the CMA survey results, 76% of physicians report that Medicare fee-for-service payments do not cover their costs to provide care, with 61% reporting average revenue losses between 11-50%. And, 13% of physicians even report average revenue losses over 50%.   Forty-one percent of physicians report they are considering closing their practices to new Medicare patients. And, 87% report that low Medicare reimbursement rates coupled with the high costs to practice in California are negatively affecting the ability to recruit and retain physicians in their communities.

Comment by: Don McCanne   It is important to realize that of the 843 physician practices surveyed, 88% reported that they did not participate in the Medicare fee-for-service program, presumably traditional Medicare. No mention was made of private Medicare Advantage participation. Might one suspect that there was an element of bias?   Regardless, the Medicare program does have some very major deficiencies that would require more than a nominal overhaul, especially now that it has been severely damaged through the CMS push for privatization.  In contrast, a well-designed single payer system is a vastly superior system of financing health care for all, and it should have the support of the medical profession. This survey would suggest that "Medicare for All" might be a poor choice for a label, especially if we want the support of organized medicine. But everyone needs to understand the policies behind single payer and how they would work so well for each and every one of us as individuals, including the physicians. Then we would have to join together to make sure that is the system that the government implements.     Pervasive Contamination of US Health System By Corporate Myths & Models Health Justice Monitor - September 8, 2022 Summary: Two recent articles characterize systemic trends and illustrate one patient’s struggles with corporate goals, values, and tactics permeating health insurance.  Value-Based Payment Is the New For-Profit Health Care Industry Truthout September 8, 2022 By Kip Sullivan, Kay Tillow & Ana Malinow   Like the insurance industry, the VBP industry hovers over doctors and patients and seeks to influence (and in some cases, dictate) doctor-patient decision-making, and in the process diverts resources away from medical care. Unlike the insurance industry, the VBP industry is almost invisible to the public. It consists of a heterogeneous mix of corporations that own, contract with, manage, consult with, or sell services to providers (doctors and hospitals). Some, such as “accountable care organizations,” mimic insurance companies. Others are consultants, such as Privia, venture capitalists like General Catalyst, or firms selling management services, such as agilon health. Large pieces of this new industry are being bought out by companies like Walgreens and Amazon. …   The phrase “value-based payment” emerged in the 2000s as the label for all methods of payment that shift insurance risk from insurance companies and public programs like Medicare onto health care providers. Risk is shifted by paying providers a set fee per patient per year (usually called “capitation”) rather than a fee for each service providers render (known as “fee-for-service”), or by tying provider payment to the profits and losses of organizations they contract with. VBP advocates claim, without evidence, that fee-for-service (FFS) induces doctors to order services patients don’t need and that shifting risk to providers will induce them to improve both components of value — cost and quality. …   The speakers at the [National Primary Care] “summit,” who included virtually every prominent advocate of VBP from the public and private sectors, studiously avoided discussion of VBP’s underwhelming effect on the cost and quality of health care, and rarely mentioned its worst side effects. A few speakers expressed frustration at how long VBP was taking to prove it can work, but even these speakers refused to discuss the research. Rather than acknowledge failure and use their time together to analyze the reasons for failure, the 150 speakers concentrated instead on repeating VBP folklore (fee-for-service is the problem and VBP schemes are the answer) and reporting cherry-picked anecdotes.   Tackling cancer while battling the insurance system The Washington Post September 9, 2022 By Annabelle Gurwitch   Even plans that are supposed to save patients money can end up costing them dearly   “You’ll receive a bill, but don’t pay it,” my caller [from SavOnSP Specialty Pharmacy] said. “Working with us ensures that you have a zero co-pay.”   [A[ few weeks later my monthly shipment of medication arrived along with an invoice from Express Scripts for $4,445. It noted that I might not owe this amount; nevertheless, it had a detachable payment slip, and a return envelope was provided. Remembering the caller’s assurances, I tossed the bill into my ever-expanding, supersize file I’ve labeled “insurance gobbledygook.” But when I visited an ATM the next day, my balance was significantly lower than I expected. $4,445 had been deducted by Express Scripts….   I’d been entangled in an increasingly exploitative scheme. In what’s become a standard industry practice, pharmacy benefit managers (PBMs) contract with secretive third-party adjusters commonly called co-pay accumulators and maximizer programs to process “specialty medication” prescriptions, including biomarker-targeted therapies for lung cancer and other chronic and deadly diseases. Once a plan engages a co-pay accumulator or maximizer, these entities reclassify these medications (some of the priciest on the market) as “nonessential.” This allows plans to exploit a loophole in the Affordable Care Act: Coverage can be denied for therapies that a plan labels “nonessential,” and a plan can reset the member’s pharmaceutical benefit deductible and out-of-pocket maximum to any amount of their choosing. Comment by: Jim Kahn   Sadly, US healthcare is increasingly distorted by a rising corporate presence, most of all for insurance but also for care. Corporations create a mythology of benefit for patients and apply aggressive business models and tactics to extract maximum profits, to the detriment of the rest of us.   The first article describes the feverish expansion of value-based payment, an array of funding mechanisms focused on capitation (named as such and de facto), with only one clear and consistent benefit: profits for corporate intermediaries. We’ve written often in HJM about the most egregious examples – Medicare Advantage, DCEs, and ACO reach (just search your emails or the HJM website). Traditional standards of evidence in medicine are routinely ignored. Instead, if a strategy is profitable we hear mindless and mind-numbing assurances that it’s beneficial. Yet often there is evidence of harm. And often there is no evidence at all, due in part to withholding of proper evaluation data by corporate interests resisting scrutiny.   The second article brings home how this ethic affects the individual, with a startling example of a women with cancer caught in a thoroughly confusing web of drug insurance entities. These layered intermediaries are proliferating out of control (pharmacy benefit managers, adjusters, accumulators, maximizers). Each complexity and inadequacy of drug insurance represents another business opportunity, a 3rd and 4th layer “remedy”. It’s a daunting challenge for anyone to understand the myriad drug insurance entities and the sequence of events described in the article. Perhaps the slimiest aspect is reclassifying a drug for cancer treatment as “nonessential” in order to burden the patient with costs far in excess of the deductible.   When will we transform our health insurance to elevate people over profits? And society over shareholders?   Single payer. Many Preventive Medical Services Cost Patients Nothing. Will a Texas Court Decision Change That? BY JULIE APPLEBYE - KAISER HEALTH NEWS - SEPTEMBER 18, 2022 A federal judge’s ruling in Texas has thrown into question whether millions of insured Americans will continue to receive some preventive medical services, such as cancer screenings and drugs that protect people from HIV infection, without making a copayment. It’s the latest legal battle over the Affordable Care Act, and Wednesday’s ruling is almost certain to be appealed. A key part of the ruling by Judge Reed O’Connor of the US District Court for the Northern District of Texas says 1 way that preventive services are selected for the no-cost coverage is unconstitutional. Another portion of his ruling says a requirement that an HIV prevention drug therapy be covered without any cost to patients violates the religious freedom of an employer who is a plaintiff in the case. Today’s top picks on the Haymarket Medical Network It is not yet clear what all this means for insured patients. A lot depends on what happens next. O’Connor is likely familiar to people who have followed the legal battles over the ACA, which became law in 2010. In  2018, he ruled that the entire ACA was unconstitutional. For this latest case, he has asked both sides to outline their positions on what should come next in filings due September 16. After that, the judge may make clear how broadly he will apply the ruling. O’Connor, whose 2018 ruling was later reversed by the US Supreme Court, has some choices. He could say the decision affects only the conservative plaintiffs who filed the lawsuit, expand it to all Texans, or expand it to every insured person in the US He also might temporarily block the decision while any appeals, which are expected, are considered. “It’s quite significant if his ruling stands,” said Katie Keith, JD, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at the Georgetown University Law Center. We asked experts to weigh in on some questions about what the ruling might mean. What does the ACA require on preventive care? Under a provision of the ACA that went into effect in late 2010, many services considered preventive are covered without a copayment or deductible from the patient. A recent estimate from the US Department of Health and Human Services found that more than 150 million people with insurance had access to such free care in 2020. The federal government currently lists 22 broad categories of coverage for adults, an additional 27 for women, and 29 for children. To get on those lists, vaccines, screening tests, drugs, and services must have been recommended by 1 of 3 groups of medical experts. But the ruling in the Texas case centers on recommendations from only 1 group: the US Preventive Services Task Force, a nongovernmental advisory panel whose volunteer experts weigh the pros and cons of screening tests and preventive treatments. Procedures that get an “A” or “B” recommendation from the task force must be covered without cost to the insured patient and include a variety of cancer screenings, such as colonoscopies and mammograms; cholesterol drugs for some patients; and screenings for diabetes, depression, and sexually transmitted diseases. Why didn’t the ACA simply spell out what should be covered for free? “As a policymaker, you do not want to set forth lists in statutes,” said Christopher Condeluci, a health policy attorney who served as tax and benefits counsel to the US Senate Finance Committee during the drafting of the ACA. One reason, he said, is that if Congress wrote its own lists, lawmakers would be “getting lobbied in every single forthcoming year by groups wanting to get on that list.” Putting it in an independent body theoretically insulated such decisions from political influence and lobbying, he and other experts said. What did the judge say? It’s complicated, but the judge basically said that using the task force recommendations to compel insurers or employers to offer the free services violates the Constitution. O’Connor wrote that members of the task force, which is convened by a federal health agency, are actually “officers of the United States” and should therefore be appointed by the president and confirmed by the Senate. The decision does not affect recommendations made by the other 2 groups of medical experts: the Advisory Committee on Immunization Practices, which makes recommendations to the Centers for Disease Control and Prevention on vaccinations, and the Health Resources and Services Administration, a part of the Department of Health and Human Services that has set free coverage rules for services aimed mainly at infants, children, and women, including birth control directives. Many of the task force’s recommendations are noncontroversial, but a few have elicited an outcry from some employers, including the plaintiffs in the lawsuit. They argue they should not be forced to pay for services or treatment they disagree with, such as HIV prevention drugs. Part of O’Connor’s ruling addressed that issue separately, agreeing with the position taken by plaintiff Braidwood Management, a Christian, for-profit corporation owned by Steven Hotze, a conservative activist who has brought other challenges to the ACA and to coronavirus mask mandates. Hotze challenged the requirement to provide free coverage of preexposure prophylaxis (PrEP) drugs that prevent HIV. He said it runs afoul of his religious beliefs, including making him “complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between 1 man and 1 woman,” according to the ruling. O’Connor said forcing Braidwood to provide such free care in its insurance plan, which it funds itself, violates the federal Religious Freedom Restoration Act. What about no-copay contraceptives, vaccines, and other items that are covered under recommendations from other groups not targeted by the judge’s ruling? The judge said recommendations or requirements from the other 2 groups do not violate the Constitution, but he asked both parties to discuss the ACA’s contraceptive mandate in their upcoming filings. Currently, the law requires most forms of birth control to be offered to enrollees without a copayment or deductible, although courts have carved out exceptions for religious-based employers and “closely held businesses” whose owners have strong religious objections. The case is likely to be appealed to the fifth US Circuit Court of Appeals. “We will have a conservative court looking at that,” said Sabrina Corlette, JD, co-director of Georgetown University’s Center on Health Insurance Reforms. “So I would not say that the vaccines and the women’s health items are totally safe.” Does this mean my mammogram or HIV treatment won’t be covered without a copayment anymore? Experts say the decision probably won’t have an immediate effect, partly because appeals are likely and they could continue for months or even years. Still, if the ruling is upheld by an appellate court or not put on hold while being appealed, “the question for insurers and employers will come up on whether they should make changes for 2023,” said Keith. Widespread changes next year are unlikely, however, because many insurers and employers have already drawn up their coverage rules and set their rates. And many employers, who backed the idea of allowing the task force to make the recommendations when the ACA was being drafted, might not make substantial changes even if the ruling is upheld on appeal. “I just don’t see employers for most part really imposing copays for stuff they believe is actually preventive in nature,” said James Gelfand, JD, president of the ERISA Industry Committee, which represents large, self-insured employers. For the most part, Gelfand said, employers are in broad agreement on the preventive services, although he noted that covering every type or brand of contraceptive without a patient copayment is controversial and that some employers have cited religious objections to covering some services, including the HIV preventive medications. Religious objections aside, future decisions may have financial consequences. As insurers or employers look for ways to hold down costs, they might reinstitute copayments or deductibles for some of the more expensive preventive services, such as colonoscopies or HIV drugs. “With some of the higher-ticket items, we could see some plans start cost sharing,” said Corlette. https://www.clinicaladvisor.com/home/topics/practice-management-information-center/many-preventive-medical-services-cost-patients-nothing-will-a-texas-court-decision-change-that/    Maine sees largest decline of any state in uninsured rate, but trails New England states overall  by Patty Wight - Maine Public - September 19, 2022 New data from the U.S. Census Bureau show that from 2019 to 2021, Maine experienced the largest decline in the uninsured rate in the U.S. In 2019, 8% of Mainers were uninsured. By 2021, that number dipped to 5.7%. That's a drop of more than two percentage points, and was the largest decline of any state. According to the Mills administration, the lower number of uninsured Mainers has also translated into an $84 million decrease in uncompensated care for hospitals. Despite those achievements, an estimated 76,000 Mainers didn't have health insurance last year. And the state's uninsured rate was the highest in New England. Massachusetts had the lowest nationwide, at 2.5%, followed by Vermont, at 3.7%.  https://www.mainepublic.org/health/2022-09-19/maine-sees-largest-decline-of-any-state-in-uninsured-rate-but-trails-new-england-states-overall   They Were Entitled to Free Care. Hospitals Hounded Them to Pay. by Jessica Silver-Greenbeerg and Katie Thomas - NYT - September 24, 2022  In 2018, senior executives at one of the country’s largest nonprofit hospital chains, Providence, were frustrated. They were spending hundreds of millions of dollars providing free health care to patients. It was eating into their bottom line. The executives, led by Providence’s chief financial officer at the time, devised a solution: a program called Rev-Up. Rev-Up provided Providence’s employees with a detailed playbook for wringing money out of patients — even those who were supposed to receive free care because of their low incomes, a New York Times investigation found. In training materials obtained by The Times, members of the hospital staff were instructed how to approach patients and pressure them to pay. “Ask every patient, every time,” the materials said. Instead of using “weak” phrases — like “Would you mind paying?” — employees were told to ask how patients wanted to pay. Soliciting money “is part of your role. It’s not an option.” If patients did not pay, Providence sent debt collectors to pursue them. More than half the nation’s roughly 5,000 hospitals are nonprofits like Providence. They enjoy lucrative tax exemptions; Providence avoids more than $1 billion a year in taxes. In exchange, the Internal Revenue Service requires them to provide services, such as free care for the poor, that benefit the communities in which they operate. But in recent decades, many of the hospitals have become virtually indistinguishable from for-profit companies, adopting an unrelenting focus on the bottom line and straying from their traditional charitable missions. To understand the shift, The Times reviewed thousands of pages of court records, internal hospital financial records and memos, tax filings, and complaints filed with regulators, and interviewed dozens of patients, lawyers, current and former hospital executives, doctors, nurses and consultants. The Times found that the consequences have been stark. Many nonprofit hospitals were ill equipped for a flood of critically sick Covid-19 patients because they had been operating with skeleton staffs in an effort to cut costs and boost profits. Others lacked intensive care units and other resources to weather a pandemic because the nonprofit chains that owned them had focused on investments in rich communities at the expense of poorer ones. And, as Providence illustrates, some hospital systems have not only reduced their emphasis on providing free care to the poor but also developed elaborate systems to convert needy patients into sources of revenue. The result, in the case of Providence, is that thousands of poor patients were saddled with debts that they never should have owed, The Times found. Founded by nuns in the 1850s, Providence says its mission is to be “steadfast in serving all, especially those who are poor and vulnerable.” Today, based in Renton, Wash., Providence is one of the largest nonprofit health systems in the country, with 51 hospitals and more than 900 clinics. Its revenue last year exceeded $27 billion. Providence is sitting on $10 billion that it invests, Wall Street-style, alongside top private equity firms. It even runs its own venture capital fund. In 2018, before the Rev-Up program kicked in, Providence spent 1.24 percent of its expenses on charity care, a standard way of measuring how much free care hospitals provide. That was below the average of 2 percent for nonprofit hospitals nationwide, according to an analysis of hospital financial records by Ge Bai, a professor at the Johns Hopkins Bloomberg School of Public Health. By last year, Providence’s spending on charity care had fallen below 1 percent of its expenses. The Affordable Care Act requires nonprofit hospitals to make their financial assistance policies public, such as by posting them in hospital waiting rooms. But the federal law does not dictate who is eligible for free care. Ten states, however, have adopted their own laws that specify which patients, based on their income and family size, qualify for free or discounted care. Among them is Washington, where Providence is based. All hospitals in the state must provide free care for anyone who makes under 300 percent of the federal poverty level. For a family of four, that threshold is $83,250 a year. In February, Bob Ferguson, the state’s attorney general, accused Providence of violating state law, in part by using debt collectors to pursue more than 55,000 patient accounts. The suit alleged that Providence wrongly claimed those patients owed a total of more than $73 million. Providence, which is fighting the lawsuit, has said it will stop using debt collectors to pursue money from low-income patients who should qualify for free care in Washington. But The Times found that the problems extend beyond Washington. In interviews, patients in California and Oregon who qualified for free care said they had been charged thousands of dollars and then harassed by collection agents. Many saw their credit scores ruined. Others had to cut back on groceries to pay what Providence claimed they owed. In both states, nonprofit hospitals are required by law to provide low-income patients with free or discounted care. “I felt a little betrayed,” said Bev Kolpin, 57, who had worked as a sonogram technician at a Providence hospital in Oregon. Then she went on unpaid leave to have surgery to remove a cyst. The hospital billed her $8,000 even though she was eligible for discounted care, she said. “I had worked for them and given them so much, and they didn’t give me anything.” (The hospital forgave her debt only after a lawyer contacted Providence on Ms. Kolpin’s behalf.) Gregory Hoffman, Providence’s chief financial officer, said in an interview that The Times’s findings about the hospital system’s treatment of poor patients “are very concerning and have our attention.” He said Providence wanted “to get things right, on behalf of our communities and on behalf of our patients,” though he acknowledged that the Rev-Up program initially had “some hiccups,” including sending Medicaid patients to debt collectors. Daily business updates  The latest coverage of business, markets and the economy, sent by email each weekday. Melissa Tizon, a spokeswoman for Providence, said the health system stopped doing that in December, although that was two years after an executive raised internal alarms about the practice. Providence has also instructed the debt collection firms it works with to not use “any aggressive tactics such as garnishing wages or reporting delinquent accounts to credit agencies,” she said. Ms. Tizon said Providence was the largest provider of charity care in Washington. While the hospital system has been providing less of that care in recent years, she said, Providence has been treating more patients on Medicaid, the federal-state insurance program for poor people. “Our practices comply with and in many instances exceed state requirements,” she said. Paying With Poultry Providence was founded in 1856 when, at the request of a local bishop, Mother Joseph and four other nuns from the Sisters of Providence trekked from Montreal to Vancouver, Wash., to provide services to the poor. Their first hospital, St. Joseph, was a single room with four beds. The hospital charged patients $1 a day, not including extras like whiskey. Patients rarely paid in cash, sometimes offering chickens, ducks and blankets in exchange for care. At the time, hospitals in the United States were set up to do what Providence did — provide inexpensive care to the poor. Wealthier people usually hired doctors to treat them at home. Given their work serving the indigent, hospitals were exempted from state and federal taxes. That system remained relatively unchanged until the federal government created Medicare and Medicaid in the 1960s. Millions more people suddenly had insurance that covered medical expenses. The I.R.S. began allowing hospitals to justify their tax exemptions by providing a broader range of loosely defined benefits to their communities beyond treating patients for free. Some hospitals took advantage of the new leeway, arguing that things like employees’ salaries counted toward the I.R.S. requirement. Top government officials warned that hospitals were abusing their privileged status as nonprofits. “Some tax-exempt health care providers may not differ markedly from for-profit providers in their operations, their attention to the benefit of the community or their levels of charity care,” the I.R.S. commissioner Mark W. Everson wrote to the Senate in 2005. Some hospital executives have embraced the comparison to for-profit companies. Dr. Rod Hochman, Providence’s chief executive, told an industry publication in 2021 that “‘nonprofit health care’ is a misnomer.” “It is tax-exempt health care,” he said. “It still makes profits.” Those profits, he added, support the hospital’s mission. “Every dollar we make is going to go right back into Seattle, Portland, Los Angeles, Alaska and Montana.” Since Dr. Hochman took over in 2013, Providence has become a financial powerhouse. Last year, it earned $1.2 billion in profits through investments. (So far this year, Providence has lost money.) Providence also owes some of its wealth to its nonprofit status. In 2019, the latest year available, Providence received roughly $1.2 billion in federal, state and local tax breaks, according to the Lown Institute, a think tank that studies health care. The greater the hospital system’s profits, the more money it could pump into expanding. In addition, the greater its cash reserves, the stronger its credit rating. A pristine rating allowed Providence to inexpensively borrow money, which it could then funnel into further growth. Over the past decade, Providence has opened or acquired 18 hospitals. Dr. Hochman earned $10 million in 2020. ‘Don’t Accept the First No’ Even before the Rev-Up program, Providence was collecting money from poor patients, sometimes in violation of state laws, according to five current and former executives and a review of patient complaints filed with regulators. Harriet Haffner-Ratliffe, 20, gave birth to twins at a Providence hospital in Olympia, Wash., in 2017. She was eligible under state law for charity care. Providence did not inform her. Instead it billed her almost $2,300. The hospital put her on a roughly $100-a-month payment plan. It was more than Ms. Haffner-Ratliffe, who was unemployed, could afford. She had to ration gas for her car. One day, her boyfriend walked into their apartment and found her surrounded by bills, crying. When she fell behind on the payments, Providence dispatched a debt collector to pursue her. For people already on the financial brink, debt collection companies can push them over the edge. The companies often inform credit-rating firms about patients’ debts, which can torpedo their credit scores. That, in turn, can make it much harder and more expensive to buy or rent a car or home or to borrow money. Ms. Haffner-Ratliffe’s ordeal chopped her credit score by about 200 points. For years, she couldn’t get a credit card. (Ms. Tizon, the Providence spokeswoman, said that the hospital had told Ms. Haffner-Ratliffe about how to seek financial aid but that she had not completed her application. Ms. Haffner-Ratliffe and her parents dispute that.) Around that time, in 2018, Providence was looking for ways to save money. It had recently merged with another nonprofit hospital system, and integrating the two was expensive. Providence turned to the consulting firm McKinsey & Company. The firm’s assignment was to maximize the money that Providence collected from its patients, the five current and former executives said. In essence, the hospital system wanted to apply the tactics it had used with Ms. Haffner-Ratliffe to even more patients. McKinsey’s solution was Rev-Up, whose name was an apparent reference to the goal of accelerating revenue growth. Training materials instructed administrative staff to tell patients — no matter how poor — that “payment is expected,” according to documents included in Washington’s lawsuit and training materials obtained by The Times. Six current and former hospital employees said in interviews that they had been told not to mention the financial aid that states like Washington required Providence to provide. One training document, titled “Don’t accept the first No,” led staff through a series of questions to ask patients. The first was “How would you like to pay that today?” If that did not work, employees were told to ask for half the balance. Failing that, staff could offer to set up a payment plan. Only as a last resort, the documents explained, should workers tell patients that they may be eligible for financial assistance. Another training document explained what to do if patients expressed surprise that a charitable hospital was pressuring them to pay. The suggested response: “We are a nonprofit. However, we want to inform our patients of their balances as soon as possible and help the hospital invest in patient care by reducing billing costs.” Staff members were then instructed to shift the conversation to “how would you like to take care of this today?” Exhorting employees to do their jobs well, some versions of the training materials invoked a famous line from a speech by the Rev. Dr. Martin Luther King Jr.: “If it falls your lot to be a street sweeper, sweep streets like Michelangelo painted pictures.” Ms. Tizon, the spokeswoman for Providence, said the intent of Rev-Up was “not to target or pressure those in financial distress.” Instead, she said, “it aimed to provide patients with greater pricing transparency.” “We recognize the tone of the training materials developed by McKinsey was not consistent with our values,” she said, adding that Providence modified the materials “to ensure we are communicating with each patient with compassion and respect.” But employees who were responsible for collecting money from patients said the aggressive tactics went beyond the scripts provided by McKinsey. In some Providence collection departments, wall-mounted charts shaped like oversize thermometers tracked employees’ progress toward hitting their monthly collection goals, the current and former Providence employees said. On Halloween at one of Providence’s hospitals, an employee dressed up as a wrestler named Rev-Up Ricky, according to the Washington lawsuit. Another costume featured a giant cardboard dollar sign with “How” printed on top of it, referring to the way the staff was supposed to ask patients how, not whether, they would pay. Ms. Tizon said such costumes were “not the culture we strive for.” The Rev-Up program alarmed some Providence employees. “It was awful working for this rich system and not being able to help people who were just crying in front of me,” said Stephanie Shufelt, who worked in patient registration at a Providence hospital in Portland, Ore., until February 2021. Taylor Davison, who worked in the emergency department of a Providence hospital in Santa Rosa, Calif., until last year, said Providence’s tactics had struck her as predatory. She was told to approach patients as soon as doctors had finished examining them. She would crouch at their bedside and ask for money. She was required to document in the patients’ charts that she had repeatedly pushed for payments. Employees were urged to collect any amount, no matter how small, she said. Some patients offered as little as $2, which she accepted. “Here are people coming in at the worst moment of their lives, and I’m asking them to empty their wallets,” Ms. Davison said. Providence paid McKinsey at least $45 million in 2019 for its assistance, tax filings show. Warning About Harm to Patients When patients left a hospital without paying, Providence sent them at least three bills. If they still did not pay, they would receive one last warning. “This is your final opportunity to pay your account,” one such letter said. Otherwise, it went on, Providence would enlist “a third-party agency that may adversely affect your credit rating.” Under Washington’s law, Providence was supposed to screen patients at the hospital to assess whether they qualified for free or discounted care. But Providence often checked patients’ income only after months of hounding them had failed, according to depositions included in the Washington lawsuit and internal memos that a former Providence executive shared with The Times. At that point, Providence ran accounts through a screening tool provided by Experian, a credit reporting company, to determine whether accounts were eligible for free care. But despite Rev-Up, the amount of free care that Providence was providing was “spiking,” an executive later explained in an email to colleagues. So in 2019, Providence’s chief financial officer at the time, Venkat Bhamidipati, and other executives made a change, according to the five current and former Providence executives and depositions included in Washington’s lawsuit. Previously, when treating patients who were on Medicaid, Providence eventually waived any outstanding portion of their bill. In 2019, Providence stopped doing that. Medicaid patients were sent to debt collectors instead. That appeared to violate laws in Washington, Oregon and California that required nonprofit hospitals to provide free care to patients earning below certain thresholds, according to regulators. Some Providence executives warned that the changes were harming patients. “I just want it made clear to our leadership that patients that would normally have been eligible for charity care are going to bad debt,” Lesa Wood, a director of financial counseling and assistance, emailed colleagues in late 2019. In 2020, a Providence executive wrote to co-workers to report that the system’s charity care spending was down “across all markets.” Skimping on Groceries In November 2020, Paulo Aguirre went to a Providence hospital in Orange County, Calif., with a splitting headache, blurred vision and nausea. Doctors gave him a shot that made the pain “go right away,” he said. Mr. Aguirre earned minimum wage working at a dental office and was on California’s version of Medicaid, known as Medi-Cal. Under California law and Providence’s financial assistance policy, his low income qualified him for free care. In early 2021, Mr. Aguirre said, he received a bill from Providence for $4,394.45. He told Providence that he could not afford to pay. Providence sent his account to Harris & Harris, a debt collection company. Mr. Aguirre said that Harris & Harris employees had called him repeatedly for weeks and that the ordeal made him wary of going to Providence again. “I try my best not to go to their emergency room even though my daughters have gotten sick, and I got sick,” Mr. Aguirre said, noting that one of his daughters needed a biopsy and that he had trouble breathing when he had Covid. “I have this big fear in me.” That is the outcome that hospitals like Providence may be hoping for, said Dean A. Zerbe, who investigated nonprofit hospitals when he worked for the Senate Finance Committee under Senator Charles E. Grassley, Republican of Iowa. “They just want to make sure that they never come back to that hospital and they tell all their friends never to go back to that hospital,” Mr. Zerbe said. Last October, an ambulance rushed Alexandra Nyfors to the Providence hospital in Everett, Wash. A diabetic, she was severely dehydrated, and her kidneys were failing. Providence put her on intravenous medications to treat an underlying infection. She spent about two weeks in the hospital. Ms. Nyfors, 66, is covered by Medicare, and her only income is about $1,700 a month in federal disability payments. Under Providence’s policies and state law, she was eligible for free care because of her low income. But Providence billed her $1,950 — the amount left over after Medicare covered its share. The remaining sum was daunting. It was getting colder, and Ms. Nyfors knew her heating bill would gobble up much of her monthly check. But when she went on the hospital’s website, she said, there were only two choices: Pay in full or set up a payment plan. Ms. Nyfors agreed to have $162.50 automatically withdrawn from her bank account each month until the bill was settled. She started buying fewer groceries, she said. She went without heat. She split her medication in two to make it last longer. She had no idea she qualified for free care until she read about Washington’s lawsuit. After Ms. Nyfors was interviewed by The Everett Daily Herald, Providence forgave her bill and refunded the payments she had made. In June, she got another letter from Providence. This one asked her to donate money to the hospital: “No gift is too small to make a meaningful impact.” Following a Script ‘Like Robots’ In 2019, Vanessa Weller, a single mother who is a manager at a Wendy’s restaurant in Anchorage, went to Providence Alaska Medical Center, the state’s largest hospital. She was 24 weeks pregnant and experiencing severe abdominal pains. “Let this just be cramps,” she recalled telling herself. Ms. Weller was in labor. She gave birth via cesarean section to a boy who weighed barely a pound. She named him Isaiah. As she was lying in bed, pain radiating across her abdomen, she said, a hospital employee asked how she would like to pay. She replied that she had applied for Medicaid, which she hoped would cover the bill. After five days in the hospital, Isaiah died. Then Ms. Weller got caught up in Providence’s new, revenue-boosting policies. The phone calls began about a month after she left the hospital. Ms. Weller remembers panicking when Providence employees told her what she owed: $125,000, or about four times her annual salary. She said she had repeatedly told Providence that she was already stretched thin as a single mother with a toddler. Providence’s representatives asked if she could pay half the amount. On later calls, she said, she was offered a payment plan. “It was like they were following some script,” she said. “Like robots.” Later that year, a Providence executive questioned why Ms. Weller had a balance, given her low income, according to emails disclosed in Washington’s litigation with Providence. A colleague replied that her debts previously would have been forgiven but that Providence’s new policy meant that “balances after Medicaid are being excluded from presumptive charity process.” Ms. Weller said she had to change her phone number to make the calls stop. Her credit score plummeted from a decent 650 to a lousy 400. She has not paid any of her bill. Susan C. Beachy and Beena Raghavendran contributed research. https://www.nytimes.com/2022/09/24/business/nonprofit-hospitals-poor-patients.html  How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits Katie Thomas, Jessica Silver-Greenberg - NYT - September 24, 2022 RICHMOND, Va. — In late July, Norman Otey was rushed by ambulance to Richmond Community Hospital. The 63-year-old was doubled over in pain and babbling incoherently. Blood tests suggested septic shock, a grave emergency that required the resources and expertise of an intensive care unit. But Richmond Community, a struggling hospital in a predominantly Black neighborhood, had closed its I.C.U. in 2017. It took several hours for Mr. Otey to be transported to another hospital, according to his sister, Linda Jones-Smith. He deteriorated on the way there, and later died of sepsis. Two people who cared for Mr. Otey said the delay had most likely contributed to his death. “He should have been able to go to the hospital and get the treatment he needed,” Ms. Jones-Smith said. “He should have been saved.” Ringed by public housing projects, Richmond Community consists of little more than a strapped emergency room and a psychiatric ward. It does not have kidney or lung specialists, or a maternity ward. Its magnetic resonance imaging machine frequently breaks, and was out of service for seven weeks this summer, said two medical workers at the hospital, who requested anonymity because they still work there. Standard tools like an otoscope, a device used to inspect the ear canal, are often hard to come by. Yet the hollowed-out hospital — owned by Bon Secours Mercy Health, one of the largest nonprofit health care chains in the country — has the highest profit margins of any hospital in Virginia, generating as much as $100 million a year, according to the hospital’s financial data. The secret to its success lies with a federal program that allows clinics in impoverished neighborhoods to buy prescription drugs at steep discounts, charge insurers full price and pocket the difference. The vast majority of Richmond Community’s profits come from the program, said two former executives who were familiar with the hospital’s finances and requested anonymity because they still work in the health care industry. The drug program was created with the intention that hospitals would reinvest the windfalls into their facilities, improving care for poor patients. But Bon Secours, founded by Roman Catholic nuns more than a century ago, has been slashing services at Richmond Community while investing in the city’s wealthier, white neighborhoods, according to more than 20 former executives, doctors and nurses. “Bon Secours was basically laundering money through this poor hospital to its wealthy outposts,” said Dr. Lucas English, who worked in Richmond Community’s emergency department until 2018. “It was all about profits.” More than half of all hospitals in the United States are set up as nonprofits, a designation that allows them to make money but avoid paying taxes. Although Bon Secours has taken a financial hit this year like many other hospital systems, the chain made nearly $1 billion in profit last year at its 50 hospitals in the United States and Ireland and was sitting on more than $9 billion in cash reserves. It avoids at least $440 million in federal, state and local taxes every year that it would otherwise have to pay, according to an analysis by the Lown Institute, a nonpartisan think tank. In exchange for the tax breaks, the Internal Revenue Service requires nonprofit hospitals to provide a benefit to their communities. But an investigation by The New York Times found that many of the country’s largest nonprofit hospital systems have drifted far from their charitable roots. The hospitals operate like for-profit companies, fixating on revenue targets and expansions into affluent suburbs. Many of these hospitals have for years slashed staffing levels, leaving them unprepared for a flood of severely ill Covid-19 patients. Others, borrowing tricks from business consultants, have trained staff to squeeze payments from poor patients who should be eligible for free care. In a statement, a spokeswoman for Bon Secours Mercy Health said the hospital system had spent nearly $10 million on improvements to Richmond Community Hospital since 2013, including opening a pharmacy and renovating the cafeteria, emergency department and other areas. The chain also invested nearly $9 million since 2018 in the neighborhood surrounding the hospital, she said. Bon Secours’s chief executive, John M. Starcher Jr., made about $6 million in 2020, according to the most recent tax filings. “Our mission is clear — to extend the compassionate ministry of Jesus by improving the health and well-being of our communities and bring good help to those in need, especially people who are poor, dying and underserved,” the spokeswoman, Maureen Richmond, said. Bon Secours did not comment on Mr. Otey’s case. In interviews, doctors, nurses and former executives said the hospital had been given short shrift, and pointed to a decade-old development deal with the city of Richmond as another example. In 2012, the city agreed to lease land to Bon Secours at far below market value on the condition that the chain expand Richmond Community’s facilities. Instead, Bon Secours focused on building a luxury apartment and office complex. The hospital system waited a decade to build the promised medical offices next to Richmond Community, breaking ground only this year. ‘Glorified Emergency Room’ For Dr. Richard Jackson, 69, an internal medicine specialist whose family has been caring for patients in this city for more than a century, walking the mostly empty halls of Richmond Community Hospital is a painful reminder of what has been lost. The hospital was founded in 1907 by Black doctors who were not allowed to work at the white hospitals across town. In the 1930s, Dr. Jackson’s grandfather, Dr. Isaiah Jackson, mortgaged his house to help pay for an expansion of the hospital. His father, also a doctor, would take his children to the hospital’s fund-raising telethons. In 1980, Richmond Community moved to its current site in the East End neighborhood, where there was no other hospital. The modest building did not have an emergency room or a maternity ward. But in addition to the intensive care unit, it had specialists in cancer as well as heart and lung disease. Dr. Jackson recruited many of them from Howard University, where he had attended medical school. But in the 1990s, the changing health care industry threatened the hospital’s survival. Large insurance companies began requiring customers to use specific networks of hospitals and doctors, in a bid to pressure providers to lower their rates. Independent institutions like Community — as it is known in the neighborhood — could not compete with larger chains, and the hospital struggled to attract patients. The doctors, who owned the hospital as part of a for-profit partnership, sold it to Bon Secours in 1995. Bon Secours was one of the dominant players in Richmond, with major medical centers throughout the city. It initially invested in the hospital, opening the emergency department, according to a history of Richmond Community by Cassandra Newby-Alexander at Norfolk State University. But as the years passed, Bon Secours began stripping the hospital’s services, including the I.C.U. The unit had only five beds, but doctors regarded it as the heart of the hospital, the place to provide critical care for the sickest patients and those recovering from major surgery. Removing the I.C.U. “really takes the meat and potatoes out of being a hospital,” Dr. Jackson said. “It’s a glorified emergency room.” With the I.C.U. closed, the hospital’s two lung specialists had nowhere to treat critically ill patients. They retired, and Bon Secours did not replace them. A team of cardiologists left a few years later. Other specialists, including gastrointestinal doctors and neurologists who were part of Bon Secours’s broader network, rarely treated patients at Richmond Community. Doctors and nurses said that when they had protested the closure of the I.C.U. and other cuts, Bon Secours argued that patients could still receive care at the chain’s other hospitals. But that promise was undermined by the arrival of the coronavirus, which disproportionately affected Black and low-income residents in the East End. In the census tract that includes Richmond Community Hospital, the Covid death rate has been 81 percent higher than the city’s overall rate, according to data provided by the Virginia Department of Health. In the summer of 2021, as the Delta variant surged through the city, a woman in the emergency room with Covid declined and needed an I.C.U. with a ventilator, according to three people involved in her case. For hours, the staff couldn’t get her to another hospital. Eventually, she was transferred to Memorial Regional Medical Center, also owned by Bon Secours, but died after arriving. Her death left some who had cared for her at Community wondering if she would have survived had she shown up at a different hospital. Bon Secours declined to comment on whether the hospital’s lack of an I.C.U. contributed to the Covid death toll. The pandemic exacerbated a problem that doctors and nurses said they had long faced — getting patients access to other hospitals in the Bon Secours system. The East End is home to Richmond’s largest Black population and, despite recent interest from real estate investors, lacks some basic services. In 2019, it got its first supermarket. In some of the neighborhoods surrounding the hospital, more than half the households do not have a car, according to research done by Virginia Commonwealth University. The public bus route to St. Mary’s, a large Bon Secours facility in the northwest part of the city, takes more than an hour. There is no public transportation from the East End to Memorial Regional, nine miles away. “It became impossible for me to send people to the advanced heart valve clinic at St. Mary’s,” said Dr. Michael Kelly, a cardiologist who worked at Richmond Community until Bon Secours scaled back the specialty service in 2019. He said he had driven some patients to the clinic in his own car. Richmond Community has the feel of an urgent-care clinic, with a small waiting room and a tan brick facade. The contrast with Bon Secours’s nearby hospitals is striking. At the chain’s St. Francis Medical Center, an Italianate-style compound in a suburb 18 miles from Community, golf carts shuttle patients from the lobby entrance, past a marble fountain, to their cars. Dr. Samuel Hunter, 81, who worked for more than four decades as a pathologist at Richmond Community until he left in May, said the disparity reminded him of his childhood in segregated Florida, where Black children like him learned from textbooks that white students had already used. “I know what it feels like to have secondhand things,” he said. A Lucrative Drug Program When Bon Secours bought Richmond Community, the hospital served predominantly poor patients who were either uninsured or covered through Medicaid, which reimburses hospitals at lower rates than private insurance does. But Bon Secours turned the hospital’s poverty into an asset. The organization seized on a federal program created in the 1990s to give a financial boost to nonprofit hospitals and clinics that serve low-income communities. The program, called 340B after the section of the federal law that authorized it, allows hospitals to buy drugs from manufacturers at a discount — roughly half the average sales price. The hospitals are then allowed to charge patients’ insurers a much higher price for the same drugs. The theory behind the law was that nonprofit hospitals would invest the savings in their communities. But the 340B program came with few rules. Hospitals did not have to disclose how much money they made from sales of the discounted drugs. And they were not required to use the revenues to help the underserved patients who qualified them for the program in the first place. In 2019, more than 2,500 nonprofit and government-owned hospitals participated in the program, or more than half of all hospitals in the country, according to the independent Medicare Payment Advisory Commission. Starting in the mid-2000s, big hospital chains figured out how to supercharge the program. The basic idea: Build clinics in wealthier neighborhoods, where patients with generous private insurance could receive expensive drugs, but on paper make the clinics extensions of poor hospitals to take advantage of 340B. Since 2013, Bon Secours has opened nine such satellite clinics in wealthier parts of the Richmond area, according to federal records. Even though the outposts are miles from Richmond Community, they are legally structured as subsidiaries of the hospital, which entitles them to buy drugs at the discounted rate. The Bon Secours Cancer Institute at St. Mary’s, for example, administers cancer drugs to patients in an office suite on the tree-lined campus of St. Mary’s Hospital. Thanks to 340B, Richmond Community Hospital can buy a vial of Keytruda, a cancer drug, at the discounted price of $3,444, according to an estimate by Sara Tabatabai, a former researcher at Memorial Sloan Kettering Cancer Center. But the hospital charges the private insurer Blue Cross Blue Shield more than seven times that price — $25,425, according to a price list that hospitals are required to publish. That is nearly $22,000 profit on a single vial. Adults need two vials per treatment course. The way hospitals use the 340B program is “nakedly capitalizing on programs that are intended to help poor people,” said Dr. Peter B. Bach, a biotechnology executive and researcher whose work has shown that hospitals participating in the 340B program have increasingly opened clinics in wealthier areas since the mid-2000s. Bon Secours did not disclose how much money it earned through the program, but said the funds “help us address health disparities while providing community support and outreach.” It said it had provided nearly $18 million in free care to poor patients at Richmond Community Hospital since 2018. In 2020, the hospital provided $3.8 million in free care to low-income patients, or about 2.6 percent of its total expenses, slightly above the national average. The federal agency that oversees the 340B program, the Health Resources and Services Administration, said that hospitals and clinics were regularly audited, and that the Biden administration had proposed requiring them to report how they spent profits generated through the program. Such a change would require congressional approval. In 2020, the most recent year for which data is available, Richmond Community Hospital — including its satellite offices — had a profit margin of nearly 44 percent, the highest in the state, according to an analysis by Virginia Health Information, a nonprofit group that collects financial data from hospitals. That year, the hospital brought in more than $110 million in revenue, after expenses and losses were deducted, according to Virginia Health Information. According to two former Bon Secours executives familiar with the hospital’s financial operations, the vast majority of Richmond Community’s profit since 2013 has come from the 340B program. Bon Secours’s other hospitals have not done as well. St. Mary’s, considered the most prestigious Bon Secours facility in Richmond, brought in $83 million in 2020. ‘Unabashedly Profit-Oriented’ On a sunny October day in Richmond in 2012, two cheerleaders for Washington’s National Football League team smiled for cameras as they gripped a large sign between them. “Bon Secours Training Center,” read the sign, which combined the Bon Secours fleur-de-lis logo with a bust of a Native American, the football team’s logo at the time. The team, Bon Secours and the State of Virginia were unveiling a major economic deal that would bring $40 million to Richmond, add 200 jobs and keep the Washington team — now known as the Commanders — in the state for summer training. The deal had three main parts. Bon Secours would get naming rights and help the team build a training camp and medical offices on a lot next to Richmond’s science museum. The city would lease Bon Secours a prime piece of real estate that the chain had long coveted for $5,000 a year. The parcel was on the city’s west side, next to St. Mary’s, where Bon Secours wanted to build medical offices and a nursing school. Finally, the nonprofit’s executives promised city leaders that they would build a 25,000-square-foot medical office building next to Richmond Community Hospital. Bon Secours also said it would hire 75 local workers and build a fitness center. “It’s going to be a quick timetable, but I think we can accomplish it,” the mayor at the time, Dwight C. Jones, said at the news conference. Today, physical therapy and doctors’ offices overlook the football field at the training center. On the west side of Richmond, Bon Secours dropped its plans to build a nursing school. Instead, it worked with a real estate developer to build luxury apartments on the site, and delayed its plans to build medical offices. Residents at The Crest at Westhampton Commons, part of the $73 million project, can swim in a saltwater pool and work out on communal Peloton bicycles. On the ground floor, an upscale Mexican restaurant serves cucumber jalapeño margaritas and a Drybar offers salon blowouts. The land next to Richmond Community Hospital, by contrast, remained inactive until February of this year, when Bon Secours broke ground on the complex. Former executives at the chain said a series of management changes in Bon Secours’s Richmond region, coupled with a change in mayoral administrations, had distracted attention from the project. And a merger with an Ohio hospital chain in 2018 accelerated the push for higher revenues, according to former administrators and doctors. “There was a major shift from being mission-oriented to being unashamedly, unabashedly profit-oriented,” said Dr. Jones, the former mayor who helped broker the original deal. Bon Secours said that since 2018, it had spent more than $19 million supporting organizations and initiatives throughout metropolitan Richmond, including more than $8 million on local businesses and charities in the East End. The work near Richmond Community Hospital is projected to be finished by the end of this year. Hospital executives have said they plan to house mental health, hospice and other services there. Disaster Medicine For years, doctors and nurses at Richmond Community have often felt as if they were working on a battlefield, doing their best with severely limited supplies and facilities. Kristen Schnurman, who began her career as a physician assistant at Bon Secours in 2014 and left in 2019, said she had once confided in a doctor that she was not learning proper medical care. “He said to me — and this will always stick with me — ‘You’re not learning medicine, you’re learning disaster medicine,’” she said. In the summer of 2016, with temperatures soaring past 90 degrees, the hospital’s air-conditioning went out for several weeks, making it hotter inside than out on the street. When asked about the air-conditioning and lack of basic supplies at Richmond Community, Bon Secours declined to comment. Ms. Richmond, the Bon Secours spokeswoman, said it would replace the M.R.I. machine as part of a $5.3 million capital improvement plan. Dr. Kelly, the cardiologist, stopped treating patients at the hospital in 2019. But there is one man’s story that haunts him. The man, who was in his 50s, arrived at the emergency room showing signs of a heart attack. To prevent permanent damage, the man needed to be swiftly catheterized, a procedure that would insert a balloon into his blocked artery and force it open. Bon Secours did not have the tools for the catheterization, so Dr. Kelly arranged for the patient to be transferred quickly to Memorial Regional. But Memorial could not guarantee a bed would be ready, Dr. Kelly said. So the patient waited for several hours in the Community emergency room. “All we could do was watch it happen,” Dr. Kelly recalled. The patient survived, he said, but the delay damaged his heart. For the rest of his life, the man will be at risk for extreme fatigue and dangerously low blood pressure, Dr. Kelly said. Every time that Bon Secours took away a service from Community, executives gave doctors the same justification: Patients were just an ambulance ride away from hospitals in the broader system. But Dr. Kelly and other doctors said many patients had wound up like the man with the heart attack. “We very, very often were stuck for many hours with patients who absolutely needed advanced care,” Dr. Kelly said. Other patients faced a different problem: Specialists who saw patients at other Bon Secours locations would not travel to the hospital. This spring, Doris Scarborough, 79, went to Richmond Community to have her toe partly amputated. Poor circulation had turned the toe black and gangrenous. She said her podiatrist had told her that she would lose some of her toe, but was likely to keep her leg if she had a standard procedure known as revascularization. Richmond Community did not offer this procedure. Ms. Scarborough had to have it done at the specialist’s office, and it took more than two weeks to get an appointment. Weeks after the procedure, Ms. Scarborough lost her entire toe. Dr. Foluso Fakorede, a cardiologist and an expert on racial disparities in amputation, said many people in poor, nonwhite communities faced similar delays in getting the procedure. “I am not surprised by what’s transpired with this patient at all,” he said. Because Ms. Scarborough does not drive, her nephew must take time off work every time she visits the vascular surgeon, whose office is 10 miles from her home. Richmond Community would have been a five-minute walk. Bon Secours did not comment on her case. “They have good doctors over there,” Ms. Scarborough said of the neighborhood hospital. “But there does need to be more facilities and services over there for our community, for us.” Susan C. Beachy contributed research. https://www.nytimes.com/2022/09/24/health/bon-secours-mercy-health-profit-poor-neighborhood.html