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Mental Health Services Wane as Insurers Appear to Skirt Parity Rules During Pandemic

Therapists and other behavioral health care providers cut hours, reduced staffs and turned away patients during the pandemic as more Americans experienced depression symptoms and drug overdoses, according to a new report from the Government Accountability Office.

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The report on patient access to behavioral health care during the covid-19 crisis also casts doubt on whether insurers are abiding by federal law requiring parity in insurance coverage, which forbids health plans from passing along more of the bill for mental health care to patients than they would for medical or surgical care.

The GAO’s findings are “the tip of the iceberg” in how Americans with mental, emotional and substance use disorders are treated differently than those with physical conditions, said JoAnn Volk, a research professor at Georgetown University’s Center on Health Insurance Reforms who studies mental health coverage.

The GAO report, shared before publication exclusively with KHN, paints a picture of an already strained behavioral health system struggling after the pandemic struck to meet the treatment needs of millions of Americans with conditions like alcohol use disorder and post-traumatic stress disorder.

Up to 4 in 10 adults on average reported anxiety or depression symptoms during the pandemic, the report showed, compared with about 1 in 10 adults in early 2019.

During the first seven months of the pandemic, there were 36% more emergency room visits for drug overdoses, and 26% more visits for suicide attempts, compared with the same period in 2019.

As the need grew, already spotty access to treatment dwindled, the GAO found: A survey of members of the National Council for Behavioral Health, an organization that represents treatment providers, showed 27% reported they laid off employees during the pandemic; 35% reduced hours; and 45% said they closed programs.

Worker shortages have long been an obstacle to accessing behavioral health services, which experts attribute in large part to problems with how providers are paid. Last fall the federal government estimated that more than one-third of Americans live in an area without enough providers available.

Provider groups interviewed by GAO investigators acknowledged staff shortages and some delays in getting patients into treatment. They noted that the pandemic forced them to cut outpatient services and limit inpatient options. They also told the researchers that payment issues are a significant problem that predated the pandemic. In particular, the GAO said, most groups cited problems getting reimbursed by Medicaid more often than any other payer.

Sen. Ron Wyden (D-Ore.), who chairs the Senate Finance Committee, requested the report from GAO after hearing complaints that constituents’ insurance claims for behavioral health care were being denied.

In an interview, Wyden said he plans to embark on a “long-running project” as chairman to make care “easier to find, more affordable, with fewer people falling between the cracks.”

Spurred by how the pandemic has intensified the system’s existing problems, Wyden identified four “essential” targets for lawmakers: denied claims and other billing issues; the workforce shortage; racial inequality; and the effectiveness of existing federal law requiring coverage parity.

For Wyden, the issue is personal: The senator’s late brother had schizophrenia. “Part of this is making sure that vulnerable Americans know that somebody is on their side,” he said.

State and federal officials rely heavily on people’s complaints about delayed or denied insurance claims to alert them to potential violations of federal law. The report cited state officials who said they “routinely” uncover violations, yet they lack the data to understand how widespread the problems may be.

Congress passed legislation in December that requires that health plans provide government officials with internal analyses of their coverage for mental and physical health services upon request.

Part of the problem is that people often do not complain when their insurer refuses to pay for treatment, said Volk, who has been working with state officials on the issue. She advised that anyone who is denied a claim for behavioral care should appeal it to their insurer and report it to their state’s insurance or labor department.

Another obstacle: Shame and fear are often associated with being treated for a mental health disorder, as well as a belief among some patients that inequitable treatment is just the way the system works. “Something goes wrong, and they just expect that’s the way it’s supposed to be,” Volk said.

The GAO report noted other ways the pandemic limited access to care, including how public health guidelines encouraging physical distancing had forced some treatment facilities to cut the number of beds available.

On a positive note, the GAO also reported widespread approval for telehealth among stakeholders like state officials, providers and insurers, who told government investigators that the increased payments and use of virtual appointments had made it easier for patients to access care.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Two Unmatched-Doctor Advocacy Groups Are Tied to Anti-Immigrant Organizations

In their last year of medical school, fourth-year students get matched to a hospital where they will serve their residency.

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The annual rite of passage is called the National Resident Matching Program. To the students, it’s simply the Match.

Except not every medical student is successful. While tens of thousands do land a residency slot every year, thousands others don’t.

Those “unmatched” students are usually left scrambling to figure out their next steps, since newly graduated doctors who don’t complete a residency program cannot receive their license to practice medicine.

At first glance, two new advocacy groups, Doctors Without Jobs and Unmatched and Unemployed Doctors of America, seem to be championing their cause, helping them find residency slots and lobbying Congress to create more medical residency positions. The groups also recently organized a protest in Washington, D.C., to draw attention to the scarcity of residencies.

But the organizations aren’t merely support groups. They are tied to Progressives for Immigration Reform, an organization that the Southern Poverty Law Center has designated as an anti-immigrant group. PFIR is financed by an anti-immigrant foundation and its executive director has been affiliated with a network of anti-immigrant groups.

The two doctor groups want U.S.-trained and U.S. citizen doctors to get top priority in the Match over foreign-educated doctors. While both Doctors Without Jobs and Unmatched and Unemployed Doctors of America do not say they are anti-immigrant, their websites include messaging that implies foreign doctors are taking residency spots away from U.S. doctors.

We need long-term solutions to the unmatched MD issue. That could include a 25 percent reduction in the number of doctors admitted on H-1B and J-1 visas.https://t.co/L81KmAY1B5
— Doctors Without Jobs (@DocsWithoutJobs) March 17, 2021

However, newly unmatched medical students searching for a source of support aren’t necessarily aware of the groups’ anti-immigrant affiliations.

Haley Canoles, a fourth-year medical student who didn’t match this year, was caught off guard when she learned of the organizations’ deeper agenda.

“I had no idea. I just recently joined Twitter and started following groups that I thought could help me network to find a residency position,” Canoles wrote in a private message on Twitter. “I absolutely do not stand for any anti-immigration agenda.”

As the percentage of unmatched U.S. medical students increases each year and the number of residency positions remains mostly static, more could be drawn to a support group such as Doctors Without Jobs.

According to 2021 data from the National Resident Matching Program, the percentage of medical school graduates who don’t match has increased. In 2021, 7.2% of students didn’t match into residency programs, up from 5.7% in 2017.

Meanwhile, the percentage of non-U.S. citizens who attended foreign medical schools who didn’t match has declined over the past five years to 45.2% in 2021, from 47.6% in 2017.

That makes advocates for international medical students worry that, if this trend continues, there could be increased resentment toward doctors educated abroad and xenophobic attitudes in the medical community.

“I obviously disagree with the idea that foreign medical graduates are taking spots from U.S. medical graduates,” said Dr. William Pinsky, president and chief executive officer of the Educational Commission for Foreign Medical Graduates, which certifies international medical graduates before they enter the U.S. graduate medical education system. “What residency directors primarily look for is who is the best qualified, and sometimes foreign medical graduates fit that bill.”

Kevin Lynn, executive director of PFIR, founded Doctors Without Jobs as an offshoot of the organization in 2018, after meeting an unmatched doctor outside a protest at the White House.

“I didn’t even know this was a problem, and then we started looking at the data and realizing that thousands of medical students weren’t getting into residency programs,” said Lynn. “At the same time, the number of foreign doctors who graduate from foreign medical schools and get taxpayer-funded residencies is increasing.”

PFIR endorses restricting immigration into the U.S., it says, to protect the American labor force and the environment. Its website also says it researches the “unintended consequences of mass migration.”

In a 2020 report, the SPLC found that Lynn had been closely involved with members of prominent Washington anti-immigration hate groups, including the Federation for American Immigration Reform (FAIR) and the Center for Immigration Studies (CIS). Both organizations push for reducing the number of immigrants in the U.S., are designated as hate groups by the SPLC and were founded by Dr. John Tanton, whom the SPLC has tied to white nationalists, racists and eugenicists.

And in July 2020, at the height of the covid pandemic, Lynn sent a letter to then-Senate Majority Leader Mitch McConnell asking him not to allow a bipartisan bill that would allocate unused green cards to foreign health care workers into the next covid stimulus bill, and instead prioritize unmatched U.S. doctors. That effort was publicized in Breitbart News, a right-wing publication that shares the anti-immigrant view. The bill died in the Senate.

The SPLC also reported that Joe Guzzardi, a writer for Doctors Without Jobs, has previously written more than 700 blog posts for a white nationalist hate website.

According to recent nonprofit filings, from 2015 to 2019 PFIR received almost $2 million in funding from the anti-immigrant Colcom Foundation, which also provides significant funds to FAIR and CIS. Neither Doctors Without Jobs nor Unmatched and Unemployed Doctors of America have made any public financial disclosures, though Doctors Without Jobs accepts donations.

The modus operandi of these types of nativist groups is to take any policy problem area and say the solution is to restrict or eliminate immigration into the U.S., said Eddie Bejarano, a research analyst at SPLC who wrote the 2020 report. Doctors not receiving residency spots is just the latest issue that the anti-immigration movement has seized on.

“They’re taking issues like this and saying that the solution is grounded in nativism, it’s not about reform,” said Bejarano. “It’s out of the textbook for nativists, if they can prey on the fears for normal Americans, such as here, where doctors are just wanting a fair shot at a job and blaming it on immigrants.”

Lynn’s rhetoric doesn’t contradict Bejarano’s observation. “I believe we should be prioritizing Americans,” Lynn said in an interview with KHN. “People say that is xenophobic, that is racist. These are attempts to quiet dissent. What I’m saying are uncomfortable truths.”

Unmatched and Unemployed Doctors of America has a less direct connection to the anti-immigrant groups. It claims it is solely volunteer-run, independent of Doctors Without Jobs and doesn’t receive any funding from the organization. But it does say on its website that it is affiliated with Doctors Without Jobs. The groups have worked together to organize a recent protest and feature each other on their respective websites and in promotional materials.

Leaders of Unmatched and Unemployed Doctors of America declined an interview but provided KHN with an emailed statement claiming nearly half its members are immigrants or are second-generation immigrants.

Doctors Without Jobs and Unmatched and Unemployed Doctors of America have increased their activity in the past couple of months. In January, members of the two groups traveled to Washington to protest outside the headquarters of the Association of American Medical Colleges, to bring attention to the issue of unmatched doctors. The AAMC runs the electronic system for submitting residency program applications.

The groups said they met with members of Congress to discuss reintroducing the Resident Physician Shortage Reduction Act, which would increase federally supported medical residency positions by 2,000 annually for seven years. The bill was introduced again in the House and Senate in March.

Doctors Without Jobs also recently released a video targeting the AAMC and saying that the organization is promoting a policy that “allows foreign medical students to take American students’ residencies.”

In an emailed statement, Karen Fisher, the AAMC’s chief public policy officer, said that any unnecessary restrictions on immigration would only accelerate and worsen the existing physician shortage and that foreign-trained doctors often fill critical gaps in the health care workforce.

“The nation’s teaching hospitals seek to recruit the most qualified candidates into their residency training programs,” said Fisher. “A blanket preference for U.S. applicants runs counter to this goal and would severely restrict the pool of highly qualified individuals and prevent U.S. patients from receiving the best possible care from a diverse and dedicated group of aspiring physicians.”

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What a Difference a Year Makes in Colorado’s Case for a Public Option Plan

DENVER — Before the pandemic, Colorado looked set to become the second state to pass what’s known as a “public option” health insurance plan, which would have forced hospitals that lawmakers said were raking in obscene profits to accept lower payments. But when covid-19 struck, legislators hit pause.

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Now, after a year of much public lionizing of doctors and other health professionals on the front lines of the covid fight, it’s a lot harder to make the case hospitals are fleecing patients.

“It is much more difficult now that we have this narrative of the health care heroes,” said Sarah McAfee, director of communications for the Center for Health Progress, a Denver-based health advocacy organization that pushed for the public option. “Part of this is separating the two: The people who are providing the health care are not the same as the corporations who are focused on the bottom line.”

Colorado legislators had tried to walk a tightrope, targeting their criticism toward the business side of the industry while continuing to praise front-line health workers and trying to get buy-in from all sides. But on Monday, Democratic legislators said they’d made a deal with the health industry to scrap the public option and instead mandate lower premiums for those buying coverage on the individual or small-group markets. The bill still must be approved.

Colorado’s compromise highlights the political tap dance likely to play out across the country as the pandemic changes the political discussion on health care costs. With states including Connecticut, Nevada and Oregon also considering public option plans this year, Colorado’s example may be a sign that major health care upheavals will be delayed for at least another year as hospitals, providers and insurers unite and push back together.

“Nationally, there’s little appetite to pursue policies that would potentially cut revenues for hospitals and other providers,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University. “It’s very hard to do when the public sees these providers as true heroes.”

At the start of this year’s legislative session, Colorado Democrats had proposed giving the health industry four years to reduce health insurance premiums by 20%. Failure to meet that target would have triggered a state-designed public option plan in 2025 that would likely undercut the cost of private insurance plans. Proponents argued that as a nonprofit-run plan without the need for hefty spending for administration, marketing and profit, it could pass on significant savings to consumers. To lower premiums, insurers would have to pressure providers into taking lower payments for their services.

Instead, under the deal reached with the health industry this week, insurance plans would commit to reducing premiums by 18% over three years. If they fail to do so, insurers would have to justify their premiums and state officials would get some say over provider payment rates. Those rates would not dip below 165% of Medicare rates for hospitals, or 135% for other health providers. Hospitals had been pushing for a floor of 200% of Medicare, and physician groups are still negotiating with the bill sponsors to increase their minimum rates.

The state would design a standardized benefit plan that would limit the insurance companies’ ability to skimp on benefits or increase cost sharing to make up for the drop in premiums.

Democratic Rep. Dylan Roberts, the legislation’s lead sponsor, said the compromise would offer significant cost reductions for Coloradans, a benefit that was ultimately more important to him than how those savings were achieved.

“Health care access is the No. 1 thing I hear from my constituents,” Roberts said. “Do they care whether their health insurance product is coming from a public entity or a private insurance company? I don’t think they care as much about that as whether it’s affordable.”

But some disconnect may be occurring between what people say they want and the political will at the Statehouse to take on the unified health care industry. According to a November poll by Healthier Colorado, 66% of Coloradans supported the public option plan, including 78% of Blacks and 76% of Hispanics. That’s virtually unchanged from polling done before the pandemic and after a hefty advertising campaign against the legislation.

Kyle Piccola, spokesperson for the advocacy group, said polling in some of the more rural, conservative districts showed 57% to 66% support. About 40% of those identifying themselves as Republicans supported the bill as it was.

“This data point,” he said, “is really showing that everybody, regardless of who you are, is really feeling the high cost of care.”

Democrats have the votes to push just about any bill through the House and Senate on their own, and Democratic Gov. Jared Polis had supported a public option after campaigning on the issue. But Joe Hanel, spokesperson for the nonpartisan Colorado Health Institute that analyzes health policy, said the sponsors likely courted industry and Republican support to avoid having opponents undermine the effort for years to come, as happened on the federal level with the Affordable Care Act.

“It just really seems like they just want buy-in to make this be more durable, and not be a lightning rod, not have millions of dollars of ads out there against them for years, like they are right now,” Hanel said.

Industry groups had opposed last year’s bill and the initial proposal this session. National groups ran a campaign with TV ads and mailers warning consumers a public option would put hospitals out of business. With the compromise, Colorado hospital, insurance and other provider associations have withdrawn their opposition.

Still, the new proposal passed its first test along a strict party-line vote in a House committee on Tuesday, as the pandemic loomed heavily over the debate. Republicans argued health care is dramatically different now than when a 2019 actuarial analysis suggested hospitals could easily absorb lower payment rates.

“And nothing has changed in the medical world since 2019?” Republican Rep. Hugh McKean asked the sponsors, tongue in cheek. “There hasn’t been any big stuff that we’re still in the middle of?”

Hospitals have also taken every opportunity to remind legislators of their role in battling the challenges of the past year.

“These are the very same hospitals who supported Colorado at every turn during the covid-19 pandemic. They were and continue to be there for their communities,” said Chris Tholen, president and CEO of the Colorado Hospital Association. “It is critical that we carefully implement this legislation and monitor it to be sure that hospitals can continue to be vital resources for their communities.”

An analysis done on behalf of the Colorado Business Group on Health found that Colorado hospitals averaged a 15.6% profit margin in 2018, beating out Utah and California for the highest margins in the country. While financial data for 2020 has not yet been released, Roberts said, many of the larger hospital systems did well amid the pandemic. They also benefited from millions in federal relief money. The bill would provide additional support for many of the smaller or rural hospitals that have struggled.

Those provisions were not enough to assuage Republicans.

“If we want to have good health care providers in Colorado, we can’t cut their funds while they are recovering from covid,” said Colorado GOP chairperson Kristi Burton Brown. “This bill completely disregards our health care workers and our health care facilities. At a time when we should be ensuring they can operate in Colorado, the Democrats are working to shut them down.”

Colorado has been aggressive on health care policy in recent years, pushing through measures aimed at reducing health care costs for its residents. Proponents of the public option bill have played up the example of the Peak Health Alliance, in which communities in seven counties in western Colorado negotiated price concessions from hospitals, lowering premiums by 20% to 40%.

Tamara Pogue, a Summit County commissioner and former CEO of the alliance, said she saw similarities between the bill’s approach and the Peak Health model. “It’s creating incentives for the industry and the communities to work together,” she said.

The Peak Health example helps to fend off criticisms that cutting costs would close hospitals and reduce access.

“We don’t even have to entertain hypotheticals,” Roberts said. “We have a real-world example there.”

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La pandemia ha puesto más en peligro a los que no hablan inglés

En marzo de 2020, a unas semanas del inicio de la pandemia, cuando todavía el Brigham and Women’s Hospital en Boston estaba tratando de entender la nueva enfermedad mortal, ya se veía que afectaba más a afroamericanos y a latinos. Pero para los hispanos había una señal de alerta adicional: el idioma.

Los pacientes que sabían poco o nada de inglés tenían un 35% más de posibilidades de morir.

Los médicos que no podían comunicarse claramente con los pacientes en las unidades de covid empezaron a notar que esto estaba afectando los resultados de salud.

“Teníamos la impresión de que el idioma iba a ser un problema desde el principio”, dijo el doctor Karthik Sivashanker, entonces director médico de Brigham para calidad, seguridad y equidad. “Recibíamos informes de seguridad que decían que el idioma era un problema”.

Sivashanker se sumergió en los registros, observando las características únicas de cada uno de los pacientes que habían fallecido: su raza, edad y sexo, y si hablaban inglés.

“Ahí es donde empezamos a descubrir realmente algunas desigualdades más profundas, antes invisibles”, dijo.

Desigualdades que no tenían que ver únicamente a la raza.

Los hospitales de todo el país han informado más hospitalizaciones y muertes de pacientes de raza negra y latinos (que pueden ser de todas las razas) que de caucásicos.

Estos pacientes pueden ser más susceptibles porque tienen más probabilidades de tener una enfermedad crónica que aumenta el riesgo de desarrollar una forma grave de covid.

Pero cuando el equipo de Brigham comparó a pacientes de raza negra y latinos con pacientes blancos no hispanos que tenían enfermedades crónicas similares, no encontraron diferencias en el riesgo de muerte por covid.

Pero sí surgió una diferencia en los pacientes latinos que no hablaban inglés. Esa comprensión aleccionadora les ayudó a concentrarse en una disparidad específica de salud, pensar en algunas posibles soluciones y comenzar a comprometerse con un cambio.

Esta disparidad de salud que puede poner en peligro la vida comenzó fuera del hospital, en comunidades de bajos ingresos dentro y fuera de Boston, donde el coronavirus se propagó rápidamente entre muchos hispanohablantes que viven lugares pequeños, con trabajos que no pueden hacer desde casa.

Algunos evitaban ir al hospital hasta que estaban muy enfermos, porque no confiaban en la atención en los grandes hospitales o temían ser detectados por autoridades de inmigración.

Sin embargo, apenas a unas semanas de comenzar la pandemia, los pacientes de covid que hablaban poco inglés comenzaron a acudir a los hospitales de Boston, incluido Brigham and Women’s.

“Francamente, no estábamos completamente preparados para ese aumento”, dijo Sivashanker. “Tenemos servicios de intérpretes realmente increíbles, pero estaban comenzando a sentirse abrumados”.

“Al principio, no sabíamos cómo actuar. Entramos en pánico”, dijo Ana María Ríos-Vélez, intérprete de español en Brigham.

Ríos-Vélez recordó haber buscado palabras para traducir esta nueva enfermedad y experiencia a los pacientes.

Cuando se los llamaba a la habitación de un paciente de covid, los intérpretes estaban confundidos acerca de si podían entrar y qué tanto debían acercarse al paciente.

Algunos intérpretes dijeron que se sintieron “desechables” en los primeros días de la pandemia, cuando no se les proporcionó el equipo de protección personal adecuado.

Ríos-Vélez dijo que, cuando ya lo tuvieron, el desafío fue ganarse la confianza del paciente detrás de una máscara, protector facial y bata. Por seguridad, se instaba a muchos intérpretes a trabajar desde casa. Pero hablar con los pacientes por teléfono creó nuevos problemas.

“Fue extremadamente difícil, extremadamente difícil”, dijo. “Los pacientes tenían problemas respiratorios. Tosían. Se ahogaban”.

Y Ríos-Vélez no podía mirar a sus pacientes a los ojos para tranquilizarlos y establecer una conexión.

“No es solo la voz. A veces necesito ver los labios, si sonrío”, dijo. “Quiero que vean la compasión en mí”.

Brigham respondió sumando más intérpretes y comprando más iPads para que los trabajadores remotos pudieran ver a los pacientes.

El hospital compró amplificadores para elevar el volumen de las voces de los pacientes por encima de los ruidos de las máquinas que zumban en una terapia intensiva.

La red Mass General Brigham está probando el uso de intérpretes disponibles por video en las oficinas de atención primaria. Un estudio encontró que, durante la pandemia, los pacientes de habla hispana utilizaban la telemedicina menos que los pacientes caucásicos.

El objetivo de Brigham es que todos los pacientes que necesiten un intérprete, lo tengan. El mayor desafío, dijo, es incluir un intérprete en el cuidado de los pacientes que pueden necesitar ayuda pero no la piden.

En la primera oleada, los intérpretes también se convirtieron en traductores del sitio web del hospital, las ventanas de información, las señales de seguridad y los folletos de covid.

“Fue muy duro. Me enfermé y tuve que tomarme una semana libre”, dijo Yilu Ma, directora de servicios de interpretación de Brigham. Ahora, Mass General Brigham está ampliando un servicio de traducción centralizado para toda la red de hospitales.

El equipo de análisis de Brigham and Women’s descubrió otras disparidades. Los empleados con salarios más bajos tenían covid con más frecuencia que las enfermeras y los médicos.

Sivashanker dijo que hubo docenas de reuniones en pequeños grupos con asistentes médicos, trabajadores del transporte, personal de seguridad y aquellos en servicios ambientales, que tenían las tasas más altas de pruebas positivas y alentó a todos a hacerse la prueba.

“Les dejamos saber que no perderían sus trabajos si tuvieran que faltar”, dijo Sivashanker. Y él, junto con los gerentes, les dijo a estos empleados “nos damos cuenta de que están arriesgando su vida al igual que cualquier otro médico o enfermero, todos los días que vienen a trabajar”.

Algunos empleados se quejaron de favoritismo en la distribución de equipos de protección, que fue investigado por el hospital.

Para asegurarse de que todos los empleados recibieran actualizaciones oportunas a medida que cambiaban las pautas para la pandemia, Brigham comenzó a traducir todos los mensajes de coronavirus al español y a otros idiomas y a enviarlos por mensaje de texto, que es más probable que lean las personas que están en movimiento todo el día.

El sistema Mass General Brigham ofreció subvenciones por dificultades económicas de hasta $1,000 para empleados con presiones financieras adicionales, como gastos en cuidado infantil.

Angelina German, una trabajadora de mantenimiento del hospital con un inglés limitado, dijo que aprecia recibir actualizaciones a través de mensajes de texto en español, y las sesiones informativas en persona con sus jefes.

“Ahora están más conscientes de todos nosotros”, dijo German a través de un intérprete, “asegurándose de que la gente se cuide a sí misma”.

El hospital también instaló sitios de prueba en algunos vecindarios de Boston con altas tasas de infección por coronavirus, incluidos barrios donde viven muchos empleados que se estaban infectando. Al menos uno de esos sitios ahora ofrece vacunas contra covid.

“No es necesario programar a nadie. No necesitas seguro. Simplemente acércate y podemos hacerte la prueba”, explicó la doctora Christin Price durante una visita el otoño pasado a un sitio de pruebas en el vecindario de Jamaica Plain.

Nancy Santiago salió del lugar de la prueba con una bolsa gratuita de frutas y verduras de 10 libras, que compartirá con su madre. Santiago dijo que está agradecida por la ayuda.

“Tuve que dejar mi trabajo por [falta de] guardería, y ha sido bastante difícil”, dijo. “Pero, ya sabes, tenemos que seguir siendo fuertes, y espero que esto termine pronto”.

Brigham abrió recientemente una operación interior similar en el Strand Theatre, en el vecindario de Dorchester. A todos los que vienen a hacerse una prueba de coronavirus se les pregunta si tienen suficiente para comer, si pueden pagar sus medicamentos, si necesitan asistencia para la vivienda y si están registrados para votar.

Los líderes de Mass General Brigham dijeron que tomarán lo que han aprendido al analizar las disparidades durante la pandemia y expandirán acciones en toda la red hospitalaria.

“Muchos de los problemas que se identificaron durante la respuesta de equidad de covid son, lamentablemente, problemas bastante universales que debemos abordar, si vamos a ser una organización antirracista”, dijo Tom Sequist, jefe de experiencia del paciente y equidad de Mass. General Brigham.

El trabajo de Brigham sobre las disparidades en salud proviene, en parte, de una colaboración con el Institute for Healthcare Improvement (IHI).

“Hay muchas rutinas defensivas que tenemos como médicos y que los datos pueden ayudar a cambiar, y revelar que hay algunos sesgos en tu propia práctica”, explicó el doctor Kedar Mate, presidente y director ejecutivo de IHI.

Mate dijo que “si no nombramos y comenzamos a hablar sobre el racismo y cómo pretendemos desmantelarlo, continuaremos colocando vendajes sobre el problema y no abordaremos las causas subyacentes”.

“La pobreza y los determinantes sociales de las necesidades de salud no desaparecerán pronto, por eso, si hay una manera de continuar atendiendo a las comunidades, creo que sería muy bueno”, dijo Price, quien ayudó a organizar el programa de pruebas de Brigham.

Pero, ¿el trabajo de Brigham ha reducido el riesgo de muerte por covid para los pacientes hispanohablantes? El hospital aún no ha actualizado el análisis, e incluso cuando lo hace, determinar si (o cómo) funcionaron las intervenciones será difícil, dijo Sivashanker.

Pero Sivashanker dijo que más intérpretes y iPads, y mejores mensajes para los empleados que no hablan inglés, además de todos los demás pasos que Brigham ha tomado durante la pandemia, han mejorado la experiencia tanto del paciente como del empleado.

Eso, dijo, cuenta como un éxito, mientras el trabajo continúa.

Esta historia es parte de una asociación que incluye a WBUR, NPR y KHN.

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Watch: What Happens When Car and Health Insurance Collide

“CBS This Morning,” in collaboration with KHN and NPR, tells the story of Mark Gottlieb, a marketing consultant in Little Ferry, New Jersey, who faced more than $700,000 in medical bills after surgery on his spine. Gottlieb was injured in a car accident, and, despite having the maximum amount of personal injury protection in his car insurance policy, his medical bills exceeded it. His health insurance could not help much, because his surgeon was out-of-network. In an interview with Anthony Mason of CBS, KHN Editor-in-Chief Dr. Elisabeth Rosenthal describes some of the pitfalls accident victims can try to avoid as they seek care.

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Big Investors Push Nursing Homes to Upgrade Care and Working Conditions

Nursing homes and long-term care facilities, where 182,000 Americans perished during the covid pandemic, have taken heat from government regulators, residents and their families. Now the industry is hearing it from an unexpected source: their investors.

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Investors who own large shares of nursing home companies now are demanding that the operators improve staff working conditions and the quality of care.

Nearly 100 investor groups that manage $3.3 trillion in assets in the U.S. and abroad told nursing home companies in a recent letter that they should increase staffing levels, boost staff pay, offer paid sick leave, improve resident safety programs and allow staff members to unionize.

It’s the latest pressure for reform of the nursing home industry, which has come under fire for an epic failure in infection control that spread covid-19 killing residents and staffers across the U.S.

The move by investors was unexpected, since it could reduce their financial returns. But they are worried about the future of the nursing home industry, which experienced a death wave inside its facilities that accounted for 34% of the nation’s covid toll. That’s not good for business.

“These are great principles that aren’t necessarily in the best financial interest of investors,” said David Grabowski, a health care policy professor at Harvard University who studies long-term care. “But it’s hard to know if this has any teeth.”

Nursing home industry groups themselves have called for reform, but they stress the need for higher Medicaid payment rates.

The investors’ statement of expectations was sent to major for-profit companies and real estate investment trusts that own nursing homes, including Genesis HealthCare, Ventas, Brookdale Senior Living and CareTrust REIT. It was signed by large investor groups including BMO Global Asset Management, Aviva Investors and the Interfaith Center on Corporate Responsibility.

“This is a moment to say, ‘Look at what happened during covid. You don’t want it to happen again,’” said Christy Hoffman, general secretary of UNI Global Union, a labor-affiliated group that organized the investors’ letter. “These workers are treated so badly, and that led to so many unnecessary deaths.”

Nursing home care aides, who provide most of the hands-on care, earn about $12 an hour. Mostly women of color, they often work at more than one facility to cobble together a full-time schedule. That increased covid transmission among facilities. These workers generally don’t get health benefits or paid sick leave, forcing them to come to work even when ill. Few are in unions, which have pushed for stronger safety protections. Annual turnover in the industry occasionally hits 80%.

There were reports across the U.S. that nursing homes did not provide adequate personal protective equipment like face masks and gowns to their workers, had too few workers on duty to properly care for residents, and engaged in shoddy infection control practices such as putting residents with and without covid in the same rooms.

BMO Global Asset Management already has contacted 13 nursing home companies and REITs urging appropriate staffing levels, improved health and safety standards, proper use of PPE, fair wages, pandemic hazard pay and freedom to unionize, said Nina Roth, director of responsible investment at BMO.

If they fail to meet the expectations with reasonable speed, her investment group, which manages or advises on $755 billion in assets, may take shareholder actions against management and ultimately divest from the companies, Roth said.

The American Health Care Association, which represents for-profit nursing home companies, said in a written statement, “We appreciate seeing investors taking a considerable interest in the quality of care and workforce challenges.” But it added that for nursing homes to offer more competitive wages and benefits, they need “more reliable resources” from federal and state governments.

While higher payments would help, said UNI Global’s Hoffman, nursing home companies “have a responsibility to do right by their workers regardless of public policy. We just don’t want companies to say they’ll do it when the government tells them to do it.”

Advocates for nursing home residents say that, if government payment rates are increased, new transparency rules should require nursing homes to show that the additional funds are used for increased staffing and improved services, not for profits or higher salaries for executives.

In line with that, the investors’ statement of expectations called on nursing home companies and REITs to publicly disclose whether they are complying with the staffing and quality-of-care targets.

Grabowski said the investors’ letter shows they recognize the inevitability of nursing home reform in the wake of the covid catastrophe and want to get ahead of the wave. “They’re thinking, ‘Why don’t we be more transparent and improve quality, or else what comes from the government could be ugly.’”

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Pandemic Imperiled Non-English Speakers More Than Others

In March 2020, just weeks into the covid-19 pandemic, the incident command center at Brigham and Women’s Hospital in Boston was scrambling to understand this deadly new disease. It appeared to be killing more Black and brown patients than whites. For Latinos, there was an additional warning sign: language.

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Patients who didn’t speak much, or any, English had a 35% greater chance of death.

Clinicians who couldn’t communicate clearly with patients in the hospital’s covid units noticed it was affecting outcomes.

“We had an inkling that language was going to be an issue early on,” said Dr. Karthik Sivashanker, then Brigham’s medical director for quality, safety and equity. “We were getting safety reports saying language is a problem.”

Sivashanker dived into the records, isolating and layering the unique characteristics of each of the patients who died: their race, age and sex and whether they spoke English.

“That’s where we started to really discover some deeper, previously invisible inequities,” he said.

Inequities that weren’t about race alone.

Hospitals across the country have reported more hospitalizations and deaths of Black and Latino patients than of whites. Black and brown patients may be more susceptible because they are more likely to have a chronic illness that increases the risk of serious covid. But when the Brigham team compared Black and brown patients with white patients who had similar chronic illnesses, they found no difference in the risk of death from covid.

But a difference did emerge for Latino patients who don’t speak English. That sobering realization helped them home in on a specific health disparity, think about some possible solutions and begin a commitment to change.

“That’s the future,” said Sivashanker.

Identifying the Risk

But first, Brigham had to unravel this latest example of a life-threatening health disparity. It started outside the hospital, in lower-income communities in and just outside Boston, where the coronavirus spread quickly among many native Spanish speakers who live in close quarters with jobs they can’t do from home.

Some avoided coming to the hospital until they were very sick, because they didn’t trust the care in big hospitals or feared detection by immigration authorities. Nevertheless, just weeks into the pandemic, covid patients who spoke little English began surging into Boston hospitals, including Brigham and Women’s.

“We were, frankly, not fully prepared for that surge,” said Sivashanker. “We have really amazing interpreter services, but they were starting to get overwhelmed.”

“In the beginning, we didn’t know how to act. We were panicking,” said Ana Maria Rios-Velez, a Spanish-language interpreter at Brigham.

Rios-Velez remembered searching for words to translate this new disease and experience for patients. When called to a covid patient’s room, interpreters were confused about whether they could go in and how close they should get to a patient. Some interpreters said they felt disposable in the early days of the pandemic, when they weren’t given adequate personal protective equipment.

When she had PPE, Rios-Velez said, she still struggled to gain a patient’s trust from behind a mask, face shield and gown. For safety, many interpreters were urged to work from home. But speaking to patients over the phone created new problems.

“It was extremely difficult, extremely difficult,” she said. “The patients were having breathing issues. They were coughing. Their voices were muffled.”

And Rios-Velez couldn’t look her patients in the eye to put them at ease and build a connection.

“It’s not only the voice. Sometimes I need to see the lips, if smiling,” she said. “I want them to see the compassion in me.”

Adding Interpreters and Tech

Brigham responded by adding more interpreters and buying more iPads so remote workers could see patients. The hospital purchased amplifiers to raise the volume of patients’ voices above the beeps and machines humming in an ICU. The Mass General Brigham network is piloting the use of interpreters available via video in primary care offices. A study found Spanish-speaking patients used telemedicine less than white patients during the pandemic.

Brigham’s goal is that every patient who needs an interpreter will get one. Sivashanker said that happens now for most patients who make the request. The bigger challenge, he said, is including an interpreter in the care of patients who may need the help but don’t ask for it.

In the first surge, interpreters also became translators for the hospital’s website, information kiosks, covid safety signs and brochures.

“It was really tough. I got sick and had to take a week off,” said Yilu Ma, Brigham’s director of interpreter services. Mass General Brigham is now expanding a centralized translation service for the entire hospital network.

Inequities Within the Hospital Workforce

Brigham and Women’s analytics team uncovered other disparities. Lower-paid employees were getting covid more often than nurses and doctors. Sivashanker said there were dozens of small group meetings with medical assistants, transport workers, security staffers and those in environmental services in which he shared the higher positive test rates and encouraged everyone to get tested.

“We let them know they wouldn’t lose their jobs” if they had to miss work, Sivashanker said. And he, along with managers, told these employees “that we realize you’re risking your life just like any other doctor of nurse is, every single day you come to work.”

Some employees complained of favoritism in the distribution of PPE, which the hospital investigated. To make sure all employees were receiving timely updates as pandemic guidance changed, Brigham started translating all coronavirus messages into Spanish and other languages and sending them via text, which people who are on the move all day are more likely to read. The Mass General Brigham system offered hardship grants of up to $1,000 for employees with added financial pressures, such as additional child care costs.

Angelina German, a hospital housekeeper with limited English, said she appreciates getting updates via text in Spanish, as well as in-person covid briefings from her bosses.

“Now they’re more aware of us all,” German said through an interpreter, “making sure people are taking care of themselves. “

Beyond the Hospital Walls

The hospital also set up testing sites in some Boston neighborhoods with high coronavirus infection rates, including neighborhoods where many employees live and were getting infected. At least one of those sites now offers covid vaccinations.

“No one has to be scheduled. You don’t need insurance. You just walk up and we can test you,” Dr. Christin Price explained during a visit last fall to a testing site in the Jamaica Plain neighborhood.

Nancy Santiago left the testing site carrying a free 10-pound bag of fruits and vegetables, which she’ll share with her mother. Santiago said she’s grateful for the help.

“I had to leave my job because of [lack of] day care, and it’s been pretty tough,” she said. “But, you know, we gotta keep staying strong, and hopefully this is over sooner rather than later.”

Brigham recently opened a similar indoor operation at the Strand Theatre in the Dorchester neighborhood. Everyone who comes for a coronavirus test is asked if they have enough to eat, if they can afford their medications, if they need housing assistance and if they’re registered to vote.

Mass General Brigham leaders said they’ll take what they’ve learned dissecting disparities during the pandemic and expand the remedies across the hospital network.

“Many of the issues that were identified during the covid equity response are unfortunately pretty universal issues that we need to address, if we’re going to be an anti-racist organization,” said Tom Sequist, chief of patient experience and equity for Mass General Brigham.

Brigham’s work on health disparities comes, in part, out of a collaboration with the Institute for Healthcare Improvement.

“There’s a lot of defensive routines into which we slip as clinicians that the data can help cut through and reveal that there are some biases in your own practice,” explained IHI President and CEO Dr. Kedar Mate.

“If we don’t name and start to talk about racism and how we intend to dismantle it or undo it,” Mate added, “we’ll continue to place Band-Aids on the problem and not actually tackle the underlying causes.”

“Poverty and social determinants of health needs are not going away any time soon, and so if there’s a way to continue to serve the communities, I think that would be tremendous,” said Price, who helped organize Brigham’s testing program.

But has Brigham’s work lowered the risk of death from covid for Spanish-speaking patients? The hospital hasn’t updated the analysis yet, and even when it does, determining whether (or how) the interventions worked will be hard, Sivashanker said.

“It’s never going to be as simple as ‘We just didn’t give them enough iPads or translators and that was the only problem,'” said Sivashanker.

But Sivashanker said more interpreters and iPads, and better messaging to non-English speaking employees — plus all the other steps Brigham has taken during the pandemic — have improved both the patient and the employee experience. That, he said, counts as a success, while work on the next layer of discrimination continues.

This story is part of a partnership that includes WBUR, NPR and KHN.

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Virtual Care Spreads in Missouri Health System, Home to ‘Hospital Without Beds’

When Tom Becker was diagnosed with an irregular heartbeat in March 2020, the 60-year-old EMS helicopter pilot from Washington, Missouri, worried he would never fly again.

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But his cardiologist, Dr. Christopher Allen, had served in the Air Force and knew aviation physiology. So Becker felt reassured when Allen told him he didn’t expect any problems, because Becker was still fairly young.

Allen told Becker — who lives about 50 minutes away from his office at Mercy Hospital South, near St. Louis — that Becker could call his cellphone with any concerns and meet with him virtually. Becker estimates they had more than 10 video appointments over six months.

“The video visits worked just the same as being in the office,” said Becker.

That’s a common assessment from patients and providers at Mercy, the St. Louis-based Roman Catholic health care organization that became a pioneer in telehealth in 2015 when it opened Mercy Virtual Care Center in the suburb of Chesterfield. Officials described the $54 million stand-alone facility as the world’s first “hospital without beds.” And after the covid-19 pandemic hit, Mercy became a model for ramping up telehealth throughout a health system.

The virtual care center, whose staff includes doctors, nurses and technology professionals, is not siloed from traditional care; it’s a hub from which some care is provided and new approaches to telehealth are introduced.

“It’s an integrated part of what we do every day,” said Mercy Virtual’s president, Dr. J. Gavin Helton.

Having the virtual center gave Mercy a head start when the pandemic forced doctors and hospitals across the nation to turn to telehealth. With insurers and the federal government footing the bill, virtual visits suddenly went from being allowed only in the narrowest of circumstances to often being the only option.

Though Mercy leaders and doctors have had years to try out and evaluate virtual care, some health experts are now concerned that the overnight adoption of telehealth nationally hasn’t allowed enough time for research to determine when it’s effective.

If the floodgates to telemedicine remain wide open, they warn, wasteful spending, fraud and bad health outcomes could ensue. Some worry doctors could start charging gratuitously for visits they used to handle as free phone calls.

“Just in the same way we would test a new drug, we should also test: How effective is adding telemedicine in improving health?” said Dr. Ateev Mehrotra, assistant professor of health care policy at Harvard University.

When Mercy Virtual Care Center opened, its leaders said the model could provide better patient care at a lower cost.

But at the time, Medicare and most insurers covered telehealth services only if patients lived in designated rural areas and traveled to a local facility to remotely see a specialist.

That changed in March 2020. The Centers for Medicare & Medicaid Services issued temporary waivers allowing providers to virtually visit with patients in their homes, outside of designated rural areas and even across state lines.

In early 2020, an average of 17,000 Medicare beneficiaries used telemedicine services each week, according to CMS. After the pandemic took hold, that number jumped to 1.1 million. A recent survey showed most were satisfied with virtual care.

Virtual visits also increased dramatically at Mercy. In 2019, fewer than 20 providers did a couple of hundred visits, spokesperson Joe Poelker said. During the pandemic, the organization has conducted an estimated 660,000 virtual visits, and 85% of its providers have used telehealth.

For presumed covid patients, Helton said, “We were able to quickly pivot to a digital-first approach.”

Mercy sent them daily text messages. If they responded that they were worried or had worsening symptoms, the system alerted providers at Mercy Virtual, who then did video visits, preventing possible exposure to covid in the emergency department. The organization has since applied the same approach to other health issues, such as congestive heart failure, with Mercy Virtual providers directing patients to in-person treatment when needed.

Allen, the cardiologist, said he had never used telehealth before the pandemic and wondered how he could take care of patients remotely.

But he suddenly had to embrace virtual care in March 2020 when he learned he had lymphoma, a cancer of the lymphatic system. His compromised immune system left him at greater risk from covid.

He was pleased to discover that telemedicine allowed him to see almost 30 patients a day, up from fewer than 20 previously. He could monitor patients’ chronic diseases more closely, preventing hospitalizations.

But more medical visits is not always a good thing, said Mehrotra, who testified at a U.S. House hearing on telemedicine last month.

“The concern is that in some circumstances telemedicine is too convenient and may encourage excessive use of care,” Mehrotra said in written testimony. “After an in-person visit, a physician could easily add a quick follow-up telemedicine visit that increases costs without any substantial improvement in health.”

The Medicare Payment Advisory Commission recommends “applying additional scrutiny to outlier clinicians who bill many more telehealth services” per person than others.

Allen said Mercy pays him a fixed salary, so, unlike private practice doctors, he has no financial incentive to schedule extra appointments.

Becker said telehealth has allowed him to get care more conveniently. His visits with Allen were covered entirely by the Tricare insurance Becker receives as an Army veteran.

“There is no evidence to support that doctors are going to start calling patients willy-nilly to get telehealth visits on the books. First off, they don’t have time for it. Secondly, if it’s not clinically appropriate, they can’t,” said Sarah-Lloyd Stevenson, a policy adviser for the U.S. Department of Health and Human Services during the Trump administration who now lobbies on behalf of the American Telemedicine Association, an industry group.

Mehrotra argues that until research shows where telemedicine is effective — which will take time — it should be covered for high-risk populations in areas with limited access to providers, such as rural towns. Otherwise, he said, it should be used only where there is “evidence of value or there is compelling need,” rather than visits with “little clinical benefit,” such as seeing a patient who likely has a common cold.

Despite calls for caution, lawmakers from both parties want to make permanent the temporary regulatory changes concerning telehealth.

Mehrotra said Medicare should not continue to reimburse providers at the same rate for virtual and in-person care, arguing virtual care should eventually cost less. He also said he expects a significant learning curve for clinicians.

“Everyone got forced to do this very, very quickly,” he said. “You have been practicing cardiology for 30 years and now all of a sudden you have telemedicine? You’re going to have to figure that out.”

Helton, on the other hand, supports payment parity because he thinks it will allow for more preventive care and lower total costs. In the long run, he said, “telemedicine is not only here to stay but will continue to grow.”

Becker, who underwent a cardiac ablation last year and is back to work rescuing people, said he’d love to continue avoiding the long drive to St. Louis to see Allen for checkups.

Allen, now in remission from cancer, said he plans to keep visiting with patients virtually.

“There is so much value in offering the telehealth option that I think patients are going to demand it,” Allen said. “If they can duck into a break room [at work] for 15 minutes or go out to their car and see us, it’s … a very effective option.”

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From Rotten Teeth to Advanced Cancer, Patients Feel the Effects of Treatment Delays

With medical visits picking up again among patients vaccinated against covid-19, health providers are starting to see the consequences of a year of pandemic-delayed preventive and emergency care as they find more advanced cancer and rotting and damaged teeth, among other ailments.

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Dr. Brian Rah, chair of the cardiology department at Montana’s Billings Clinic, was confused in the early days of the covid pandemic. Why the sudden drop in heart attack patients at the Billings Clinic? And why did some who did come arrive hours after first feeling chest pains?

Two patients, both of whom suffered greater heart damage by delaying care, provided what came to be typical answers. One said he was afraid of contracting covid by going to the hospital. The other patient went to the emergency room in the morning, left after finding it too crowded, and then returned that night when he figured there would be fewer patients — and a lower risk of catching covid.

“For a heart attack patient, the first hour is known as the golden hour,” Rah said. After that, the likelihood of death or a lifelong reduction in activities and health increases, he said.

Dr. JP Valin, executive vice president and chief clinical officer at SCL Health of Colorado and Montana, said he is “kept awake at night” by delays in important medical tests. “People put off routine breast examinations, and there are going to be some cancers hiding that are not going to be identified, potentially delaying intervention,” he said.

Valin is also concerned that patients aren’t seeking timely treatment when suffering appendicitis symptoms like abdominal pain, fever and nausea. A burst appendix generally involves more risk and a week’s hospitalization, instead of one day of treatment for those who get care quickly, he said.

Dr. Fola May, a gastroenterologist who is also quality director and a health equity researcher at UCLA Health, worries about the consequences of an 80% to 90% drop in colonoscopies performed by the health system’s doctors during the first months of covid.

“All of a sudden we were downplaying health measures that are usually high-priority, such as trying to prevent diseases like cancer, to manage the pandemic,” May said.

Along with exacerbating existing health problems, the covid pandemic has also caused a host of new medical issues in patients. The American population will be coming out of the pandemic with teeth worn down from grinding, back problems from slouching at makeshift home-work stations and mental health problems from a combination of isolation and being too close to family.

Dr. Despina Markogiannakis, a dentist in Chevy Chase, Maryland, said patients don’t argue when she tells them they have been grinding or clenching their teeth and might require a root canal procedure, dental implant or night guard.

“These are people stuck at home all day and feeling lonely and feeling a little depression. It is induced by the world we live in and all the changes in our lives,” said Markogiannakis.

A recent American Dental Association survey found that more than 70% of member dentists reported an increase in patients grinding or clenching their teeth since covid. More than 60% reported an increase in other stress-related conditions, such as chipped and cracked teeth.

Dr. Gerard Mosby, a Detroit pediatrician, finds his young patients are suffering more stress, depression and weight gain than before the pandemic. They are confined in their homes, and many are living in multigenerational homes or foster homes or have experienced covid illnesses or death among family members.

“Since their ability to get out is limited, they can’t vent to friends or other family members. Also, most will not have access to mental health for grief counseling,” Mosby said.

Nancy Karim, a Bridgeport, Connecticut, licensed professional counselor and art therapist, said that, in addition to struggling with isolation, her patients are conversely stressed by living too closely with people without the benefit of breaks on work and school days.

Meanwhile, optometrist Matthew Jones, who practices in Blytheville and Osceola, Arkansas, reports worsening eye conditions for patients, some of whom stopped taking drops during covid for conditions like glaucoma. He’s also seeing much more eyestrain “because people are spending so much time in front of a computer screen” and recommends eyeglasses that filter out blue light to his patients.

Physical therapy needs are also on the rise.

“Patients that have transitioned to remote work are typically working with poor ergonomic set-ups and spending a lot more time sitting,” said Kaylee Smith, founder and president of Smith Physical Therapy and Performance Studio in San Diego.

“I am seeing more pain and injuries related to poor posture (i.e., neck pain, low back pain, etc.) and a significant increase in patients coming in with tight hips related to increased sitting time,” Smith said in an email.

Some providers report they are finally nearing pre-covid patient levels, but others still face covid resistance.

“Although we have seen an improvement over the past six weeks, it’s still not much,” said Neville Gupta of Gupta Gastro in Brooklyn and Far Rockaway, New York. “Our patients are still avoiding getting the care they need, no matter the safety precautions in place.”

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UVA Health Will Wipe Out Tens of Thousands of Lawsuits Against Patients

University of Virginia Health System, which for years has sued thousands of patients annually for unpaid bills, said Monday it will cancel a massive backlog of court judgments and liens resulting from those lawsuits dating to the 1990s.

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Combined with reforms UVA announced in 2019, the move is likely to benefit tens of thousands of families and make UVA Health’s collections policies much more generous than those of many hospital systems, said scholars who study health care finance. The decision to wipe out liens that can drain home equity years after a hospital visit is extremely rare, they said.

UVA had been suing patients for decades, many with unpaid bills in the tens or hundreds of thousands of dollars, KHN reported in 2019. Once the health system won cases in court, it could seize wages and the value of patient homes when they were sold. UVA limited its collections lawsuits after KHN’s investigation.

“This is very significant and a much-needed and overdue step,” said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. “I don’t know if I’ve heard of that [lien abolition] happening anywhere else.”

But most families who have already surrendered money to UVA as a result of lawsuits or liens will not get their money back.

UVA will release all liens and judgments filed against all households making less than 400% of federal poverty guidelines, or $106,000 for a family of four, which should account for most of them, said Douglas Lischke, the system’s chief financial officer.

“This is a proud moment for us,” he said in an interview. “We want our financial care to be as good as our clinical care.”

“I am proud to see UVA Health System taking real steps to scale back aggressive medical collections and address the pain they’ve caused,” said Virginia Gov. Ralph Northam, a pediatric neurologist.

Doris Hutchinson was surprised two years ago to find a UVA lien related to a relative’s bill on her mother’s Charlottesville, Virginia, home. The medical system demanded $39,000 from the family before the house could be sold. The money was placed in escrow.

Three weeks ago, she learned the judgment would be canceled and the money released.

“I’ll be excited about that,” said Hutchinson, who said she needs the funds to help pay for her grandchildren’s college education and replace income from her husband, who died two years ago. “I’m also happy for everybody else” who gets UVA bill relief, she said.

UVA will also stop blocking enrollment for university students with outstanding balances at the health system, university spokesperson Brian Coy said Monday. Keeping students from completing their education because they owed hospital bills was another practice revealed by KHN.

KHN reported in 2019 that UVA Health had sued patients 36,000 times over six years for more than $100 million, often for amounts far higher than what an insurer would have paid for their care. In response to the articles, the system suspended lawsuits against patients and wage garnishments, increased discounts for the uninsured and broadened financial assistance, including for cases dating to 2017.

The system named an advisory council of UVA officials and community leaders to consider permanent changes. The council delivered recommendations in October.

Like most hospitals, UVA wasn’t using property liens to foreclose on patients’ homes. But it was seizing money owed — plus 6% interest — from home equity when home sales went to settlement.

In response to KHN’s investigation, UVA said in 2019 it would improve financial assistance but continue to use the courts to recover money owed from families making more than 400% of the poverty threshold.

While unusual, UVA’s decision to substantially reduce lawsuits and erase liens stops short of moves recently made by VCU Health, its sister system based at another state university. VCU pledged to stop suing all patients and, in a process taking more than a year in courthouses across Virginia, is abolishing all old judgments and liens regardless of a family’s income.

“This seems like many steps in the right direction” for UVA, said Jenifer Bosco, an attorney at the National Consumer Law Center who specializes in health care. “There is always more that could be done. But providing assistance to families with income of up to 400% of the poverty level is a great step.”

The number of outstanding UVA Health judgments is unknown. For its part, VCU eventually found about 80,000 statewide. In Virginia, liens expire after 20 years, but UVA was taking the trouble to renew claims dating to the 1990s, KHN found.

Canceling them should take more than a year, Lischke said. UVA’s changes to billing and collections, including improvements to financial assistance announced in late 2019, will cost the system about $12 million a year, he said.

UVA’s move is far more beneficial to its patients and its region than other so-called community benefits that many nonprofit hospitals offer to justify their tax-exempt status, said Ge Bai, associate professor at Johns Hopkins Bloomberg School of Public Health.

Instead of testing services or medical education that are often hospital marketing campaigns in disguise, “this action is a concrete effort to relieve the financial burden of the community,” she said. “It also improves mental health. It relieves the stress.”

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Pandemic Highlights Need for Urgent Care Clinics for Women

SAN JOSE — Last spring, only weeks into the pandemic, Christina Garcia was spending her days struggling to help her two young sons adjust to online schooling when she got such a heavy, painful period she could barely stand. After a few days, her vision began to blur and she found herself too weak to open a jar.

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Garcia’s regular OB/GYN — like most medical offices at the time — was closed, and she was terrified by the prospect of spending hours waiting in an emergency room shoulder to shoulder with people who might have covid.

By the time she stumbled into the newly opened Bascom OB-GYN urgent care clinic at the Santa Clara Valley Medical Center, clutching a pillow to her belly, Garcia was pale and dehydrated from blood loss and certain she was dying.

“If I didn’t get to the clinic when I did, I think, things could have ended up very different,” said Garcia, 34, who underwent an emergency hysterectomy for uterine fibroids.

Her story illustrates a long-standing gap in women’s health care. For years, many women with common but urgent conditions like painful urinary tract infections or excessive bleeding in the aftermath of a miscarriage have faced a grim choice between waiting weeks for an appointment with their regular OB-GYN or braving hours in an ER waiting room.

Urgent care OB-GYN clinics have begun popping up around the country in recent years, and the covid pandemic has increased demand. While no data is available on the number of urgent care clinics for women, they are part of a surge of interest in urgent care clinics in general and other alternative models like retail clinics and so-called digital-first health care startups. One of these, the New York-based women’s health startup Tia (“aunt” in Spanish), won $24 million in venture capital funding last spring and is opening physical clinics nationwide.

“It’s clear that access and convenience are increasingly more important to consumers than seeing a specific provider,” said Rob Rohatsch, chief medical officer at Solv, an app that books urgent care appointments.

The Urgent Care Association has reported steadily increasing visits by people who use its members’ walk-in clinics as an alternative to hospital emergency departments. Traffic to these clinics has surged during the past year, according to Solv.

The Bascom clinic had been a nearly decadelong dream of Drs. Cheryl Pan and Anita Sit, two obstetrician-gynecologists at the Santa Clara Valley Medical Center, a sprawling public hospital that serves as the regional trauma center, treating critical cases like car accident and gunshot victims and relegating people suffering less life-threatening problems to long waits.

“Women — perhaps pregnant or bleeding — could be sitting there 12 to 14 hours, depending on the time of day,” Pan said.

After the onset of the pandemic, doctors worried that women with serious or even deadly issues like Garcia’s might avoid seeking treatment for fear of contracting covid. ER visits plummeted an unprecedented 42% in the early months of the pandemic, according to the Centers for Disease Control and Prevention. A June CDC report noted that, while the number of ER visits for heart attacks had increased, visits for nonspecific chest pain had decreased, suggesting that people might be risking their lives by avoiding the ER.

“You can imagine that a woman with three kids at home might be even more scared,” Sit said. “We just couldn’t keep sending women having miscarriages to wait hours in the covid tent.”

Instead, women can now be triaged over the phone and seen within a day or two at the Bascom OB-GYN urgent care clinic — much the way they would at their local Planned Parenthood branch for contraceptives or a sexually transmitted disease screening. Bascom is equipped to treat conditions from severe morning sickness to ectopic pregnancies that require emergency surgery. In its first year, the clinic has treated some 1,300 women and served as a backup to local clinics that provide basic reproductive health services in counties hundreds of miles away.

It’s still in its pilot phase, however, operating weekdays from 8:30 a.m. to 5 p.m., which “leaves a big chunk of off-hours that we cannot serve women,” Sit acknowledges.

A handful of other clinics have taken the concept of urgent care for women a step further. Dr. Miriam Mackovic runs Complete Women Care, a chain of four clinics in the Los Angeles area that also has an emergency care center in Long Beach, which is staffed 24/7 with a nurse practitioner and equipped with a lab and a pharmacy. Women who walk in are typically seen within 30 minutes, according to Mackovic, and every patient receives a follow-up call the next day.

One woman who turned up at a Complete Women Care clinic said that, after desperately seeking treatment at an ER one Saturday night for a nasty yeast infection, she got a bill in the mail for $1,500.

“In the middle of the night, urgent care centers are closed. OB-GYN offices are definitely closed. So, what is her option except the ER?” asked Mackovic, an obstetrician-gynecologist who also has an MBA.

Mackovic ticked off cautionary tales of patients who’ve arrived at her clinics from as far away as Arizona and Nevada after suffering for weeks while trying to schedule routine operations for uterine cysts or twisted ovaries.

“The medical advances are here. Most emergencies can be resolved on an outpatient basis — a woman can have a hysterectomy with just a fine incision and be home the same day,” Mackovic said. “But a woman who has a miscarriage calls her OB, who says there’s no openings for weeks, so she goes to the ER, and the physician says: Are you dying? No? Then follow up with your OB-GYN.”

Fees for the uninsured — around 20% of Mackovic’s clientele — run from $100 to around $600, she said.

Women in the United States have for years lagged behind those in other rich countries in both their access to health care and their health status. America has the highest maternal mortality rate among developed nations.

Some women see a doctor only in an emergency.

“We have diagnosed so many cancers in the last few years because women walked in for another reason,” said Dr. Adeeti Gupta, founder and CEO of a chain of open-daily clinics in New York City called Walk In Gyn Care that provides comprehensive care without appointments.

Gupta’s three clinics have grown steadily since she opened them seven years ago, largely out of frustration with the months-long wait for an appointment at her own Queens OB-GYN practice. But after the coronavirus hit the city hard, she has seen an uptick in patients — 40% in one location.

The country needs more accessible, comprehensive women’s health care to treat everything from the menstrual pains of adolescents to the hot flashes of postmenopausal grannies, Gupta said.

“The thing about women,” she said, “is their problems never stop.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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from Health Industry – Kaiser Health News

The FDA Seeks a New Way to Review Old Drugs Without Causing Prices to Soar

Chuck Peterson of Omaha, Nebraska, recently experienced a swollen, painful knuckle caused by arthritis. He got a prescription for colchicine.

Doctors have used the drug for treating gout and other rheumatic conditions for well over two centuries.

When Peterson went to the pharmacy, he was shocked to discover that a two-month supply of 120 pills, distributed by Par Pharmaceutical, would cost him $225 out-of-pocket on his Medicare Part D drug plan. Taking it for an additional three months, as his rheumatologist wanted him to do, would cost him nearly $600 under his drug plan.

A dozen years ago, the drug cost about a dime per pill.

“My reaction was ‘goodness gracious,’ or maybe something I couldn’t say in polite company,” he said.

The startling price hike was precipitated by a well-intentioned federal government program, called the Unapproved Drugs Initiative, that created unforeseen consequences. It was supposed to protect the public by ensuring that older drugs went through a Food and Drug Administration approval process to determine their safety and efficacy and that older versions were taken off the market.

In November, the departing Trump administration unexpectedly ended the FDA program that led to a price spike for colchicine and other older drugs, saying it drove up drug costs and in some cases caused shortages. Now the FDA is considering whether and how to replace it, while advancing the Biden administration’s goal of reducing prescription drug prices overall. An announcement is expected soon.

But health care policy analysts and executives fear drugmakers still will find ways to maintain high prices for drugs already approved through the program, and to jack up prices for remaining unapproved drugs on the market, estimated to number at least 1,500. They note that the manufacturers of drugs that were granted FDA approval and market exclusivity through the UDI program, including colchicine, have aggressively used the courts to block other drug companies from marketing cheaper generic alternatives, often for many years.

Colchicine was one of many drugs that were sold before the FDA was created in 1938. No manufacturer ever took it through the agency’s approval process for determining safety and efficacy, but its approval for wide use was effectively grandfathered in.

Then the FDA, under the UDI program it launched in 2006, approved a branded version of colchicine in 2009, gave the manufacturer seven years of exclusivity and ordered previous versions off the market. With no competition, the price soared to about $4.50 a pill. That has since dipped to less than $2 a pill since generic competitors were approved by the FDA and entered the market in the past few years. However, the price is still much higher than before.

Price increases of drugs approved through UDI have boosted U.S. health spending by $3.2 billion so far, and will increase costs by tens of billions more in coming years, according to a study last year by Vizient, a purchasing firm serving hospitals.

Drug policy experts would like to see the Biden administration develop alternatives to UDI for reviewing the safety and efficacy of unapproved drugs that don’t lead to big price hikes. One way, especially for common drugs that physicians and hospitals have used safely for decades, is having the FDA work with health care providers to collect and analyze data on their own through patient registries.

“If other entities collect the data, thus minimizing the research expense, it would perhaps be more appropriate for the manufacturers not to take enormous price increases,” said Steven Lucio, a vice president at Vizient.

Other older drugs whose prices skyrocketed after drugmakers won exclusive rights to sell branded versions include selenium, a common mineral supplement used in patients who need feeding through a stomach tube. It soared 1,190% after American Regent gained FDA approval for branded “Selenious Acid” in 2019.

Belcher Pharmaceuticals hiked the price of branded “Dehydrated Alcohol 99%,” used to treat severe heart disease, 668% after it won FDA approval in 2018.

Hospital executives are particularly vexed about the price hike for Vasostrict — formerly known as vasopressin and first developed in 1928 — because that drug, used to increase a patient’s blood pressure, has been widely used in intensive care units to treat covid-19 patients. From 2019 to 2020, hospital spending for the drug rose 56%, to nearly $600 million, according to the American Society of Health-System Pharmacists.

The price of the drug increased 1,644% after Par Pharmaceutical won FDA approval in 2014, according to Vizient. It received market exclusivity through 2035. And Par Pharmaceutical has hiked the price 7% to 10% each year, said Eric Tichy, vice chair of supply chain management at the Mayo Clinic.

“I don’t mind paying a lot for innovative drugs, but vasopressin has been around much longer than I’ve been alive,” he said. “Par has made a windfall from covid. That’s just gaming the system. It’s outrageous.”

Two other drugmakers have sought, unsuccessfully so far, to develop and market a generic alternative to Vasostrict. A German drug company, Fresenius Kabi, sued Par in a New Jersey federal court for alleged antitrust violations in blocking its access to information about the drug’s active ingredients. Par sued Sandoz for patent infringement to block that drugmaker from marketing a generic version of vasopressin. Par recently reached confidential settlements with both companies, Tichy said.

None of the three companies would comment on the settlements.

Heather Zoumas-Lubeski, vice president of corporate affairs for Endo International, which owns Par, justified Vasostrict’s price by saying the company “invested significant time and resources in the formulation, approval, and manufacturing” and “continues to invest in efforts that benefit patients.”

Drug manufacturers, including makers of generics, opposed the elimination of the UDI program and have urged the FDA to continue to grant approvals and market exclusivity to branded versions of previously unapproved older drugs.

They particularly oppose the Trump administration’s proposal to let the FDA determine that some older, non-patented drugs are “generally recognized as safe and effective,” known as having GRASE status, and don’t need to go through a new drug approval process.

Broadly granting GRASE status would “allow potentially unsafe, ineffective, or poor-quality drugs to enter the U.S. market, and put patients at risk,” the Pharmaceutical Research and Manufacturers of America warned in December in response to the Trump administration’s request for comments on what should replace the UDI program. The trade group stressed that the FDA is not allowed under law to consider drug prices in making approval decisions.

But drug policy researchers say drugmakers generally have done little or no original research to improve the safety and efficacy of old unapproved drugs or expand clinical uses for these products. They also say there’s no justification for the much higher prices of the FDA-approved branded versions.

One exception they cite is L-cysteine, an amino acid used in intravenous nutrition for preterm infants, which Exela Pharma Sciences improved by removing potentially harmful metals. The company won FDA approval for its new branded version, Elcys, in 2019. Its wholesale price is $8.24 per milliliter, compared with $0.24 per milliliter for the previous generic product.

“That company did a lot of work to bring a new and improved formulation to market,” said Soumi Saha, vice president of advocacy for Premier, which does group purchasing for health care providers. “That’s different than taking the same recipe, slapping a different label on it and seeking market exclusivity.”

This isn’t just an abstract policy issue. The higher prices resulting from the branding of cheap old drugs can significantly affect patient care.

Colchicine’s higher price prompted Dr. Marcus Snow, a rheumatologist in Omaha, to switch some of his gout patients to more affordable anti-inflammatory drugs. But those drugs can elevate blood sugar and affect kidney function, so he has to be vigilant.

The drug’s price also could become a bigger issue as its use expands. Recent studies have shown that colchicine is effective in preventing complications after heart attacks, and that it may be effective in reducing heart problems in covid patients. If demand soars for these new uses, Par and other colchicine distributors might seek further price hikes for this ancient drug.

“I would love to see colchicine drop to the old days of pennies per pill through generic availability,” said Snow, who heads the American College of Rheumatology’s Committee on Rheumatic Care. “But I’m not expecting that.”

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