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A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.

Claire Lang-Ree was in a lab coat taking a college chemistry class remotely in the kitchen of her Colorado Springs, Colorado, home when a profound pain twisted into her lower abdomen. She called her mom, Jen Lang-Ree, a nurse practitioner who worried it was appendicitis and found a nearby hospital in the family’s health insurance network.

After a long wait in the emergency room of Penrose Hospital, Claire received morphine and an anti-nausea medication delivered through an IV. She also underwent a CT scan of the abdomen and a series of tests.

Hospital staffers ruled out appendicitis and surmised Claire was suffering from a ruptured ovarian cyst, which can be a harmless part of the menstrual cycle but can also be problematic and painful. After a few days — and a chemistry exam taken through gritted teeth — the pain went away.

Then the bill came.

Patient: Claire Lang-Ree, a 21-year-old Stanford University student who was living in Colorado for a few months while taking classes remotely. She’s insured by Anthem Blue Cross through her mom’s work as a pediatric nurse practitioner in Northern California.

Total Bill: $18,735.93, including two $722.50 fees for a nurse to “push” drugs into her IV, a process that takes seconds. Anthem’s negotiated charges were $6,999 for the total treatment. Anthem paid $5,578.30, and the Lang-Rees owed $1,270 to the hospital, plus additional bills for radiologists and other care. (Claire also anted up a $150 copay at the ER.)

Service Provider: Penrose Hospital in Colorado Springs, part of the regional health care network Centura Health.

What Gives: As hospitals disaggregate charges for services once included in an ER visit, a hospitalization or a surgical procedure, there has been a proliferation of newfangled fees to increase billing. In the field, this is called “unbundling.” It’s analogous to the airlines now charging extra for each checked bag or for an exit row seat. Over time, in the health industry, this has led to separate fees for ever-smaller components of care. A charge to put medicine into a patient’s IV line — a “push fee” — is one of them.

Though the biggest charge on Claire’s bill, $9,885.73, was for a CT scan, in many ways Claire and her mom found the push fees most galling. (Note to readers: Scans often are significantly more expensive when ordered in an ER than in other settings.)

“That was so ridiculous,” said Claire, who added she had previously taken the anti-nausea drug they gave her; it’s available in tablet form for the price of a soda, no IV necessary. “It works really well. Why wasn’t that an option?”

In Colorado, the average charge for the code corresponding to Claire’s first IV push has nearly tripled since 2014, and the dollars hospitals actually get for it has doubled. In Colorado Springs specifically, the cost for IV pushes rose even more sharply than it did statewide.

A typical nurse in Colorado Springs makes about $35 an hour. At that rate, it would take nearly 21 hours to earn the amount of money Penrose charged for a push of plunger that likely took seconds or at most minutes.

The hospital’s charge for just one “IV push” was more than Claire’s portion of the monthly rent in the home she shared with roommates. In the end, Anthem did not pay the push fees in its negotiated payment. But claims data shows that in 2020 Penrose typically received upward of $1,000 for the first IV push. And patients who didn’t have an insurer to dismiss such charges would be stuck with them. Colorado hospitals on average received $723 for the same code, according to the claims database.

“It’s insane the variation that we see in prices, and there’s no rhyme or reason,” said Cari Frank with the Center for Improving Value in Health Care, a Colorado nonprofit that runs a statewide health care claims database. “It’s just that they’ve been able to negotiate those prices with the insurance company and the insurance company has decided to pay it.”

Penrose initially charged more money for Claire’s visit than the typical Colorado hospital would have charged for live birth, according to data published by the Colorado Division of Insurance.

Even with the negotiated rate, “it was only $1,000 less than an average payment for having a baby,” Frank said.

In an emailed statement, Centura said it had “conducted a thorough review and determined all charges were accurate” and went on to explain that “an Emergency Room (ER) must be prepared for anything and everything that comes through the doors,” requiring highly trained staff, plus equipment and supplies. “All of this adds up to large operating costs and can translate into patient responsibility.”

As researchers have found, little stands in the way of hospitals charging through the roof, especially in a place like an emergency room, where a patient has no choice. A report from National Nurses United found that hospital markups have more than doubled since 1999, according to data from the United States Bureau of Labor Statistics. In an email, Anthem called the trend of increasing hospital prices “alarming” and “unsustainable.”

But Ge Bai, an associate professor of accounting and health policy at Johns Hopkins University, said that when patients see big bills it isn’t only the hospital’s doing — a lot depends on the insurer, too. For one, the negotiated price depends on the negotiating power of the payer, in this case, Anthem.

“Most insurance companies don’t have comparable negotiating or bargaining power with the hospital,” said Bai. Prices in a state like Michigan, where Bai said the autoworkers union covers a big portion of patients, will look very different from those in Colorado.

Also, insurers are not the wallet defenders patients might assume them to be.

“In many cases, insurance companies don’t negotiate as aggressively as they can, because they earn profit from the percentage of the claims,” she said. The more expensive the actual payment is, the more money they get to extract.

Though Anthem negotiated away the push fees, it paid the hospital 30% more than the average Level IV emergency department visit in Colorado that year, and it paid quadruple what Medicare would allow for her CT scan.

Resolution: Claire and her mom decided to fight the bill, writing letters to the hospital and searching for information on what the procedures should have cost. The prices of the IV pushes and the CT scan infuriated them — the hospital wanted more than double what top-rated hospitals typically charged in 2019.

But the threat of collections wore them out and ultimately they paid their assigned share of the bill, $1,420.45, which was mostly coinsurance.

“Eventually it got to the point where I was like, ‘I don’t really want to go to collections, because this might ruin my credit score,’” said Claire, who didn’t want to graduate from college with dinged credit.

Bai and Frank said Maryland can be a useful benchmark for medical bills, since the state sets the prices that hospitals can charge for each procedure. Data provided by the Maryland Health Care Commission shows that Anthem and Claire paid seven times what she likely would have paid for the CT scan there, and nearly 10 times what they likely would have paid for the Level IV ER visit. In Maryland, IV pushes typically cost about $200 apiece in 2019. A typical Maryland hospital would have received only about $1,350 from a visit like Claire’s, and the Lang-Rees would have been on the hook for about $270.

Claire’s pain has come back a few times but never as bad as that night in Colorado. After visiting multiple specialists back home in California, she learned it might have been a condition called ovarian torsion. Claire has avoided reentering an emergency room.

The Takeaway: Even at an in-network facility and with good insurance, patients can get hurt financially by visiting the ER. A few helpful documents can help guide the way to fighting such charges. The first is an itemized bill.

“I just think it’s wrong in the U.S. to charge so much,” said Jen Lang-Ree. “It’s just a little side passion of mine to look at those and make sure I’m not being scammed.”

Bai, of Johns Hopkins, suggests asking for an itemized explanation of benefits from the insurance company, too. That will show what the hospital actually received for each procedure.

Find out if the hospital massively overcharged. The Medicare price lookup tool can be useful for getting a benchmark. And publicly available data on health claims in Colorado and at least 17 other states can help, too.

Vincent Plymell with the Colorado Division of Insurance encourages patients to reach out if something looks sketchy. “Even if it’s not a plan we regulate,” he wrote in an email, such departments “can always arm the consumer with info.”

Finally, make it fun. Claire and Jen made bill-fighting their mother-daughter hobby for the winter. They recommend pretzel chips and cocktails to boost the mood.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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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Covid’s Lingering Effects Can Put the Brakes on Elective Surgeries

The week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for covid-19. What he thought at first was a head cold had morphed into shortness of breath and chest congestion coupled with profound fatigue and loss of balance.

Now, seven months have passed and Colvin, 44, is still waiting to feel well enough for surgery. His surgeon is concerned about risking anesthesia with his ongoing respiratory problems, while Colvin worries he’ll lose his balance and fall on his shoulder before it heals.

“When I last spoke with the surgeon, he said to let him know when I’m ready,” Colvin said. “But with all the symptoms, I’ve never felt ready for surgery.”

As the number of people who have had covid grows, medical experts are trying to determine when it’s safe for them to have elective surgery. In addition to concerns about respiratory complications from anesthesia, covid may affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent study compared the mortality rate in the 30 days following surgery in patients who had a covid infection and in those who did not. It found that waiting to undergo surgery for at least seven weeks after a covid infection reduced the risk of death to that of people who hadn’t been infected in the first place. Patients with lingering covid symptoms should wait even longer, the study suggested.

But, as Colvin’s experience illustrates, such guideposts may be of limited use with a virus whose effect on individual patients is so unpredictable.

“We know that covid has lingering effects even in people who had relatively mild disease,” said Dr. Don Goldmann, a professor at Harvard Medical School who is a senior fellow and chief scientific officer emeritus at the Institute for Healthcare Improvement. “We don’t know why that is. But it’s reasonable to assume, when we decide how long we should wait before performing elective surgery, that someone’s respiratory or other systems may still be affected.”

The study, published in the journal Anaesthesia in March, examined the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October. Researchers found that patients who had surgery within two weeks of their covid diagnosis had a 4.1% adjusted mortality rate at 30 days; the rate decreased to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery occurred at least seven weeks after their covid diagnosis had a mortality rate of 1.5% 30 days after surgery, the same as for patients who were never diagnosed with the virus.

Even after seven weeks, however, patients who still had covid symptoms were more than twice as likely to die after surgery than people whose symptoms had resolved or who never had symptoms.

Some experts said seven weeks is too arbitrary a threshold for scheduling surgery for patients who have had covid. In addition to patients’ recovery status from the virus, the calculus will be different for an older patient with chronic conditions who needs major heart surgery, for example, than for a generally healthy person in their 20s who needs a straightforward hernia repair.

“Covid is just one of the things to be taken into account,” said Dr. Kenneth Sharp, a member of the Board of Regents of the American College of Surgeons and vice chair of the Department of Surgery at Vanderbilt University Medical Center.

In December, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation issued these guidelines for timing surgery for former covid patients:

• Four weeks if a patient was asymptomatic or had mild, non-respiratory symptoms.

• Six weeks for a symptomatic patient who wasn’t hospitalized.

• Eight to 10 weeks for a symptomatic patient who has diabetes, is immunocompromised or was hospitalized.

• Twelve weeks for a patient who spent time in an intensive care unit.

Those guidelines are not definitive, according to the groups. The operation to be performed, patients’ medical conditions and the risk of delaying surgery should all be factored in.

“Long covid” patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require a more thorough evaluation before surgery, said Dr. Beverly Philip, president of the society.

Now that covid has been brought to heel in many areas and vaccines are widely available, hospital operating rooms are bustling again.

“In talking to surgical colleagues, hospitals are really busy now,” said Dr. Avital O’Glasser, medical director of the outpatient preoperative clinic at Oregon Health and Sciences University in Portland. “I’ve seen patients with delayed knee replacements, bariatric surgery, more advanced cancer.”

At the beginning of the pandemic, surgical volumes dropped dramatically as many hospitals canceled nonessential procedures and patients avoided facilities packed with covid patients.

From March to June 2020, the number of inpatient and outpatient surgeries at U.S. hospitals was 30% lower than in the same period the year before, according to McKinsey & Company’s quarterly Health System Volumes Survey. By May 2021, surgical volumes had mostly rebounded, and were just 2% lower than their May 2019 totals, according to the May survey.

Oregon Health and Sciences University clinicians developed a protocol a year ago for clearing any patient who had covid for elective surgery. When obtaining patients’ medical history and conducting physical exams, clinicians look for signs of covid complications that aren’t readily identifiable and determine whether patients have returned to their pre-covid level of health.

The pre-op exam also includes lab and other tests that evaluate cardiopulmonary function, coagulation status, inflammation markers and nutrition, all of which can be disrupted by covid.

If the assessment raises no red flags, patients can be cleared for surgery once they have waited the minimum seven weeks since their covid diagnosis.

Originally, the minimum wait for surgery was four weeks, but clinicians pushed it back to seven after the international study was published, O’Glasser said.

“We are still learning about covid, and uncertainty in medicine is one of the biggest challenges we face,” said O’Glasser. “Right now, our team is erring on the side of caution.”

At Memorial Sloan Kettering Cancer Center in New York, doctors don’t follow a specific protocol. “We’re taking every patient one at a time. There are no hard-and-fast rules at this institution,” said Dr. Jeffrey Drebin, chair of surgery.

Clinicians work to find a balance between the urgency of the cancer surgery and the need to allow enough time to ensure covid recovery, he said.

For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and may worsen the tear. But the rest of his life is on hold, too. A sales representative for an auto parts company, he hasn’t been able to work since he got sick. His balance problems make him reluctant to stray far from his home in Crest Hill, Illinois, the Chicago suburb where he lives with his wife and 15-year-old son.

Some days he has more energy and isn’t as short of breath as others. Colvin hopes it’s a sign he’s slowly improving. But at this point, it’s hard to be optimistic about the virus.

“It’s always something,” he said.

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Doctors’ Lobby Scores ‘Major Victory’ on Bill to Hold Physicians Accountable

SACRAMENTO, Calif. — The board that licenses and disciplines doctors in California is failing to hold bad actors accountable, endangering patients in the process.

That’s the verdict of state lawmakers and patient advocates who have been working for years to reform the Medical Board of California.

But an attempt this year to give the board more money and power to investigate complaints of fraud, gross negligence, sexual misconduct and other misbehavior is under attack from one of the most politically potent forces in California’s Capitol: doctors themselves.

And so far, it seems, the doctors are winning.

The California Medical Association (CMA), whose top lobbyist sat next to Gov. Gavin Newsom at the infamous French Laundry dinner last fall, swooped in to slash a proposed hike on physicians’ licensing fees even though the board, which relies on those fees, is teetering on insolvency. It also beat back a proposal to put more non-physician members of the public on the board, which would have diminished the influence of the doctors who represent a majority.

“The strength and the power of the CMA is that they are able to deflect and obstruct the beneficial and necessary legislation to protect the consumer and to ensure the success of the medical board,” said former state Sen. Jerry Hill, who four years ago lost his push to overhaul the board. “That’s what I found, and that’s what I see occurring this year.”

This year’s bill was approved by the state Senate after it was amended under pressure from the doctors’ group. The measure is now before the state Assembly, where it remains a target of the California Medical Association. As currently written, SB 806 would authorize a smaller licensing fee increase, restore the board’s authority to recoup investigative costs from doctors who have been disciplined and create an independent monitor to evaluate the board’s complaint and disciplinary processes.

The mission of the medical board, composed of eight physicians and seven members of the public, is to license and discipline doctors. But critics say the board has allowed some doctors who have committed wrongdoing to keep their licenses, despite reports of egregious behavior, while families complain they’ve been left in the dark for years.

The board received 10,868 complaints in the 2019-20 fiscal year. During that period, it initiated 1,956 investigations, revoked 35 physician licenses, put 170 doctors on probation and reprimanded 108 doctors, according to the board’s 2019-2020 Annual Report. An additional 96 physicians surrendered their licenses.

In his independent review of cases that came before the panel last year, board member Eserick “TJ” Watkins told lawmakers the board had settled 84% of complaints, with a bias toward allowing doctors to continue to practice without real rehabilitation.

“This board’s value is we protect the doctors, and we’ll go over and above in order to do so,” said Watkins, one of the board’s members representing the public.

Earlier this year, the board’s executive director told lawmakers the board is taking longer to investigate complex cases than it did six years ago, in part because of more complaints and vacancies among the board’s support staff. In fiscal year 2019-20, those cases took an average of 548 days from start to end, he said, compared with 310 in fiscal year 2013-14.

Patients and their families who have testified at legislative hearings describe an unresponsive and uncommunicative board that usually allows doctors accused of negligence or malpractice to continue to practice.

“I thought there would be a lot of integrity and thoroughness to the investigation process, and I didn’t get a sense that the medical board really looked at the matter,” said Alka Airy, who in 2019 filed a complaint of unprofessional conduct and potential negligence against the University of California-San Francisco’s Lung Transplant Program after her sister, Shilpa Airy, died the year before.

According to the complaint, doctors who treated Shilpa Airy between 2015 and 2018 failed to evaluate how her lung failure affected her heart or refer her to a cardiologist. She died of end-stage heart failure while waiting for a lung transplant. Airy said the board closed the complaint without taking action. The board declined to comment.

By comparison, when Alka Airy filed a complaint with the California Board of Registered Nursing, she said, she was interviewed by an investigator who requested additional records beyond what the doctors or hospital may have provided. Airy said she is still waiting to learn the outcome of the case.

A UCSF spokesperson said its clinicians have fully cooperated with all investigators and could not comment on pending investigations.

“I think my experience was very similar to thousands of other folks who sent in complaints to the medical board,” Airy said. “It’s not a transparent process. So much happens behind closed doors.”

Board spokesperson Carlos Villatoro said the board bases its disciplinary decisions “on the facts and circumstances of each case” to determine whether revoking a physician’s license is necessary.

“The board does not have the authority to punish a licensee by imposing a level of discipline that goes beyond what is necessary to protect the public,” Villatoro said via email.

Advocates for patients and even some board members believe that tipping the board’s balance of power to public members could regain some of the public’s trust. But that provision was removed from this year’s bill after the California Medical Association argued the panel — like other comparable state boards — needed the expertise of people in the profession it regulates.

Dr. Howard Krauss, himself a former trustee of the CMA, has been on the board for eight years. In that time, he said, he’s never witnessed a decision that pitted physicians on the board against public members.

“The optics of having a board with one more public member than a physician might be of benefit,” Krauss said at an emergency hearing this month.

Critics say the board also lacks the resources and the ability to pursue timely investigations, hamstrung by a legislature beholden to the CMA, whose 50,000 pediatricians, surgeons and other physicians are influential members of every lawmaker’s district.

The California Medical Association is one of the most prolific campaign contributors in Sacramento and has given to Newsom and all but one of the 119 lawmakers currently serving in the state legislature.

In addition to making campaign contributions directly to lawmakers, the association spent $18.6 million between Jan. 1, 2011, and March 30, 2021, lobbying lawmakers and state agencies on a variety of issues, from flavored tobacco to medical malpractice caps, according to records filed with the California secretary of state’s office. It employs its own lobbyists and hires outside lobbying firms.

The group routinely scores access to the state’s top leaders. Among the movers and shakers at the French Laundry dinner party in Napa Valley in November were the association’s top lobbyist, Janus Norman, and CEO, Dustin Corcoran.

CMA spokesperson Anthony York said the organization is “like any other group in the Capitol” that advocates for its members. He said the $367 increase in licensing fees that lawmakers initially proposed — from $783 to $1,150 — would have been too big a burden on doctors who fought to stay open during the pandemic.

Family medicine physicians in California earned an average annual wage of $220,240 as of the first quarter of this year, according to the state Employment Development Department. “A lot of physician practices are struggling to keep their doors open,” York said. “Now is not the time for a fee increase.”

After state Sen. Richard Roth (D-Riverside) introduced the legislature’s must-pass bill to reauthorize the medical board in May, the CMA issued an “action alert” to its members, urging doctors to call, text and email their senators to voice their opposition. Eight days later, it declared a partial victory when Roth amended his bill to lower the fee increase to $863 and eliminate a requirement that the board be controlled by public members, a provision that had been backed by Senate leader Toni Atkins.

“While the bill is not perfect,” the association wrote on its website, the removal of those provisions “was a major victory.”

Despite repeated requests from the medical board, lawmakers haven’t approved a licensing fee increase in 16 years, even though the fees are the board’s primary source of income. The CMA agreed to the last fee increase in 2005 as part of a deal that also took away the board’s ability to recover legal and investigative costs for cases in which doctors had been disciplined.

York said the association remains opposed to the provision that would restore the board’s ability to recoup investigative costs and has concerns about the role of the independent monitor.

In its report to the legislature, the medical board projected it would be insolvent by the end of 2021-22 without an increase in licensing fees.

Doctors “just don’t want to pay for it,” said Bridget Gramme, an attorney at the Center for Public Interest Law at the University of San Diego School of Law. “What is the money going for? It’s going for a stronger discipline system, which they don’t want.”

Roth, who chairs the Senate Business, Professions and Economic Development Committee, said the CMA’s influence wasn’t the reason he amended the bill to reduce the fee increase. Rather, he said the board hadn’t justified the large fee increase — even though he included it in the original version of the bill — and could make do with a modest fee increase combined with better money management.

“Everybody had an opportunity to voice their perspective,” Roth said, pointing out that the bill still includes provisions that doctors oppose. “The goal is to make sure that we have a medical board that is functioning effectively and efficiently, that the enforcement process does the right thing at the right time for the right reasons, and that we squeeze every bit of operational efficiency that we can afford.”

As he watches from afar, Hill, the former legislator, said he doesn’t think the California Medical Association will give up until it kills every provision it opposes.

“This whole thing is part of CMA’s playbook. It’s how they operate,” Hill said. “They hire just about every available lobbyist in Sacramento to remove the rest of what was in the bill.”

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

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No Vacancy: How a Shortage of Mental Health Beds Keeps Kids Trapped Inside ERs

One evening in late March, a mom called 911. Her daughter, she said, was threatening to kill herself. EMTs arrived at the home north of Boston, helped calm the 13-year-old, and took her to an emergency room.

Melinda, like a growing number of children during the covid-19 pandemic, had become increasingly anxious and depressed as she spent more time away from in-person contact at school, church and her singing lessons.

KHN and NPR have agreed to use only the first names of this teenager and her mother, Pam, to avoid having this story trail the family online. Right now in Massachusetts and in many parts of the U.S. and the world, demand for mental health care overwhelms supply, creating bottlenecks like Melinda’s 17-day saga.

Emergency rooms are not typically places you check in for the night. If you break an arm, it gets set, and you leave. If you have a heart attack, you won’t wait long for a hospital bed. But sometimes if your brain is not well, and you end up in an ER, there’s a good chance you will get stuck there. Parents and advocates for kids’ mental health say that the ER can’t provide appropriate care and that the warehousing of kids in crisis can become an emergency itself.

What’s known as emergency room boarding of psychiatric patients has risen between 200% and 400% monthly in Massachusetts during the pandemic. The CDC says emergency room visits after suicide attempts among teen girls were up 51% earlier this year as compared with 2019. There are no current nationwide mental health boarding numbers.

“This is really unlike anything we’ve ever seen before, and it doesn’t show any signs of abating,” said Lisa Lambert, executive director of Parent/Professional Advocacy League, which pushes for more mental health care for children.

Melinda spent her first 10 days in a hospital lecture hall with a dozen other children, on gurneys, separated by curtains because the emergency room had run out of space. At one point, Melinda, who was overwhelmed, tried to escape, was restrained, injected with drugs to calm her and moved to a small, windowless room.

Day 12: Cameras Track Her Movements

I met Melinda in early April, on her 12th day in the ER. Doctors were keeping her there because they were concerned she would harm herself if she left. Many parents report spending weeks with their children in hospital hallways or overflow rooms, in various states of distress, because hospital psychiatric units are full. While demand is up, supply is down. Covid precautions turned double rooms into singles or psych units into covid units. While those precautions are beginning to ease, demand for beds is not.

Inside her small room, Melinda was disturbed by cameras that tracked her movement, and security guards in the hallways who were there, in part, for her safety.

“It’s kinda like prison,” she said. “It feels like I’m desperate for help.”

“Desperate” is a word both Melinda and Pam use often to describe the prolonged wait for care in a place that feels alien.

“We occasionally hear screaming, yelling, monitors beeping,” said Pam. “Even as the parent — it’s very scary.”

But this experience is not new. This was Melinda’s fourth trip to a hospital emergency room since late November. Pam said Melinda spiraled downward after a falling out with a close family member last summer. She has therapists, but some of them changed during the pandemic, the visits were virtual, and she hasn’t made good connections between crises.

“Each time, it’s the same routine,” Pam said. Melinda is rushed to an ER, where she waits. She’s admitted to a psych hospital for a week to 10 days and goes home. “It’s not enough time.”

Pam said each facility has suggested a different diagnosis and adjusted Melinda’s medication.

“We’ve never really gotten a good, true diagnosis as to what’s going on with her,” Pam said. “She’s out of control; she feels out of control in her own skin.”

Melinda waited six months for a neuropsychiatric exam to help clarify what she needs. She finally had the exam in May, after being discharged from the psychiatric hospital, but still doesn’t have the results. Some psychiatrists say observing a patient’s behavior is often a better way to reach a diagnosis.

Lambert, the mental health advocate, said there are delays for every type of psychiatric care — both residential and outpatient.

“We’ve heard of waits as long as five weeks or more for outpatient therapy,” Lambert said. “If your child is saying they don’t want to live or don’t want to ever get out of bed again, you don’t want to wait five weeks.”

Day 13: ‘The Longer She’s Here, the More She’s Going to Decline’

As her stay dragged on, Melinda bounced from manic highs to deep emotional lows. The emergency room is a holding area; it isn’t set up to offer treatment or psychiatric therapy.

On this day Melinda was agitated.

“I just really want to get out of here,” she said in an audio diary she was keeping at the time for this story. “I feel kind of helpless. I miss my pets and my bed and real food.” She’d had a panic attack the night before and had to be sedated. Her mom, Pam, wasn’t there.

“The longer she’s here, the more she’s going to decline,” Pam recorded in her own audio diary. “She has self-harmed three times since she’s been here.”

The hospital and its parent network, Beth Israel Lahey Health, declined requests to speak about Melinda’s care. But Dr. Nalan Ward, the network’s chief medical officer for behavioral health services, hosts a daily call to discuss the best place for inpatient psychiatric treatment for each patient. Some may have unique medical or insurance constraints, she said. Many insurers require prior approval before they’ll agree to pay for a placement, and that, too, can add delays.

“It takes a case-by-case approach,” said Ward. “It’s really hands-on.”

Day 14: Increasingly Isolated From School and Friends

For Melinda, the issue keeping her from moving out of the ER and into an effective treatment program could have been her behavior. Pam was told her daughter may be harder to place than children who don’t act out. Hospitals equipped to provide inpatient mental health care say they look for patients who will be a good fit for their programs and participants. Melinda’s chart included the attempted escape as well as some fights while she was housed in the lecture hall.

“She’s having behaviors because she has a mental illness, which they’re supposed to help her with,” Pam said, “but yet they’re saying no to her because she’s having behaviors.”

Secluding Melinda in the ER didn’t help, Pam said. “She’s, at times, unrecognizable to me. She just is so sure that she’s never going to get better.”

Melinda described feeling increasingly isolated. She lost touch with friends and most family members. She’d stopped doing schoolwork weeks earlier. The noise and commotion of a 24/7 ER was getting to Melinda.

“I’m not sleeping well,” she noted in her diary. “It’s tough here. I keep waking up in the middle of the night.”

Day 15: Mom Retreats to Her Car to Cry

Boarding is difficult for parents as well. Pam works two jobs, but she visited Melinda every day, bringing a change of clothes, a new book or something special to eat.

“Some days I sit and cry before I get out of the car, just to get it out of my system, so I don’t cry in front of her,” Pam said in her diary entry that day.

Some hospitals say they can’t afford to care for patients with acute mental health problems because insurance reimbursements don’t cover costs. Massachusetts is spending $40 million this year on financial incentives to create more inpatient psychiatric care. But emergency rooms are still flooded with psychiatric patients who are in limbo, boarding there.

Day 16: ‘I Wish Someone Would Just Understand Me’

“I never thought we’d be here this long,” said Pam.

At the nurses’ station, Pam was told it could be two more weeks before there would be an opening at an appropriate hospital.

In Massachusetts, Gov. Charlie Baker’s administration says it has a plan that will keep children out of ERs and reduce the need for inpatient care by providing more preventive and community-based services. Parents and providers say they are hopeful but question whether there are enough counselors and psychiatrists to staff proposed community clinics, therapy programs and more psychiatric hospital beds.

Meanwhile, in the ER, Melinda was growing listless.

“Life is really hard because things that should be easy for everyone are just hard for me,” she said. “When I ask for help, sometimes I picture going to the hospital. Other times I wish someone would just understand me.”

Then, in the late evening on Day 16, the family got word that Melinda’s wait would soon end.

Day 17: Limbo Ends and Real Treatment Begins

On Day 17, Melinda was taken by ambulance to a Boston-area hospital that had added child psychiatric beds during the pandemic. She was lucky to get a spot. The day she arrived, there were 50 to 60 children on the waiting list.

“That’s dramatically higher” than before the pandemic, said Dr. Linsey Koruthu, one of Melinda’s doctors and a pediatric psychiatrist at Cambridge Health Alliance. “About double what we would have seen in 2019.”

Doctors there adjusted Melinda’s medications. She met with a psychiatrist and social worker daily and had group therapy and time for schoolwork, yoga and pet therapy. Hospital staff members met with Melinda and her family. She stayed two weeks, a bit longer than the average stay.

Doctors recommended that Melinda move from inpatient care to a community-based residential treatment program — a bridge between being in the hospital and returning home. But those programs were full and had weeks-long delays. So, Melinda went straight home.

She now has three therapists helping her make the transition and use what she’s learned. And as covid restrictions have begun to ease, some sessions are in person — which Koruthu said should be more effective for Melinda.

Pam said the transition has been rough. Police came to the house once and suggested Melinda go to an ER, but she was able to calm down before it came to that. Melinda has developed an eating disorder.

The first available appointment with a specialist is in August. But, by mid-June, Melinda was able to graduate from middle school, after finishing a backlog of schoolwork.

“If you had asked me two months ago, I would have said I don’t think she’ll make it,” Pam said. “We’re getting there.”

If you or someone you know are in mental health crisis or may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en Español: 1-888-628-9454; for the deaf and hard of hearing: Dial 711 then 1-800-273-8255) or the Crisis Text Line by texting HOME to 741741.

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Hemmed In at Home, Nonprofit Hospitals Look for Profits Abroad

Across the street from the Buckingham Palace Garden and an ocean away from its Ohio headquarters, Cleveland Clinic is making a nearly $1 billion bet that Europeans will embrace a hospital run by one of America’s marquee health systems.

Cleveland Clinic London, scheduled to open for outpatient visits later this year and for overnight stays in 2022, will primarily offer elective surgeries and other profitable treatments for the heart, brain, joints and digestive system. The London strategy attempts to attract a well-off, privately insured population: American expatriates, Europeans drawn by the clinic’s reputation, and Britons impatient with the waits at their country’s National Health Service facilities. The hospital won’t offer less financially rewarding business lines, like emergency services.

“There are very few people out there in the world who would not choose to have Cleveland Clinic as their health care provider,” said chief executive Dr. Tomislav Mihaljevic.

Facing the prospect of stagnant or declining revenues at home, around three dozen of America’s elite hospitals and health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.

For years, a handful of hospitals have partnered with foreign companies or offered consulting services in places like Dubai, where Western-style health care was rare and money plentiful. Now a few, like the clinic, are taking on a bigger risk — and a potentially larger financial reward.

These foreign forays prompt questions about why American nonprofit health systems, which pay little or no taxes in their hometowns, are indulging in such nakedly commercial ventures overseas. The majority of U.S. hospitals are exempt from taxes because they provide charity care and other benefits to their communities. Nonprofit hospitals routinely tout these contributions, though studies have found they often amount to less than the tax breaks.

Despite their tax designation, nonprofit hospitals are as aggressive as commercial hospitals in seeking to dominate their health care markets and extract prices as high as possible from private insurers. Though they do not pay dividends, some nonprofits amass large surpluses most years even as more and more patients are covered by Medicare and Medicaid, the U.S. government’s insurance programs for the elderly, disabled and poor, which pay less than commercial insurance. Cleveland Clinic, one of the wealthiest, ran an 11% margin in the first three months of this year and paid Mihaljevic $3.3 million in 2019, the most recent salary disclosed.

The advantages of international expansion for their local communities are tenuous. Venturing overseas does not provide Americans with the direct or trickle-down benefits that investing locally does, such as construction work and health care jobs. Even when hospitals abroad add to the bottom line, the profits funneled home are minimal, according to the few financial documents and tax returns that disclose details of the operations.

“It’s a distraction from the local mission at a minimum,” said Paul Levy, a former chief executive at Boston’s Beth Israel Deaconess Medical Centerand now a consultant. “People get into them at the beginning, thinking this is easy money. The investment bankers get involved because they get the financing, and the senior faculty get on board and say, ‘This is great; it means I can go to Italy for two years’ — and there’s not a real business plan.”

There are financial hazards. For instance, Cleveland Clinic has warned bondholders that its performance could suffer if its London project does not launch as planned. There are also risks to a system’s reputation if a foreign venture goes awry.

Finance experts temper expectations that operations of overseas hospitals will have a major bearing on a system’s balance sheet. “Even though they do well, they’re small hospitals — they’re never part of the overall picture,” said Olga Beck, a senior director at Fitch Ratings. “It does help [the U.S. operations] because it gives a global name and presence in other markets.”

Hospital executives say their foreign ventures provide an additional source of revenue, thus adding stability, and benefit the care of their hometown patients.

“As we go to different areas around the world, we learn and we continuously improve for all our patients,” said Dr. Brian Donley, CEO of Cleveland Clinic London. He said the clinic has learned from U.K. practices more efficient ways to sterilize surgical instruments and perform X-rays.

For decades, wealthy foreigners — who are willing to pay the list prices for specialized surgeries and cancer care that domestic insurers bargain down — have been appealing targets for U.S. hospitals. Hospitals like MedStar Health’s Georgetown University Hospital in Washington, D.C., solicit and assist foreign patients with special offices staffed by people with job titles such as “international services coordinator” and “international services finance administrator.”

Between July 2019 and June 2020, U.S. hospitals treated more than 53,000 foreign patients, charging them more than $2.8 billion, according to a survey of members by the Chicago-based U.S. Cooperative for International Patient Programs. In addition, instead of just importing patients, 37 of 51 health systems in the survey said they offer international advisory or consulting services abroad.

“‘Send us your patients’ is pretty much a dying approach,” said Steven Thompson, a consultant who has spearheaded international programs for Baltimore’s Johns Hopkins Medicine and Boston’s Brigham and Women’s Hospital. “People see it on both sides for what it is: a one-way relationship.”

One of the oldest foreign ventures is the organ transplant program the Pittsburgh-based nonprofit system UPMC has run in Palermo, Italy, since 1997, when Sicily’s government and Italian insurers realized it would be cheaper to perform those procedures there than continue to send patients to the U.S. Since then, UPMC’s Palermo facility has performed more than 2,300 transplants.

In this initial expansion, the U.S. hospital was providing a highly specialized type of surgery — one that UPMC is renowned for — that was not available locally. But UPMC, one of the most entrepreneurial U.S. health systems, didn’t stop there. In Ireland, UPMC owns a cancer center and provides care for concussions through sports medicine clinics. Since 2018, the system has acquired hospitals in Waterford, Clane and Kilkenny. They are staffed mostly by independent Irish physicians, but UPMC regularly sends over its leading U.S. specialists to lend expertise, according to Wendy Zellner, a UPMC spokesperson.

UPMC has company in Ireland: in 2019, Bon Secours Mercy Health, a Roman Catholic system with hospitals in Eastern states, merged with a five-hospital Catholic system there.

Over the past two decades, UPMC did advisory and consulting work in 15 countries but ultimately decided to narrow its involvement to four: Italy, Ireland, China and Kazakhstan, where UPMC is helping a university develop a medical teaching hospital. Charles Bogosta, president of UPMC International, said UPMC wanted to focus its efforts where it was confident it could improve the quality of care, bolster UPMC’s reputation and earn profit margins greater than its U.S. hospitals do.

UPMC officials said the economics are favorable abroad because labor is cheaper and the mix of patients is heavily tilted toward those with commercial insurance, which pays better than government programs.

“What we’ve been doing overseas has been really helpful in addressing what everyone in the U.S. is trying to do, which is come up with diversified revenue sources,” Bogosta said.

Even so, that extra revenue remains a small part of UPMC’s earnings. The health system’s foreign hospital business generated gross revenues of $96 million, or 1% of UPMC’s $9.3 billion total hospital revenues in 2019, according to a KHN analysis of a UPMC financial disclosure. Since that figure is before accounting for the costs of running the hospitals, taxes and other expenses, the actual profits the foreign hospitals might send back to Pittsburgh are much smaller. In Ireland, where corporations are required to disclose audited financial statements, UPMC Investments Ltd., an umbrella group that owns the Waterford hospital operation and property, reported net profits of about a half-million dollars in 2019 on more than $47 million in gross revenues.

In an email, Zellner said the Ireland statements “do not give you the totality of the picture in Ireland or International, where our results are far better than these documents would suggest.” UPMC declined to provide more detailed financial data.

Like other systems, UPMC has expanding ambitions in China. In 2019 it signed an agreement with the multinational corporation Wanda Group to help manage several “world-class” hospitals, starting with one opening in Chengdu next year.

But foreign ventures can misfire. “These partnerships can turn into nightmares, as Hopkins has learned,” Thompson wrote in a 2012 article for the Harvard Business Review that described his observations as the founder and first CEO of Johns Hopkins Medicine International, a for-profit venture jointly owned by Johns Hopkins Medicine and Johns Hopkins University.

Anadolu Medical Center, which Hopkins helped establish in Istanbul in 2005, was “plagued by quality problems,” including overbooked operating rooms and physicians who refused to follow evidence-based procedures and quality protocols, he wrote. Thompson attributed the problem to the Turkish mandate that the hospital be run by a Turkish citizen and wrote that the problems did not dissipate until Hopkins was allowed to install its own manager in the second-highest position and dissolve the top position to get around the citizenship requirement “while remaining in technical compliance with the law.”

While “the project is now thriving,” he warned that “lending the Hopkins name to a hospital that delivers unimpressive care could significantly damage our 135-year-old brand — and that’s a real danger in developing areas, especially in a project’s early days.”

Hopkins has remained skittish about outright ownership or even management responsibilities. Instead, it has affiliations with hospitals and health systems in 13 countries, including Vietnam, China, Turkey, Lebanon, Brazil and Saudi Arabia. Hopkins does not run any of the hospitals but helps develop hospital master plans and clinical programs, trains doctors, and advises on patient safety and infection control.

Even so, in 2014 it created a joint venture with the oil and gas company Saudi Aramco to provide health care to 255,000 employees and their dependents and retirees. Hopkins, which owns a fifth of the venture, said all foreign net revenue is returned to the system’s parent organizations to fund research, expansion of care and scholarships. But its public records report meager income from its foreign subsidiary, just $7 million in 2018 — a tenth of a percent of the health system’s $7 billion revenues.

Charles Wiener, the current president of Johns Hopkins Medicine International, focused on other benefits. “If we can put in robust quality and safety at one of our affiliates, their patients do better,” he said. “If we can export our education and training models, we believe that allows our people to benefit from learning from other cultures, and some of their people come here to train.”

Cleveland Clinic London is unusual in that U.S. health systems rarely build a hospital abroad from scratch without a local partner. The clinic chose that more cautious approach with Cleveland Clinic Abu Dhabi, a 364-bed hospital owned by the Mubadala Investment Co. that the clinic manages. It also has a consulting practice that is helping a Singapore health care company build a hospital in Shanghai.

Foreign enterprises appeal to the clinic because it has limited growth opportunities in Ohio, where the population is growing slowly and aging, meaning more patients are leaving high-paying commercial insurers for lower-paying Medicare. The clinic has expanded in Florida, acquiring five hospitals to take advantage of population increases and wealthier patients there.

The London project will have 184 beds and eight operating rooms. Donley said it will be staffed primarily by U.K. physicians, including ones who also work for the National Health Service.

“The clinic has a long track record of being able to execute on its strategies,” said Lisa Martin, an analyst at the bond rating agency Moody’s Investors Service. “The London project is obviously the biggest venture and the biggest financial risk that they’ve made abroad.”

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The Hard Realities of a ‘No Jab, No Job’ Mandate for Health Care Workers

Christopher Richmond keeps a running tab on how many workers at the ManorCare skilled nursing facility he manages in western Pennsylvania have rolled up their sleeves for a covid-19 vaccine.

Although residents were eager for the shots this year, he’s counted only about 3 in 4 workers vaccinated at any one time. The excuses, among its staff of roughly 100, had a familiar ring: Because covid vaccines were authorized only for emergency use, some staffers worried about safety. Convenience mattered. In winter, shots were administered at work through a federal rollout. By spring, though, workers had to sign up online through a state program — a time-sucking task.

ManorCare urges every worker to be immunized against covid but turnover has vexed that effort. Managers at ProMedica, a nonprofit health system that operates ManorCare and senior care facilities in 26 states, faced a workforce conundrum familiar to all manner of providers during the pandemic: how to persuade essential workers to get vaccinated — and in a way that didn’t drive them away. Raises and bonuses, costing millions of dollars, did not move the needle to 100%.

Animus toward the vaccine created turmoil for some providers. Dr. Eric Berger, a pediatrician in Philadelphia who opened his practice more than a dozen years ago, enforced mandatory shots in May and saw six of his 47 staff members walk out. Berger said he worked for months to educate resistant workers. In April, he learned that several, women in their 20s and 30s, had attended a private karaoke party. Within days, four staffers were infected with covid.

Berger, who had seen in-office costs for protective equipment soar, then set a deadline for shots. He looks back with steely resolve over the last-minute “I quit” texts he received — and the hassle of finding a new receptionist and billing and medical assistants.

“Fortunately, we had some wonderful people who put in extra time,” he said. “It’s been stressful, but I think we did the right thing.”

Brittany Kissling, 33 and a mother of four, was one of the hesitant workers at Berger’s practice who decided — largely for financial reasons — to get vaccinated. The clinic manager couldn’t afford to lose her job. But she said she was nervous and that most of the workers who left recoiled at being told vaccinations were not negotiable. “I was a no-show my first time,” Kissling said about her first vaccine appointment. “I was scared. There were a lot of unknowns.”

But Kissling said Berger’s practice has spent “thousands and thousands and thousands of dollars” on masks and even paid workers for five days a week when they worked only two during the pandemic’s worst months. She said she understood how and why the karaoke episode prompted a mandate. “I get it from the business side,” said Kissling, about the requirement. “I do think it’s fair. I do think it is tough.”

Berger saw no other choice. “Vaccines are fundamental to our practices. That’s what we do,” he said. “Some got it in their heads that it could cause infertility; some had other reasons. It’s frustrating … [and] I don’t think it was political. If anything, most of these people are apolitical.”

At ManorCare, managers decided money could make a difference. Bonuses — up to $200 per employee — were added as an incentive, which in Pennsylvania alone cost ProMedica $3 million, said Luke Pile, vice president and general manager for ProMedica Senior Care skilled nursing centers.

Richmond, at ManorCare, said the resident council has been pivotal in keeping the focus on the risks of covid to the elderly — and no one there needs a reminder about the stress of the past year. According to Medicare records, the facility had 107 cases of covid among staffers and residents — and 14 deaths among residents beginning in March 2020.

“I constantly wear a mask. Not out of fear, but I don’t want to spread it by being asymptomatic,” Richmond said. “I tell people here: Whatever is happening in the community, that is what is happening in the community. But we are a health care institution and caring for the elderly. We need to be constantly vigilant.”

Richmond and other administrators admit it can be a struggle to understand why some health workers are unmoved by the science.

“Everything has been so polarized this past year. I don’t know that there is a single reason that individuals don’t get the vaccine,” Pile said. “In trying to educate people, personally and professionally, we talk about the history and science. Unfortunately, individual opinions don’t always align with that.”

Mandating vaccines is a step that ProMedica has yet to take, even as more businesses, universities and health care providers do so. A few long-term care operators, such as Atria Senior Living, operating in the United and Canada, and Juniper Communities, announced mandates. Some have been met with lawsuits from workers aligned with conservative groups. In May, more than 100 staffers at Houston Methodist Hospital filed suit to dispute and derail the hospital system’s compulsory vaccination. A judge dismissed the challenge this month on the grounds that the hospital’s requirement did not violate state or federal law or public policy.

Last week, the U.S. Labor Department issued a temporary emergency standard for health care workers, saying they face “grave danger” in the workplace when “less than 100 percent of the workforce is fully vaccinated.”

In Pennsylvania, whose population ranks among the oldest according to 2019 census data, statistical snapshots published in April underscored the need for vigilance. Two state agencies overseeing skilled nursing care and personal care homes reported that only half of their workers were vaccinated. Covid was notably devastating to long-term care facilities nationwide in 2020; some of Pennsylvania’s deadliest outbreaks were reported by local media in places shown later to have low staff vaccination rates.

A survey by the Delphi Group, begun in March 2020 with over 700,000 Facebook respondents ages 18 to 64, recently was analyzed by researchers from Carnegie Mellon and the University of Pittsburgh, who found that health care workers were largely leading the vaccine uptake. But there were notable differences over the winter among people working, side by side, in health care settings.

Pharmacists, physicians and registered nurses were the least hesitant to get vaccinated. Home health care aides, EMTs and nursing assistants showed the highest hesitancy among front-line health workers. Overall hesitancy across professions decreased from January to March 2021, as much as 5 percentage points, as vaccinations expanded, according to the analysis by the university researchers.

University of Pittsburgh researcher Wendy King said people indicated they were receptive to the vaccine if they were familiar with its science. Educators, overall, displayed the least hesitancy; workers in construction, mining and oil/gas extraction showed the greatest. Half of those who were hesitant cited possible side effects — a fear that could be eased by education, King said. A third among the hesitant gave other reasons: They didn’t believe they needed the vaccine. They didn’t trust the government. Or they didn’t trust the covid-19 vaccines.

“We expected hesitancy to vary by group, but how much they varied was surprising,” King said. “These were not people who were anti-vaccine, but they were worried about the effect of the vaccine.”

Still, King said the percentage who didn’t trust the government was alarming. “If somebody doesn’t understand the vaccine, that’s one thing. If you don’t trust that government, that is a much more difficult issue to address.”

That may change as two prominent vaccine makers approach full approval by the Food and Drug Administration. Pfizer and BioNTech applied for approval in May; Moderna applied in early June. A recent KFF poll found nearly a third of unvaccinated adults said they would be more likely to get a vaccine once it was fully approved by the FDA.

At ProMedica, Pile described a multipronged approach in such states as Florida and Pennsylvania, home to large elderly populations. On-site counseling in groups, with familiar doctors and staff, helped persuade some who were reluctant, he said. Short videos on why and how the vaccine worked were readied. ProMedica senior medical staff flew to Florida to advise as the National Guard arrived at its facility in Pinellas County, the health system’s first to receive the vaccine.

Falon Blessing, a nurse, manages other practitioners at ManorCare Health Services Center throughout the Tampa region. She recounted how employees had wondered aloud how such newly created vaccines could be safe.

“I think people at first just wanted to know: I’m not going to grow a tail in five years,” she said. “But then there was a momentum. It wasn’t so much ‘Are you going to get vaccinated?’ but rather ‘Of course, I’m going to get vaccinated.’”

During three vaccinations sessions ended in January, though, the facility reached about the same rate as Pennsylvania overall — about 76% of its workers were vaccinated. That rate has fallen to 62% this month because of attrition. An education effort continues, a ProMedica spokesperson said.

“My takeaway was it mattered to have one-on-one discussions,” Pile said. “If you talk to 10 people, why they wouldn’t get the vaccine, you’d get 10 different reasons.”

“And there were political opinions — what they heard on Facebook — and then they’d say: I want to see how it goes,” he said.

The questions and qualms about vaccines came at the end of a deeply distressing pandemic year for health care workers, and facilities are now finding fewer applicants for essential care.

By spring, ProMedica had 1,500 job postings in Pennsylvania alone, compared with a typical 400 openings. Pile said ProMedica raised wages in dozens of locations, though he declined to provide wage ranges or rates. It spent $4.5 million in Pennsylvania from March through last week — and still supplemented its workforce across the U.S. by hiring through staffing agencies.

“In 2020, we spent over $32 million on staffing agencies,” he said. Through this spring, ProMedica was on course to spend $66 million on staffing agencies for 2021, said Pile, who has worked in the care sector for 18 years.

“I have less employees than ever before,” he said. “I have never seen anything like it.”

The Pennsylvania Health Care Association, an advocacy group, surveyed members in April to better understand vaccine reluctance. Zachary Shamberg, the group’s president, said it found that defining “hesitancy is not that simple.”

Shamberg said PHCA focused on why people had yet to be immunized and the characteristics of the workforce were telling: About 92% of all its workers are women; 65% are between ages 16 and 44. Among them, some worried early on about possible infertility from the new vaccine, he said, and some wanted to wait for the single-shot Johnson & Johnson vaccine. Others were sick with covid and were advised, once recovered, not to get a vaccine for 90 days.

Shamberg was also critical of the state data. Those surveys, taken in March and released in April, reflected a time when the vaccine was new to many people.

Pennsylvania, a battleground state in recent presidential elections, remains politically charged, and Shamberg noted that politics likely plays a role among holdouts. In recent months, PHCA enlisted churches and doctors’ consortiums to change minds. Keeping residents and workers safe should be a priority in a state that, in a few years, will face a “silver tsunami” of residents in their 80s, Shamberg said.

In recent weeks, there has been clear momentum among the general population for shots in Pennsylvania. The state now ranks among the top 10 states in the nation to administer first doses of vaccines, according to data from the Centers for Disease Control and Prevention.

“Pennsylvania is a big and diverse state,” Shamberg said. “And it’s interesting why some of our staff in western Pennsylvania were hesitant versus workers in the city of Philadelphia.”

“The vast majority of workers in Philadelphia are female and, among them, minority populations that have some inherent distrust based on historical experience. Then you go out west and you have a more conservative viewpoint — and a distrust of government today and a distrust of government vaccine.”

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Device Makers Have Funneled Billions to Orthopedic Surgeons Who Use Their Products

Dr. Kingsley R. Chin was little more than a decade out of Harvard Medical School when sales of his spine surgical implants took off.

Chin has patented more than 40 pieces of such hardware, including doughnut-shaped plastic cages, titanium screws and other products used to repair spines — generating $100 million for his company SpineFrontier, according to government officials.

Yet SpineFrontier’s success arose not from the quality of its goods, these officials say, but because it paid kickbacks to surgeons who agreed to implant the highly profitable devices in hundreds of patients.

In March 2020, the Department of Justice accused Chin and SpineFrontier of illegally funneling more than $8 million to nearly three dozen spine surgeons through “sham consulting fees” that paid them handsomely for doing little or no work. Chin had no comment on the civil suit, one of more than a dozen he has faced as a spine surgeon and businessman. Chin and SpineFrontier have yet to file a response in court.

Medical industry payments to orthopedists and neurosurgeons who operate on the spine have risen sharply, despite government accusations that some of these transactions may violate federal anti-kickback laws, drive up health care spending and put patients at risk of serious harm, a KHN investigation has found. These payments come in various forms, from royalties for helping to design implants to speakers’ fees for promoting devices at medical meetings to stock holdings in exchange for consulting work, according to government data.

Health policy experts and regulators have focused for decades on pharmaceutical companies’ payments to doctors — which research has shown can influence which drugs they prescribe. But far less is known about the impact of similar payments from device companies to surgeons. A drug can readily be stopped if deemed harmful, while surgical devices are permanently implanted in the body and often replace native bone that has been removed.

Every year, a torrent of cash and other compensation flows to these surgeons from manufacturers of hardware for spinal implants, artificial knees and hip joints — totaling more than $3.1 billion from August 2013 through the end of 2019, a KHN analysis of government data found. These bone specialists make up a quarter of U.S. doctors who have accepted at least $100,000 or more, and two-thirds of those who raked in $1 million or more, from the medical device and drug industries last year, the data shows.

“It is simply so much money that it is staggering,” said Dr. Eugene Carragee, a professor of orthopedic surgery at the Stanford University Medical Center and critic of the medical device industry’s influence. Much of the money is deemed to be compensation for consulting duties or medical research, or royalties for inventing, or fine-tuning, new surgical tools and techniques. In some cases, it pays for trips or splashy junkets or rewards surgeons for promoting products to their peers.

Device makers say the long-established practice leads to higher-quality, safer products. “Doctors help develop and refine medical devices, and they even create new devices themselves, sharing their intellectual property with companies to help save and improve patients’ lives,” said Scott Whitaker, president and CEO of AdvaMed, the medical technology industry’s trade group.

But industry whistleblowers and government investigators say all that money changing hands can corrupt medical judgment and tempt surgeons to perform unnecessary and wasteful operations. In ongoing lawsuits, patients say they have suffered life-altering injuries from screws or other spinal hardware that snapped apart or live with disabilities they blame on defective knee or hip implants. Patients alleging injuries range from seniors on Medicare to celebrities such as Olympic gold medalist Mary Lou Renner, who had surgery to replace both her hips. The gymnast sued device maker Biomet in January 2018, alleging the hip implants were defective. The suit has since been settled under confidential terms.

The case of Chin’s company, SpineFrontier, is among more than 100 federal fraud and whistleblower actions, filed or settled mostly in the past decade, that accuse implant surgeons of taking illegal compensation from device makers — from surgeon entrepreneurs like Chin to marquee names like Medtronic and Johnson & Johnson. In some cases, device makers have paid hundreds of millions of dollars in fines to wrangle out of trouble for their involvement, often without admitting any wrongdoing.

Court pleadings examined by KHN identified more than 700 surgeons who have taken money, including dozens who pocketed millions in royalties, fees or other compensation from 2013 through 2019.

The names of hundreds more surgeons were redacted in court filings or sealed by judges.

Court filings named 35 spine surgeons who used SpineFrontier’s surgical gear, some for years. At least six of those surgeons have admitted wrongdoing and paid a total of $3.3 million in penalties. Another has pleaded guilty to criminal charges. It’s illegal under federal law to accept anything of value from a device maker for using its wares, though most offenders don’t face criminal prosecution.

Chin, 57, who lives in Fort Lauderdale, Florida, and owns SpineFrontier through his investment company, declined comment about the DOJ lawsuit or the consulting agreements.

“There is a court date [for the DOJ case] as ordered by a judge,” Chin said via email. “If we get to that point the facts of the case will be litigated.”

Back Surgeries Under Scrutiny

The nation’s outlay for spine surgery to treat back pain, or to replace worn-out knees and hips, tops $20 billion a year, according to one industry report.

Taxpayers shoulder much of that cost through Medicare, the federal program for those 65 and older, and Medicaid, which caters to low-income people.

In one common spinal procedure, surgeons may replace damaged discs with an implant and screws and metal rods that hold it in place. The demand for surgery to replace worn-out knees and hips also has mushroomed as aging boomers and others seek relief from joint pain that restricts their movement.

Perhaps not surprisingly, the competition for sales of orthopedic devices is fierce: Some 250 companies proffer a dizzying array of products. Industry critics blame the Food and Drug Administration, which allows manufacturers to roll out new hardware that is substantially equivalent to what already is sold — though it often is marketed as more durable, or otherwise better for patients.

“The money is just phenomenal for this medical hardware,” said Dr. James Rickert, a spine surgeon and head of the Society for Patient Centered Orthopedics, an advocacy group. He said most of the products are “essentially the same,” adding: “These are not technical instruments; [it’s often] just a screw.”

Hospitals can end up charging patients $20,000 or more for the materials, though they pay much less for them. Spine surgeons — who make upward of $500,000 a year — bill separately and may charge $8,000 to $20,000 for major procedures.

Which equipment hospitals choose may fall to the preference of surgeons, who are wooed by manufacturing sales reps possibly present in the operating room.

And it doesn’t stop there. Whistleblower cases filed under the federal False Claims Act allege a startling array of schemes to influence surgeons, including compensating them for joining a medical society created and financed by a device company. In other cases, companies bought billboard space or other advertising to promote medical practitioners, hired surgeons’ relatives, paid for hunting trips — even mailed checks to their homes.

Orthopedic and neurosurgeons collected more than half a billion dollars in industry consulting fees from 2013 through 2019, federal payment records show.

These gigs are legal so long as they involve professional work done at fair market value. But they have drawn fire as far back as 2007, when four manufacturers that dominated the hip and knee implant market, including a J&J division, agreed to pay $311 million to settle charges of violating anti-kickback laws through their consulting deals.

KHN found at least 20 whistleblower suits, some settled, others pending, that have since accused device makers of camouflaging kickbacks as consulting work, including paying doctors to sit on suspect “advisory boards” or other activities that entailed little work to justify the fees.

In November 2019, device maker Life Spine and two of its executives admitted to paying consulting fees to induce dozens of surgeons to use Life Spine’s implants in the operating room. In all, 21 of the top 30 Life Spine adopters were paid and they accounted for about half its total device sales, according to the Justice Department. Life Spine and the executives paid a total of $6 million in penalties. The company did not respond to requests for comment.

Similarly, SpineFrontier received “the vast majority” of its sales, more than $100 million worth, from surgeons who were compensated, the Justice Department alleges. Often, they were paid by way of a “sham” company run by Chin’s wife, Vanessa, from a mail drop in Fort Lauderdale, according to the Justice Department. Vanessa Dudley Chin, a defendant in the DOJ civil case, had no comment.

Kingsley Chin told KHN via email that he takes no salary from SpineFrontier, based in Malden, Massachusetts. In 2013, Chin received $4.3 million in income from the company, according to court filings in a divorce case in Philadelphia from an earlier marriage. In 2018, SpineFrontier valued Chin’s interest in the company at $75 million, according to government records, though its current worth is unclear.

SpineFrontier’s management thought paying doctors was “the only reliable way to steadily increase its market share and stave off competition,” Charles Birchall, a former business associate of Chin’s, alleged in a whistleblower complaint. The case is one of two whistleblower suits filed against SpineFrontier that the DOJ has joined and consolidated. Chin has yet to file a response in court.

From March 2013 through December 2018, the company offered some surgeons $500 or more an hour for “consulting,” which could include the time they spent operating on patients — even though they already were being paid by Medicare or other health insurers. Other surgeons were paid repeatedly to “evaluate” the same products, though their feedback was “often minimal or nonexistent,” according to the DOJ complaint.

Patient Injuries Pile Up

While the payments have piled up for doctors, so have injuries for patients, according to lawsuits against device makers and whistleblower testimony.

Orthopedic surgeon-turned-whistleblower Dr. Manuel Fuentes is suing his former employer, Florida device maker Exactech, alleging it offered “phony” consulting deals to surgeons who had complained about alarming defects in one of its knee implants.

Their findings should have been forwarded to the FDA to protect the public, Fuentes and two former Exactech sales reps alleged in their suit. Instead, the company paid the surgeons “to retain their business and secure their silence” about patients needlessly undergoing a second operation to address the defects implanted in the first, according to the suit. Lawyer Thomas Beimers, who represents Exactech in the case, said the company “emphatically denies the allegations and looks forward to presenting the real facts to the court.” In a court filing, the company said the suit was “full of conclusory, vague and immaterial facts” and said it should be dismissed.

In Maryland, spine surgeon Dr. Randy F. Davis faces a lawsuit filed in early 2020 by 14 former patients who claim he implanted counterfeit hardware from a device distributor that had paid him hundreds of thousands of dollars in consulting fees and other compensation.

Davis used the hardware, which had not been FDA-approved, on about 250 patients at the University of Maryland Baltimore Washington Medical Center in Glen Burnie, Maryland, according to the suit. Several patients say screws or other implants failed and they sustained permanent injuries as a result. One woman said she was left with little feeling in her right foot and needs a cane or walker to get around. Others claim “extreme mental anguish” for fear the hardware inside them will fail, according to the suit.

The patients allege that Davis improperly disposed of defective screws and other hardware he removed rather than send the items for analysis or report the failures to authorities. Instead, the University of Maryland hospital sent “hush” letters to patients that falsely told them that no defects had been found, according to the suit. A spokesperson for the hospital, which also is a defendant in the suit, denied the allegations, noting: “We will vigorously defend this lawsuit and at its conclusion are quite confident we will prevail.” Davis and his lawyer didn’t respond to repeated requests for comment. The lawsuit is pending in Anne Arundel County state court.

Surgeons are free to implant devices they helped bring to market or promoted, though doing so can prompt criticism when injuries or defects occur.

That happened when three patients filed lawsuits in 2018 against Arthrex, a Florida device company. The patients argued they were forced to undergo repeat operations to replace defective Arthrex knee devices implanted by Pennsylvania orthopedic surgeon Dr. Thomas Meade.

Meade was not a defendant in the cases. But the patients accused him of misleading them about the product’s safety and a recall. One noted that Meade had served as a prominent consultant to Arthrex and had “participated in the design, testing, marketing, promotion and sales” of the knee implant. The patient alleged that Arthrex had paid Meade more than $250,000 for work that included “promotional speaking, travel, lodging, and consulting.”

In court filings, Arthrex admitted making payments to Meade for “consulting and royalties” but denied wrongdoing. The cases were settled in 2020. Meade did not respond to requests for comment.

Chin’s dual roles as SpineFrontier’s CEO and user of its hardware was called a “huge” conflict of interest by a judge in a pending malpractice case filed against him and the company in South Florida.

In that case, Miami resident Patrick Chapoteau alleges Chin performed back surgery in 2014 using SpineFrontier hardware even though it had little chance of success. According to the suit, a Chin-designed screw implanted to stabilize Chapoteau’s spine broke in half, causing him pain and disabling injuries.

In a legal brief, Chin’s lawyers argued that he regularly operates on people with disabling back problems, noting: “The surgery is sophisticated and challenging. On a few rare occasions, his patients have not obtained the relief they expected or experienced unanticipated complications that required additional care.”

Joseph Wooten, a former Chin patient and Florida power company employee, alleged in a 2014 lawsuit in Broward County Circuit Court that Chin had 15 previous malpractice claims that had ended in more than $8 million in settlements, an assertion Chin’s lawyers disputed.

“He never told me of his bad record injuring people,” Wooten, 64, wrote in a court filing. He and his wife, Kim, said the surgery caused “debilitating and life-altering injuries.” The case has since been settled. Chin acknowledged no wrongdoing and the terms are confidential.

KHN reviewed court pleadings in nine settled malpractice cases in Philadelphia, where Chin served on the faculty of the University of Pennsylvania Medical School from 2003 to 2007, and six in South Florida filed since 2012. Details of the settlements are confidential. Five of the six South Florida cases are pending, including one filed in December by the widow of a man who died shortly after spine surgery. In all the cases and settlements, Chin has denied negligence.

In her lawsuit pending against Chin in South Florida, Nancy Lazo of Hialeah Gardens, Florida, said she slipped and tumbled down the stairs outside her Miami office, landing on her back and arm. When the pain would not go away, she turned to Chin and had two operations, in 2014 and 2015. Her lawyers allege that a SpineFrontier screw Chin implanted in her spine in the second procedure caused nerve damage. Lazo, 51, a former billing clerk with two adult sons, said she can no longer work and remains in “constant” pain. “Based on what my doctors have told me,” she said, “I will never get back to normal.” Chin denied any negligence and the case is pending.

“Based on what my doctors have told me, I will never get back to normal.”
— Nancy Lazo

Government Struggles to Keep Pace

Concerns that industry payments can corrupt medical practice have been aired repeatedly at congressional hearings, in media exposés and in federal investigations. The recurring scandals led Congress to require that device makers and pharmaceutical companies report the payments, starting in August 2013, to a government-run website called Open Payments. That website shows that payments to all doctors have risen from $8.6 billion in 2014 to just over $10 billion last year. A recent study found payments by device makers exceeded those of pharmaceutical companies by a wide margin.

Both the North American Spine Society and the American Academy of Orthopaedic Surgeons told KHN that close ties with the industry, while seeming to generate huge payouts to some surgeons, lead to the design of safer and better implants. “These interactions are really essential for good outcomes in patient care and that needs to be preserved,” said Dr. Joshua J. Jacobs, who chairs the orthopedic surgery department at Rush University Medical Center in Chicago and the AAOS’ ethics committee.

Although more than 600,000 American doctors lap up industry largesse, most do so through small payments that cover the cost of food, drinks and travel to industry-sponsored events. When it comes to big money, however, orthopedists and neurosurgeons dominate, collecting 25% of the total — even though they represent only 5% of the doctors accepting payments, according to the KHN analysis of Open Payments data.

Dr. Charles Rosen, a spine surgeon and co-founder of the advocacy group Association for Medical Ethics, said he was once offered $2,000 just to show up and watch an industry-sponsored panel. “It was quite unbelievable,” he said.

Rosen said while he believes a “relatively small number” of surgeons cash whopping industry checks, many who do so are influential figures who can “help direct medical care.”

Government data confirms that even as several orthopedic and neurosurgeons received tens of millions of dollars in 2019, 81% of them got less than $5,000 from industry.

Federal officials recently signaled their displeasure with the hefty fees paid to doctors who promote their products to peers, especially at restaurants, entertainment or sports venues that feature free food and booze but little educational content. In November, the inspector general at the Department of Health and Human Services issued a special fraud alert that such gestures could violate anti-kickback laws.

Companies that ignore the reporting law can be fined up to $1 million, though no fines were levied from 2014 through spring 2020, according to a CMS report. That changed in October, when device giant Medtronic agreed to pay the government $9.2 million to settle allegations that it paid kickbacks to Sioux Falls, South Dakota, neurosurgeon Dr. Wilson Asfora to promote its goods. Officials said the company sponsored more than 100 events at a Brazilian restaurant owned by the surgeon to clinch the sales. Just over $1 million of the fine was assessed for failing to report the transactions. A Medtronic spokesperson said the company fired or took other disciplinary action against the sales employees involved and “remains committed to maintaining the highest standards of ethical conduct.”

KHN identified four spinal device makers — including SpineFrontier — that have been accused in whistleblower cases of scheming to hide consulting payments from the government.

Responding to written questions, a CMS spokesperson said the agency “has multiple formal compliance actions pending which it is unable to discuss further at this time.”

But penalties for paying, or accepting, kickbacks often are small compared with the profits they can generate.

“Some people would say if you penalize companies enough, they won’t be making these offers,” said Genevieve Kanter, an assistant professor at the University of Pennsylvania Perelman School of Medicine. She said small fines may be chalked up to the “cost of doing business.”

The Federation of State Medical Boards does not keep data on how often its members discipline doctors for civil kickback offenses, according to spokesperson Joe Knickrehm. The federation has “long advocated for stronger reporting requirements,” Knickrehm said.

Justice Department officials would not discuss whether they are seeking fines from more surgeons. But in a statement in April 2020, then-U.S. Attorney for the District of Massachusetts Andrew E. Lelling noted that the government will investigate any doctor “who accepts money from a device manufacturer simply for using that company’s products.”

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from Health Industry – Kaiser Health News

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