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Atención primaria directa con un toque de Robin Hood

MODESTO, California – Britta Foster y Minerva Tiznado están en ligas diferentes en lo que respecta a la atención sanitaria.

Foster, que se casó con un miembro de la familia propietaria de la empresa avícola Foster Farms, con ingresos anuales de $2,500 millones, tiene cobertura de Blue Shield, así como un plan de atención primaria de alto nivel que le da acceso digital a su médico las 24/7, por una cuota anual de $5,900 que también cubre a su marido y a dos de sus hijos.

Tiznado es de Nayarit, México, y no tiene seguro. Tiene visitas gratuitas de atención primaria y grandes descuentos en medicamentos, pruebas de laboratorio y diagnóstico por imagen.

Pero Tiznado, de 32 años, y Foster, de 48, reciben atención médica en el mismo lugar: Luke’s Family Practice, en esta ciudad del Valle Central de unos 217,000 habitantes. Luke’s, una clínica con una plantilla de cuatro personas situada en un anodino centro comercial, ofrece una combinación poco ortodoxa de medicina a medida para los más adinerados, y atención benéfica para los que no tienen seguro.

Las cuotas anuales que St. Luke’s cobra a la familia de Foster y a otros 550 pacientes que pagan ayudan a cubrir la atención gratuita de un número algo mayor de pacientes sin seguro, muchos de ellos, como Tiznado, inmigrantes de habla hispana que no pueden obtener Medicaid por no tener documentos.

La clínica no acepta ningún tipo de seguro, pero exige a los pacientes que pagan que tengan cobertura para afrontar los gastos médicos fuera de su ámbito de atención.

Estos pacientes, a los que St. Luke’s llama “benefactores”, dicen estar contentos de participar en este modelo “Robin Hood”. Les proporciona una atención muy personalizada con gran acceso a sus médicos y la satisfacción emocional de apoyar a los menos privilegiados, los “beneficiarios”.

Foster dijo que para su familia ha sido un “enorme beneficio” poder enviar un mensaje de texto o llamar a su médico en cualquier momento y ser atendidos en poco tiempo: “Saber que su grupo está aquí también para servir a nuestra comunidad hace que todo parezca aún más importante”.

Tiznado, que fue a la clínica una mañana de septiembre para una revisión programada de quistes ováricos, dijo que St Luke’s “nos ha ayudado mucho, económicamente y en todos los sentidos. Creo que, si nos mudáramos a otro lugar, seguiría viniendo aquí”.

Pero Tiznado y los demás pacientes sin seguro no tienen el mismo acceso 24/7 que los benefactores. Los dos grupos utilizaban salas de espera separadas hasta que llegó la pandemia.

Luke’s es una respuesta local a los problemas sistémicos de la sanidad estadounidense, como el agotamiento de los médicos, la insatisfacción de los pacientes y el hecho de que millones de personas sigan careciendo de asistencia.

Casi 3,2 millones de californianos, entre ellos 1,3 millones de indocumentados, no tendrán seguro en 2022, aunque el estado está ampliando gradualmente la cobertura de Medicaid a muchos inmigrantes. Luke’s forma parte del movimiento a favor de la atención primaria directa, una alternativa para los doctores que huyen de los grupos médicos dominados por los seguros.

Cada año se abren en Estados Unidos unos 200 consultorios de atención primaria directa, y en la actualidad hay 1,581 que emplean a unos 3,000 médicos, según el doctor Philip Eskew, fundador de DPC Frontier, que ofrece recursos a médicos que quieren hacer el cambio. Se trata de una pequeña porción de los casi 209,000 médicos de atención primaria que hay en los Estados Unidos.

“Es cierto que somos un movimiento pequeño en este momento”, señaló Eskew.

Sus mayores retos son de tipo normativo. Por ejemplo, si las clínicas aceptan honorarios de personas inscritas en Medicare, sus médicos deben renunciar al reembolso de Medicare allí donde ejerzan. Además, algunos organismos reguladores estatales pueden considerar las prácticas de atención primaria directa como planes de salud e imponer condiciones o restricciones que dificulten o impidan su funcionamiento.

Los médicos de atención primaria directa suelen cobrar a los pacientes una cuota mensual o anual a cambio de un mayor acceso por teléfono, texto o video, tiempos de espera más cortos y visitas presenciales más largas. Y generalmente no aceptan seguros, lo que elimina la necesidad de perseguir facturas y autorizaciones de tratamiento.

“En mi antigua consulta, dedicábamos casi la mitad de nuestro tiempo procesando cobros. Pensé que, si podíamos deshacernos de todos esos gastos, podríamos dedicar más tiempo a los pacientes, y resultó ser cierto”, afirmó el doctor Bob Forester, creador del concepto y cofundador de St. Luke’s.

Muchos médicos de atención primaria directa no ven con buenos ojos a las empresas de alta tecnología propiedad de inversores, como One Medical o Forward Health. Se las considera empresas de atención primaria directa, pero sus críticos dicen que están más centradas en ampliar el volumen que en ofrecer un servicio personalizado.

“La atención primaria directa es aquella en la que el médico tiene una relación con el paciente. No tenemos que rendir cuentas a un inversor, porque nuestros inversores son nuestros pacientes”, explicó la doctora Maryal Concepción, médica de familia en Arnold, un pequeño pueblo en las montañas de California, y quien hace poco dejó una consulta comercial para poner en marcha su propia consulta de atención primaria directa.

Los pacientes de pago de St. Luke’s deben tener un seguro que cubra la hospitalización, las cirugías, la atención especializada, el diagnóstico por imágenes y los medicamentos recetados.

La clínica suele conseguir grandes descuentos para sus pacientes no asegurados. Por ejemplo, Quest Diagnostics les cobra sólo entre el 10% y el 15% de su precio habitual por los análisis de laboratorio, contó el doctor R.J. Heck, uno de los dos médicos de familia de St. Luke’s y cofundador de la clínica. Se suele remitir a los pacientes sin seguro que necesitan operaciones a Cirugía sin Fronteras, un centro quirúrgico de Bakersfield con tarifas reducidas.

St. Luke’s ha recibido recientemente una subvención de $75,000 para diagnóstico por imágenes, pruebas de laboratorio, radiografías y algunos medicamentos de la Legacy Health Endowment, una fundación local. Y trabaja con varios grupos de radiología que ofrecen descuentos, agregó Heck.

Tiznado, que necesita ecografías periódicas para sus quistes ováricos, explicó que paga unos $150 por ellas. “Si lo hiciera en otro lugar, me costaría entre $900 y $1,200”, dijo.

El estatus de entidad sin fines de lucro exenta de impuestos de St. Luke’s fomenta las donaciones, incluidas las de empresas benefactoras locales como Foster Farms y el productor de vinos E. & J. Gallo. Algunos trabajadores de las empresas que donan se encuentran entre los pacientes no asegurados de St. Luke’s.

La exención de impuestos también confiere un beneficio a los pacientes que pagan: pueden deducir de sus impuestos la parte de sus cuotas anuales que no utilizan para la atención médica. St. Luke’s les envía todos los años un extracto en el que se asigna un valor en dólares, basado en los precios de Medicare, de los servicios que han recibido.

Forester aseguró que St. Luke’s surgió de su preocupación por los no asegurados y su desprecio por los sistemas burocráticos. Pero “lo esencial”, dijo, “es que la idea de St. Luke’s nació en un momento inspirado de oración”. Forester y Heck lo pusieron en marcha hace más de 17 años como consultorio médico de inspiración católica.

Sin embargo, aunque los símbolos católicos adornan las paredes de St. Luke’s, muchos de sus pacientes no son cristianos, y la doctrina médica católica no es fundamental en su práctica.

“Aquí no viene nadie a controlar ni a decirnos lo que debemos o no debemos hacer”, afirmó la doctora Erin Kiesel, la otra médica de familia de la clínica.

Kiesel dijo que no prescribiría un aborto, pero que le diría a alguien a dónde ir si se lo pidiera, cosa que nadie ha hecho.

Heck y Kiesel aceptaron grandes recortes salariales para venir a St. Luke’s. Kiesel gana unos $60,000 menos al año que en su anterior consulta. Para ella, tener más tiempo con los pacientes, menos papeleo y un mejor equilibrio entre el trabajo y la vida personal compensa con creces el salario más bajo.

Los pacientes citaron las relaciones personales que han establecido con sus proveedores de St. Luke’s.

Paul Neumann, paciente de Heck desde hace 25 años y que lo siguió a St. Luke’s, dijo que esa relación ha sido un regalo del cielo.

Contó que en 2009 regresó de un viaje a Roma con neumonía. Cuando su mujer llamó a Heck a la mañana siguiente, éste acudió inmediatamente a la casa.

Neumann, de 84 años, paga a St. Luke’s más de $10,000 al año para él, su mujer y la familia de su hijo.

“Estaría encantado de extender un cheque por el doble”, añadió.

Este artículo fue producido por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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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ERs Are Swamped With Seriously Ill Patients, Although Many Don’t Have Covid

Inside the emergency department at Sparrow Hospital in Lansing, Michigan, staff members are struggling to care for patients showing up much sicker than they’ve ever seen.

Tiffani Dusang, the ER’s nursing director, practically vibrates with pent-up anxiety, looking at patients lying on a long line of stretchers pushed up against the beige walls of the hospital hallways. “It’s hard to watch,” she said in a warm Texas twang.

But there’s nothing she can do. The ER’s 72 rooms are already filled.

“I always feel very, very bad when I walk down the hallway and see that people are in pain, or needing to sleep, or needing quiet. But they have to be in the hallway with, as you can see, 10 or 15 people walking by every minute,” Dusang said.

The scene is a stark contrast to where this emergency department — and thousands of others — were at the start of the pandemic. Except for initial hot spots like New York City, in spring 2020 many ERs across the country were often eerily empty. Terrified of contracting covid-19, people who were sick with other things did their best to stay away from hospitals. Visits to emergency rooms dropped to half their typical levels, according to the Epic Health Research Network, and didn’t fully rebound until this summer.

But now, they’re too full. Even in parts of the country where covid isn’t overwhelming the health system, patients are showing up to the ER sicker than before the pandemic, their diseases more advanced and in need of more complicated care.

Months of treatment delays have exacerbated chronic conditions and worsened symptoms. Doctors and nurses say the severity of illness ranges widely and includes abdominal pain, respiratory problems, blood clots, heart conditions and suicide attempts, among other conditions.

But they can hardly be accommodated. Emergency departments, ideally, are meant to be brief ports in a storm, with patients staying just long enough to be sent home with instructions to follow up with primary care physicians, or sufficiently stabilized to be transferred “upstairs” to inpatient or intensive care units.

Except now those long-term care floors are full too, with a mix of covid and non-covid patients. People coming to the ER get warehoused for hours, even days, forcing ER staffers to perform long-term care roles they weren’t trained to do.

At Sparrow, space is a valuable commodity in the ER: A separate section of the hospital was turned into an overflow unit. Stretchers stack up in halls. A row of brown reclining chairs lines a wall, intended for patients who aren’t sick enough for a stretcher but are too sick to stay in the main waiting room.

Forget privacy, Alejos Perrientoz learned when he arrived. He came to the ER because his arm had been tingling and painful for over a week. He couldn’t hold a cup of coffee. A nurse gave him a full physical exam in a brown recliner, which made him self-conscious about having his shirt lifted in front of strangers. “I felt a little uncomfortable,” he whispered. “But I have no choice, you know? I’m in the hallway. There’s no rooms.

“We could have done the physical in the parking lot,” he added, managing a laugh.

Even patients who arrive by ambulance are not guaranteed a room: One nurse runs triage, screening those who absolutely need a bed, and those who can be put in the waiting area.

“I hate that we even have to make that determination,” Dusang said. Lately, staff members have been pulling out some patients already in the ER’s rooms when others arrive who are more critically ill. “No one likes to take someone out of the privacy of their room and say, ‘We’re going to put you in a hallway because we need to get care to someone else.'”

ER Patients Have Grown Sicker

“We are hearing from members in every part of the country,” said Dr. Lisa Moreno, president of the American Academy of Emergency Medicine. “The Midwest, the South, the Northeast, the West … they are seeing this exact same phenomenon.”

Although the number of ER visits returned to pre-covid levels this summer, admission rates, from the ER to the hospital’s inpatient floors, are still almost 20% higher. That’s according to the most recent analysis by the Epic Health Research Network, which pulls data from more than 120 million patients across the country.

“It’s an early indicator that what’s happening in the ED is that we’re seeing more acute cases than we were pre-pandemic,” said Caleb Cox, a data scientist at Epic.

Less acute cases, such as people with health issues like rashes or conjunctivitis, still aren’t going to the ER as much as they used to. Instead, they may be opting for an urgent care center or their primary care doctor, Cox explained. Meanwhile, there has been an increase in people coming to the ER with more serious conditions, like strokes and heart attacks.

So, even though the total number of patients coming to ERs is about the same as before the pandemic, “that’s absolutely going to feel like [if I’m an ER doctor or nurse] I’m seeing more patients and I’m seeing more acute patients,” Cox said.

Moreno, the AAEM president, works at an emergency department in New Orleans. She said the level of illness, and the inability to admit patients quickly and move them to beds upstairs, has created a level of chaos she described as “not even humane.”

At the beginning of a recent shift, she heard a patient crying nearby and went to investigate. It was a paraplegic man who’d recently had surgery for colon cancer. His large post-operative wound was sealed with a device called a wound vac, which pulls fluid from the wound into a drainage tube attached to a portable vacuum pump.

But the wound vac had malfunctioned, which is why he had come to the ER. Staffers were so busy, however, that by the time Moreno came in, the fluid from his wound was leaking everywhere.

“When I went in, the bed was covered,” she recalled. “I mean, he was lying in a puddle of secretions from this wound. And he was crying, because he said to me, ‘I’m paralyzed. I can’t move to get away from all these secretions, and I know I’m going to end up getting an infection. I know I’m going to end up getting an ulcer. I’ve been laying in this for, like, eight or nine hours.'”

The nurse in charge of his care told Moreno she simply hadn’t had time to help this patient yet. “She said, ‘I’ve had so many patients to take care of, and so many critical patients. I started [an IV] drip on this person. This person is on a cardiac monitor. I just didn’t have time to get in there.'”

“This is not humane care,” Moreno said. “This is horrible care.”

But it’s what can happen when emergency department staffers don’t have the resources they need to deal with the onslaught of competing demands.

“All the nurses and doctors had the highest level of intent to do the right thing for the person,” Moreno said. “But because of the high acuity of … a large number of patients, the staffing ratio of nurse to patient, even the staffing ratio of doctor to patient, this guy did not get the care that he deserved to get, just as a human being.”

The instance of unintended neglect that Moreno saw is extreme, and not the experience of most patients who arrive at ERs these days. But the problem is not new: Even before the pandemic, ER overcrowding had been a “widespread problem and a source of patient harm, according to a recent commentary in the New England Journal of Medicine.

“ED crowding is not an issue of inconvenience,” the authors wrote. “There is incontrovertible evidence that ED crowding leads to significant patient harm, including morbidity and mortality related to consequential delays of treatment for both high- and low-acuity patients.”

And already-overwhelmed staffers are burning out.

Burnout Feeds Staffing Shortages, and Vice Versa

Every morning, Tiffani Dusang wakes up and checks her Sparrow email with one singular hope: that she will not see yet another nurse resignation letter in her inbox.

“I cannot tell you how many of them [the nurses] tell me they went home crying” after their shifts, she said.

Despite Dusang’s best efforts to support her staffers, they’re leaving too fast to be replaced, either to take higher-paying gigs as a travel nurse, to try a less-stressful type of nursing, or simply walking away from the profession entirely.

Kelly Spitz has been an emergency department nurse at Sparrow for 10 years. But, lately, she has also fantasized about leaving. “It has crossed my mind several times,” she said, and yet she continues to come back. “Because I have a team here. And I love what I do.” But then she started to cry. The issue is not the hard work, or even the stress. She struggles with not being able to give her patients the kind of care and attention she wants to give them, and that they need and deserve, she said.

She often thinks about a patient whose test results revealed terminal cancer, she said. Spitz spent all day working the phones, hustling case managers, trying to get hospice care set up in the man’s home. He was going to die, and she just didn’t want him to have to die in the hospital, where only one visitor was allowed. She wanted to get him home, and back with his family.

Finally, after many hours, they found an ambulance to take him home.

Three days later, the man’s family members called Spitz: He had died surrounded by family. They were calling to thank her.

“I felt like I did my job there, because I got him home,” she said. But that’s a rare feeling these days. “I just hope it gets better. I hope it gets better soon.”

Around 4 p.m. at Sparrow Hospital as one shift approached its end, Dusang faced a new crisis: The overnight shift was more short-staffed than usual.

“Can we get two inpatient nurses?” she asked, hoping to borrow two nurses from one of the hospital floors upstairs.

“Already tried,” replied nurse Troy Latunski.

Without more staff, it’s going to be hard to care for new patients who come in overnight — from car crashes to seizures or other emergencies.

But Latunski had a plan: He would go home, snatch a few hours of sleep and return at 11 p.m. to work the overnight shift in the ER’s overflow unit. That meant he would be largely caring for eight patients, alone. On just a few short hours of sleep. But lately that seemed to be their only, and best, option.

Dusang considered for a moment, took a deep breath and nodded. “OK,” she said.

“Go home. Get some sleep. Thank you,” she added, shooting Latunski a grateful smile. And then she pivoted, because another nurse was approaching with an urgent question. On to the next crisis.

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

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Medicare Punishes 2,499 Hospitals for High Readmissions

The federal government’s effort to penalize hospitals for excessive patient readmissions is ending its first decade with Medicare cutting payments to nearly half the nation’s hospitals.

In its 10th annual round of penalties, Medicare is reducing its payments to 2,499 hospitals, or 47% of all facilities. The average penalty is a 0.64% reduction in payment for each Medicare patient stay from the start of this month through September 2022. The fines can be heavy, averaging $217,000 for a hospital in 2018, according to Congress’ Medicare Payment Advisory Commission, or MedPAC. Medicare estimates the penalties over the next fiscal year will save the government $521 million. Thirty-nine hospitals received the maximum 3% reduction, and 547 hospitals had so few returning patients that they escaped any penalty.

An additional 2,216 hospitals are exempt from the program because they specialize in children, psychiatric patients or veterans. Rehabilitation and long-term care hospitals are also excluded from the program, as are critical access hospitals, which are treated differently because they are the only inpatient facility in an area. Of the 3,046 hospitals for which Medicare evaluated readmission rates, 82% received some penalty, nearly the same share as were punished last year.

The Hospital Readmissions Reduction Program (HRRP) was created by the 2010 Affordable Care Act and began in October 2012 as an effort to make hospitals pay more attention to patients after they leave. Readmissions occurred with regularity — for instance, nearly a quarter of Medicare heart failure patients ended up back in the hospital within 30 days in 2008 — and policymakers wanted to counteract the financial incentives hospitals had in getting more business from these boomerang visits.

MedPAC has found readmission rates declined from 2008 to 2017 after the overall health conditions of patients were taken into account. Heart failure patient readmission rates dropped from 24.8% to 20.5%, heart attack patient rates dropped from 19.7% to 15.5%, and pneumonia patient rates decreased from 20% to 15.8%, according to the most recent MedPAC analysis. Readmission rates for chronic obstructive pulmonary disease, hip and knee replacements, and conditions that are not tracked and penalized in the penalty program also decreased.

“The HRRP has been successful in reducing readmissions, without causing an adverse effect on beneficiary mortality,” MedPAC wrote. The commission added that untangling the exact causes of the readmission rates was complicated by changes in how hospitals recorded patient characteristics in billing Medicare and an increase in patients being treated in outpatient settings. Those factors made it difficult to determine the magnitude of the readmission rate drop due to the penalty program, MedPAC said.

The current penalties are calculated by tracking Medicare patients who were discharged between July 1, 2017, and Dec. 1, 2019. Typically, the penalties are based on three years of patients, but the Centers for Medicare & Medicaid Services excluded the final six months in the period because of the chaos caused by the pandemic as hospitals scrambled to handle an influx of covid-19 patients.

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Look Up Your Hospital: Is It Being Penalized By Medicare?

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year.

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How Billing Turns a Routine Birth Into a High-Cost Emergency

Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn’t prepare her for the resources the conservation biologist would owe after the birth of her second son.

Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colorado, because it was the only entrance open.

Despite the weird covid vibe — the emptiness, the quiet — everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse offering to wheel her to the labor and delivery department. She even took a selfie, smiling, as she entered the delivery room.

“I was just thrilled that he was here and it was on his due date, so we didn’t have to have an induction,” she said. “I was doing great.”

Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.

Wells Salerno expected the bill for Gus’ birth to be heftier than that for her first child, Hank, which had cost the family a mere $30. She was a postdoctoral fellow in California with top-notch insurance when Hank was born, about four years earlier. They were braced to pay more for Gus, but how much more?

Then the bill came.

The Patient: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.

Medical Service: A routine vaginal delivery of a full-term infant.

Total Bill: $16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.

Service Provider: Poudre Valley Hospital in Fort Collins, Colorado, operated by UCHealth, a nonprofit health system.

What Gives: In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.

The total bill was huge, but what really made Wells Salerno’s eyes pop was a line for the highest level of emergency services. It didn’t make any sense. Was it for checking in at the ER desk, as she’d been instructed to? She recalls going through security there on her way to labor and delivery, yet there was a $2,755 charge for “Level 5” emergency department services — as if she had received care there like a patient with a heart attack or fresh from a car wreck. It is the biggest item on the bill other than the delivery itself.

Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California-San Francisco and a practicing ER doctor, said Level 5 charges are supposed to be reserved for serious cases — “a severe threat to life, or very complicated, resource-intense cases” — not for patients who can walk through a hospital on their own. Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required.

But over the past 20 years, hospitals and doctors have learned there’s great profit in upcoding visits. After all, the insurer isn’t in the exam room to know what transpired. An investigation by the Center for Public Integrity found that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent homefrom the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5 steadily grew from 23% to 34% for patients with commercial insurance.

After repeated calls questioning the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with KHN, explaining that “the emergency room charge is actually the OB triage little area before they take you to the labor and delivery room.”

A customer service representative later explained it was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken — although none of that was performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately — and are routine, not emergency, procedures.

Some hospitals provide that package of services via an “obstetrical emergency department.” OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they aren’t physically located anywhere near the ER.

Health care staffing company TeamHealth — owned by the investment company Blackstone, and known for marking up ER bills to boost profit — essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In a white paper, the company said an OB-ED is an “entrepreneurial approach to strengthening hospital finances” because with “little to no structural investment” it allows hospitals to “collect facility charges that are otherwise lost in the obstetrical triage setting.”

The OB Hospitalist Group, which is owned by a private equity company, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitals “leave a lot of money on the table” by billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.

An Arizona facility said its revenue increased $365,000 per quarter after turning their obstetric triage area into an OB-ED. Poudre Valley Hospital’s website doesn’t list “OB-ED” as part of the facility’s offerings, though UCHealth documents do reference OB-ED beds in other facilities.

KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other area moms after getting a whopping charge — for the 10 minutes she spent in the triage room, while fully dilated and in active labor.

In Wells Salerno’s case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. “Being seen there in OB-ED did not impact this bill whatsoever,” said Dan Weaver, a spokesperson with UCHealth.

But in one of the other moms’ cases, it did: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.

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Pharma Campaign Cash Delivered to Key Lawmakers With Surgical Precision

The Biden administration and Congress are embroiled in high-stakes haggling over what urgent priorities will make it into the ever-shrinking social spending bill. But for the pharmaceutical industry there is one agenda: Heading off Medicare drug price negotiation, which it considers an existential threat to its business model.

The siren call to contain rising drug costs helped catapult Democrats to power, and the idea is popular among voters regardless of their politics. Yet granting Medicare broad authority to intervene in setting prices has nonetheless divided the party.

And so, as it normally does, the drug industry gave generously to members of Congress, according to new data from KHN’s Pharma Cash to Congress database. Contributions covering the first half of this year show that some of its biggest donations were delivered with surgical-strike precision to sympathetic or moderate Democratic lawmakers the industry needs to remain in its corner.

Campaign donations to members of Congress — which must be reported to the Federal Election Commission — are the tip of the iceberg, signaling far greater activity in influence peddling that includes spending millions on lobbying activities and advertising campaigns.

Unusually, in the first half of this year Republicans and Democrats in Congress were virtually neck and neck in pulling in drug industry money, according to a KHN analysis of campaign contributions. In prior years, Republicans dominated giving from that sector, often by huge margins.

Pharmaceutical companies and their lobbying groups gave roughly $1.6 million to lawmakers during the first six months of 2021, with Republicans accepting $785,000 and Democrats $776,200, the Pharma Cash to Congress database shows. Since the 2008 cycle, the industry has generally favored Republicans. The exception was 2009-10, the last time Democrats controlled both chambers of Congress and the White House.

Democrats again narrowly hold both the House and Senate, and political scientists and other money-in-politics experts said the contributions likely reflect who is in power, which lawmakers face tougher reelection bids next year, and who has outsize sway over legislation affecting the industry’s bottom line.

Several pharmaceutical companies paused contributions to Republican lawmakers who voted against certifying the results of the 2020 election, blunting the GOP’s total fundraising haul and overall industry giving compared with other years.

The drug industry’s campaign contributions are markedly strategic, said Steven Billet, an associate professor at the Graduate School of Political Management at George Washington University.

“This is a really well-organized commercial sector,” Billet said. “If I’m one of these PACs, I’ve surveyed the landscape at the front end of the process, decided on our agenda and budget, and figured out who I may be able to get to and who I wouldn’t be able to get to.”

Of the top 10 recipients of funding, Republican lawmakers accounted for six; Democrats, four. Rep. Scott Peters (D-Calif.) received the most money of any member of Congress, with $63,900 in contributions in the first half of the year. Peters, whose San Diego-area district includes multiple drug companies, has consistently accepted money from drugmakers since he took office in 2013, according to KHN’s database. Right behind Peters was Rep. Cathy McMorris Rodgers (R-Wash.), who received $50,000 from the industry in the first six months of 2021. McMorris Rodgers was chosen this year to be the most senior Republican on the House Energy and Commerce Committee, which has significant influence on pharmaceutical issues. Peters sits on the same committee.

“They’re typically going to saturate the committees that are relevant to their industry,” said Nick Penniman, CEO of Issue One, a nonprofit that advocates reforming money’s influence in politics.

Next in line was Sen. Robert Menendez (D-N.J.), who accepted $49,300, the most of any senator this year despite not facing reelection until 2024. The vote of Menendez, a longtime ally of the industry, would be crucial for Democrats to pass any proposal giving the government greater control over drug prices. The pharmaceutical industry is a major employer in New Jersey, home to headquarters of behemoths like Johnson & Johnson, Merck, Novo Nordisk and Sanofi.

Menendez said he’s waiting to see the proposal, “which I expect will include language to allow Medicare to negotiate drug prices.”

“The focus of any proposal must be lowering patient costs,” he said, “and that will drive my analysis.”

Among other moderate Democrats is Sen. Kyrsten Sinema (D-Ariz.), whose vote also is critical to passage. She received $108,500 in pharma contributions in 2019-20, according to the KHN database. However, in the first half of this year, she received only $8,000. She has not said publicly where she stands on the current pricing proposal.

As Billet sees it, the pharmaceutical industry knew allowing Medicare to negotiate drug prices would likely be on the table, and drug companies shored up members, such as Peters and Menendez, who have sided with them in the past. Plus, “right now, the Democrats are driving the train, and because of that they’re going to get a few more contributions,” Billet added.

Peters received funds from nearly two dozen companies or industry groups, including Eli Lilly, Takeda Pharmaceutical, Pfizer, Merck, GlaxoSmithKline, EMD Serono and Amgen. Menendez’s donors included Boehringer Ingelheim, Sanofi, Pfizer, Merck, Gilead Sciences, Eli Lilly, Teva and Novo Nordisk. A spokesperson for Peters did not respond to request for comment.

Controlling drug prices has broad support among adults regardless of political party, according to polling from KFF (KHN is an editorially independent program of KFF). But facing industry opposition, Democrats have yet to agree on a plan as lawmakers weigh which policies make it into a massive domestic spending bill to expand the social safety net and address climate change. Central to the industry’s argument is that greater government intervention in setting prices would harm new drug development; however, drug pricing experts generally say this argument is overblown. Republicans remain unanimously opposed, which means Senate Democrats can’t afford any defections to advance legislation.

Fourth in industry contributions was Sen. Catherine Cortez Masto (D-Nev.), a freshman lawmaker on the powerful Senate Finance Committee, which oversees legislation pertaining to federal health programs like Medicare. Cortez Masto received $46,000, with cash flowing in from companies like Eli Lilly, Merck, Pfizer, Johnson & Johnson and Mallinckrodt Pharmaceuticals, the latter of which filed for bankruptcy in 2020 after being swamped with litigation over its alleged role in the opioid crisis. One of her recent aides, Eben DuRoss, was hired as a lobbyist this year by the Pharmaceutical Research and Manufacturers of America, or PhRMA, federal disclosures show.

Cortez Masto is up for reelection next year in a battleground state that’s been competitive between Republicans and Democrats in recent elections. She was narrowly elected in 2016, and recent polling showed she held a small lead against her expected Republican challenger in 2022, former Nevada attorney general Adam Laxalt.

But her contributions dwarf those of other Senate Democrats in close races. For example, in the first half of this year, Sen. Maggie Hassan (D-N.H.), who also sits on the Senate Finance Committee, reported having accepted $6,000.

Two other lawmakers in competitive seats, Sen. Raphael Warnock (D-Ga.) and Sen. Mark Kelly (D-Ariz.), didn’t receive funding from the pharmaceutical sector.

Sarah Bryner, research director of OpenSecrets, a nonprofit that tracks money in politics, noted several reasons Cortez Masto would pull in more money. In addition to her committee seat and competitive race, politically she’s more moderate than progressive lawmakers who have been bigger agitators against the drug industry.

“She’s not seen as an extremist, which is the kind of person who would typically take in more money” from political action committees, Bryner said.

Cortez Masto was also a recent past chair of the Democratic Senatorial Campaign Committee and therefore heavily involved in the party’s national fundraising efforts to preserve Democrats’ Senate majority. Those relationships with corporate and other donors could be leveraged for her own race, Bryner said. “Once you’ve made all the relationships, it’s not like they just disappear,” she said.

Still, the freshman Democrat has openly supported allowing Medicare to negotiate prescription drug prices, in contrast to Menendez, who voted against the idea in 2019. The Nevada senator recently told KHN that she “absolutely” backs the policy and that the pharma cash flowing into her campaign coffers doesn’t influence her decisions.

“I’ve already supported it in Finance and actually voted to pass legislation to do just that,” Cortez Masto said. “We need to reduce the health care costs for so many in this country, and that’s what I’m focused on doing, including reducing prescription drug costs.”

Peters — who unseated a Republican in 2012 — was one of four moderate House Democrats who in September voted against a plan to give Medicare broad authority to negotiate prescription drug prices. They backed a narrower alternative that includes caps on out-of-pocket spending and limits the scope of Medicare’s negotiating authority to a smaller set of medications.

The money Peters and McMorris Rodgers got from drugmakers ($63,900 and $50,000, respectively) significantly jumped from the same periods in past cycles. In the first half of 2019, Peters received $19,500, and during those same quarters in 2017 he got $36,000. McMorris Rodgers’ haul for the first six months of 2019 was $2,500, and two years earlier it was $3,000. However, Menendez received more funding in the first half of 2019 ($52,000) than this year.

That some drugmakers — including Pfizer, Johnson & Johnson, Gilead and Eli Lilly — as well as PhRMA and the Biotechnology Innovation Organization, another lobbying group for the industry, paused contributions to Republicans after the events of Jan. 6 seems at least in part to account for overall pharma contributions dropping in comparison with other years. In the first half of 2019 drugmakers gave $3.7 million, and in the first half of 2017 they gave about $4.4 million, versus 2021’s $1.6 million.

However, other drug company PACs and their industry groups kept up contributions or failed to void checks they’d issued to those who refused to certify the election results, according to a KHN analysis of the FEC data.

They include Merck, Novo Nordisk, GlaxoSmithKline, AstraZeneca, Genentech, Boehringer Ingelheim, Amgen, Teva, EMD Serono and the Association for Accessible Medicines, which all gave $1,000 or more to at least one of the 147 Republicans who voted to overturn the election results.

Direct contributions to lawmakers’ political accounts are only one way for the industry to channel cash to Congress. Companies also give money to trade associations and 501(C)(4)s, which are nonprofits that often function as “dark money” groups because they are not required to disclose their donors.

“We know that they’re giving; they didn’t stop giving. Their giving went underground,” said Carlos Holguin, research director for the Center for Political Accountability, a nonprofit that tracks money in politics.

Groups also funnel money into advertising — in September, PhRMA announced a seven-figure ad campaign opposing Democrats’ drug pricing plan — or into advocacy groups from which it may eventually trickle down to political candidates.

Another factor? Hail Mary covid-19 vaccines, developed and distributed in record time, that may have shored up goodwill with lawmakers. Or that, despite everything lawmakers have said about lowering drug costs, the industry suspects drug pricing legislation will stall once again and don’t want to spend their political capital on the issue.

“I think, frankly, drugmakers know they’ve won the match when it comes to drug pricing. This whole question of the cost of pharmaceuticals, it has come up for literally decades now and they have successfully shut it down, year after year,” Penniman said. “At a certain point, they know they have driven the nail far enough in the wood and they don’t need to do much more.”

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Pharma Cash to Congress

Every year, pharmaceutical companies contribute millions of dollars to U.S. senators and representatives as part of a multipronged effort to influence health care lawmaking and spending priorities. Use this tool to explore the sizable role drugmakers play in the campaign finance system, where many industries seek to influence Congress. Discover which lawmakers rake in the most money (or the least) and which pharma companies are the biggest contributors. Or use our search tool to look up members of Congress by name or home state, as well as dozens of drugmakers that KHN tracks.

Methodology

UPDATE: KHN has removed contributions from Abbott Laboratories after 2013, when the company spun off its pharmaceutical business as Abbvie Inc. Abbott Laboratories is a medical device and health care company.

Kaiser Health News uses campaign finance reports from the Federal Election Commission (FEC) to track donations from political action committees (PACs) registered with the FEC by pharmaceutical companies. Totals include donations to the principal campaign committees and leadership PACs for current members of Congress. We include only donations to members for election cycles in which they hold office (even if they weren’t in office for the full cycle, in the case of special elections). Donations are assigned to the quarter in which they were given, regardless of when they are reported by the receiving committee or PAC. Exact amounts can change as amendments and refunds are reported; KHN will update the analysis quarterly. Occasionally, refunds are reported in a different cycle from the original contribution, resulting in a negative total for the cycle.

There is a legal limit to how much each PAC can give to a member of the Senate or House of Representatives: $5,000 per election (including primaries and general elections) and per committee, or $10,000 per cycle. Each cycle is two calendar years, e.g. Jan. 1, 2017-Dec. 31, 2018.

When calculating changes in contributions from one cycle to another, we compare the latest quarter in the current cycle to the same point in the previous cycle for all drugmakers and for members of the House, who run for re-election every two years. For senators, who run for re-election every six years, we compare the current cycle to the cycle six years prior. We use the ProPublica Congress API to gather some information about past and present members. We use both Open Secrets and CQ Political Moneyline to collect additional information about PACs and verify our work.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

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Direct Primary Care, With a Touch of Robin Hood

MODESTO, Calif. — Britta Foster and Minerva Tiznado are in different leagues as far as health care is concerned.

Foster, who married into the family that owns the $2.5 billion Foster Farms chicken company, has Blue Shield coverage as well as a high-octane primary care plan that gives her 24/7 digital access to her doctor for a $5,900 annual fee that also covers her husband and two of their children.

Tiznado is from Nayarit, Mexico, and has no insurance. She gets free primary care visits and steep discounts on prescription drugs, lab tests and imaging.

But Tiznado, 32, and Foster, 48, go to the same place for their care: St. Luke’s Family Practice, in this Central Valley city of about 217,000. St. Luke’s, a clinic with a staff of four in a nondescript shopping center, offers an unorthodox combination of concierge-style medicine for the well-off and charity care for the uninsured.

The annual fees that St. Luke’s collects from Foster’s family and some 550 other paying patients help cover free care for a somewhat larger number of uninsured patients, many of them, like Tiznado, Spanish-speaking immigrants who can’t get Medicaid because they lack documents.

The clinic does not accept insurance of any kind but requires its paying patients to have coverage for major medical expenses outside its scope of care.

The paying patients, whom St. Luke’s calls “benefactors,” say they are happy to participate in this “Robin Hood” model. It gives them highly personalized care with great access to their doctors and the emotional satisfaction of supporting those less privileged, the “recipients.”

Foster said it’s been a “huge, huge benefit” for her family to be able to text or call their doctor at any time and be seen on short notice: “Knowing that their group is here also to serve our community makes it all feel even more important.”

Tiznado, who visited the clinic one September morning for a scheduled monitoring of ovarian cysts, said St Luke’s “has helped us a lot — economically and in every way. I think if we moved somewhere else, I would continue coming here.”

But Tiznado and the other uninsured patients don’t get the same 24/7 access that benefactors do. The two groups used separate waiting rooms until the pandemic hit.

St. Luke’s is a local response to systemic U.S. health care problems including physician burnout, patient dissatisfaction and the fact that millions still lack care. Nearly 3.2 million Californians, including 1.3 million undocumented people, will be uninsured in 2022, although the state is gradually expanding Medicaid coverage to many immigrants. St. Luke’s is part of the movement for direct primary care, an alternative for doctors fleeing insurance-dominated medical groups.

Roughly 200 direct primary care practices start up each year in the United States, and there are currently 1,581 of them employing an estimated 3,000 doctors, according to Dr. Philip Eskew, founder of DPC Frontier, which provides resources for doctors who want to make the switch. That’s a tiny fraction of the nearly 209,000 primary care doctors in the U.S.

“We are indeed a small movement at this time,” Eskew said.

Their biggest challenges are regulatory. If the clinics take fees from people enrolled in Medicare, for example, their doctors must forgo Medicare reimbursement anywhere they practice. And some state regulators may consider direct primary care practices to be health plans and impose terms or restrictions that make it difficult or impossible for them to operate.

Doctors in direct primary care typically charge patients a monthly or annual fee in exchange for enhanced access via phone, text or video, shorter wait times and longer face-to-face visits. And they generally don’t accept insurance, thus eliminating the need to chase bills and treatment authorizations.

“In my old practice, we spent almost half our time collecting payments. I thought if we could just get rid of all that overhead, we could spend more time with patients — and it proved true,” said Dr. Bob Forester, the conceptual father and co-founder of St. Luke’s, who retired earlier this year.

Many direct primary care docs scoff at the high-tech investor-owned firms such as One Medical and Forward Health. They are widely viewed as direct primary care companies, but critics say they are more focused on expanding volume than on offering personalized service.

“Direct primary care is where a physician has a relationship with a patient. We do not have to be accountable to an investor, because our investors are our patients,” said Dr. Maryal Concepcion, a family doctor in the remote mountain town of Arnold, California, who recently left a commercial practice to launch her own one-woman direct primary care practice.

St. Luke’s paid patients must have insurance to cover hospitalization, surgeries, specialty care, imaging and prescription drugs.

The clinic is often able to find steep discounts for its uninsured patients. For example, Quest Diagnostics charges them only 10% to 15% of its regular price for lab work, said Dr. R.J. Heck, one of the two family physicians at St. Luke’s and co-founder of the clinic. It often refers uninsured patients who need operations to Cirugía sin Fronteras, a reduced-rate surgery center in Bakersfield.

St. Luke’s recently got a $75,000 grant for imaging, lab tests, X-rays and some prescription drugs from the Legacy Health Endowment, a local foundation. And it works with several radiology groups that provide discounts, Heck said.

Tiznado, who needs periodic ultrasounds for her ovarian cysts, said she pays around $150 for them. “If I did it in another place, it would cost between $900 and $1,200,” she said.

St. Luke’s nonprofit tax-exempt status encourages donations, including from local corporate benefactors such as Foster Farms and winemaker E. & J. Gallo. Some workers at donor companies are among St. Luke’s uninsured patients.

Tax-exempt status also confers a benefit on paying patients: They can take a tax deduction on the portion of their annual fees they don’t use for medical care. Every year, St. Luke’s sends them a statement that puts a dollar value, based on Medicare prices, on the services they received.

Forester said St. Luke’s arose from his concern for the uninsured and his disdain for bureaucratic systems. But “the bottom line,” he said, “is that the idea for St. Luke’s came in an inspired moment of prayer.” He and Heck launched it over 17 years ago as a Catholic-inspired medical office.

However, while Catholic symbols adorn the walls of St. Luke’s, many of its patients are not Christian, and Catholic medical doctrine is not central to its practice.

“There’s nobody coming in here and looking or telling us what we should or shouldn’t do,” said Dr. Erin Kiesel, the clinic’s other family doctor.

Kiesel said she wouldn’t prescribe an abortion, but she would tell somebody where to go if they asked — which nobody has.

Heck and Kiesel took big pay cuts to come to St. Luke’s. Kiesel makes about $60,000 less a year than in her previous practice. Having more time with patients, less paperwork and better work-life balance more than offsets the lower pay, she said.

Patients cited the personal relationships they’ve built with their St. Luke’s providers.

Paul Neumann, a patient of Heck’s for 25 years who followed him to St. Luke’s, said that relationship has been a godsend.

He told of returning from a trip to Rome in 2009 with a case of walking pneumonia. When his wife called Heck the next morning, he came to the house immediately.

Neumann, 84, pays St. Luke’s well north of $10,000 a year for himself, his wife and his son’s family.

“I’d be happy to write a check twice as large,” he said.

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

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Analysis: A Procedure That Cost $1,775 in New York Was $350 in Maryland. Here’s Why.

For the past 18 months, while I was undergoing intensive physical therapy and many neurological tests after a complicated head injury, my friends would point to a silver lining: “Now you’ll be able to write about your own bills.” After all, I’d spent the past decade as a journalist covering the often-bankrupting cost of U.S. medical care.

But my bills were, in fact, mostly totally reasonable.

That’s largely because I live in Washington, D.C., and received the majority of my care in next-door Maryland, the one state in the nation that controls what hospitals can charge for services and has a cap on spending growth.

Players in the health care world — from hospitals to pharmaceutical manufacturers to doctors’ groups — act as if the sky would fall if health care prices were regulated or spending capped. Instead, health care prices are determined by a dysfunctional market in which providers charge whatever they want and insurers or middlemen like pharmacy benefit managers negotiate them down to slightly less stratospheric levels.

But for decades, an independent state commission of health care experts in Maryland, appointed by the governor, has effectively told hospitals what each of them may charge, with a bit of leeway, requiring every insurer to reimburse a hospital at the same rate for a medical intervention in a system called “all-payer rate setting.” In 2014, Maryland also instituted a global cap and budget for each hospital in the state. Rather than being paid per test and procedure, hospitals would get a set amount of money for the entire year for patient care. The per capita hospital cost could rise only a small amount annually, forcing price increases to be circumspect.

If the care in the Baltimore-based Johns Hopkins Medicine system ensured my recovery, Maryland’s financial guardrails for hospitals effectively protected my wallet.

During my months of treatment, I got a second opinion at a similarly prestigious hospital in New York, giving me the opportunity to see how medical centers without such financial constraints bill for similar kinds of services.

Visits at Johns Hopkins with a top neurologist were billed at $350 to $400, which was reasonable, and arguably a bargain. In New York, the same type of appointment was $1,775. My first spinal tap, at Johns Hopkins, was done in an exam room by a neurology fellow and billed as an office visit. The second hospital had spinal taps done in a procedure suite under ultrasound guidance by neuroradiologists. It was billed as “surgery,” for a price of $6,244.38. The physician charge was $3,782.

I got terrific care at both hospitals, and the doctors who provided my care did not set these prices. All the charges were reduced after insurance negotiations, and I generally owed very little. But since the price charged is often the starting point, hospitals that charge a lot get a lot, adding to America’s sky-high health care costs and our rising insurance premiums to cover them.

It wasn’t easy for Maryland to enact its unique health care system. The state imposed rate setting in the mid-1970s because hospital charges per patient were rising fast, and the system was in financial trouble. Hospitals supported the deal — which required a federal waiver to experiment with the new system — because even though the hospitals could no longer bill high rates for patients with commercial insurance, the state guaranteed they would get a reasonable, consistent rate for all their services, regardless of insurer.

The rate was more generous than Medicare’s usual payment, which (in theory at least) is calculated to allow hospitals to deliver high-quality care. The hospitals also got funds for teaching doctors in training and taking care of the uninsured — services that could previously go uncompensated.

In subsequent decades, however, hospitals did end runs around price controls by simply ordering more hospital visits and tests. Spending was growing. Maryland risked losing the federal waiver that had long underpinned its system. Also, under the waiver’s terms, Maryland’s hospitals were at risk for paying a hefty penalty to the federal government for the excessive growth in cost per patient.

That’s why in 2014 the state worked with the federal Centers for Medicare & Medicaid Services to institute the global cap and budget system in place today. Dr. Joshua Sharfstein, who was the state’s health and mental hygiene secretary, met skeptical hospital administrators to “sell the concept,” as he described it, assuring them the hospitals would still get reasonable revenue while gaining new opportunities to improve the health of their communities with money to invest in preventive services.

Studies show the program, which was further revised in 2019, generally worked at keeping costs down and generated savings of $365 million for Medicare in 2019 and over $1 billion in the prior four years. What’s more, working with a fixed budget has provided incentives for hospitals to keep patients out, resulting in programs like better outpatient efforts to manage chronic illnesses and putting doctors in senior housing to keep residents out of hospitals through on-site care.

Instituting this type of plan may be politically unacceptable statewide in other places today, given the much greater power now of hospital trade groups and large consolidated hospital networks. “Where hospitals are making money hand over fist, it’s a hard sell to switch,” Sharfstein said. “But where hospitals are facing economic pressure, there is much more openness to financial stability and the opportunity to promote community health.”

Sharfstein thinks the Maryland approach can be especially attractive for financially strapped rural and urban hospitals that treat mostly people on Medicaid and the uninsured.

Though Maryland is an oddity in the United States (the few other states that tried price controls in the 1970s abandoned the experiment long ago), many countries successfully use price guidelines and budget limits to control medical spending. Notable among them is Germany, whose health system is otherwise similar to the United States’, with multiple insurers. A landmark 1994 study comparing efforts here and abroad did find that the German system, for example, can be stingier at providing care that is expensive or elective.

But, referring in part to that issue, the study’s author concluded that costs are so high in the United States that the country “could probably lower our expenditures and see none of the problems that we found in our study for a number of years.”

Data also shows that operating margins, a measure of profit, are generally slimmer in Maryland than those of big health systems in the rest of the country. Johns Hopkins’ margin was 1.2% in fiscal year 2019, compared with 6.9% at the Mayo Clinic in Minnesota and 5.8% at the University of Pennsylvania Health System; Stanford Health Care’s was 7.1%.

But those margins can also reflect how much of its income a hospital chooses to spend on things like amenities and executive pay. Living with financial constraints may be at least partly why Johns Hopkins Hospital’s main entrance is pleasant but functional, lacking the elegant art-filled marble lobbies I often encounter at its peer hospitals.

My experience demonstrates that excellent care can be delivered to patients by a system that works within financial limits. And that’s something America needs.

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In Maine, Vaccine Mandate for EMTs Stresses Small-Town Ambulance Crews

On a recent morning, Jerrad Dinsmore and Kevin LeCaptain of Waldoboro EMS in rural Maine drove their ambulance to a secluded house near the ocean, to measure the clotting levels of a woman in her 90s.

They told the woman, bundled under blankets to keep warm, they would contact her doctor with the result.

“Is there anything else we can do?” Dinsmore asked.

“No,” she said. “I’m all set.”

This wellness check, which took about 10 minutes, is one of the duties Dinsmore and LeCaptain perform in addition to the emergency calls they respond to as staffers with Waldoboro Emergency Medical Service.

EMS crews have been busier than ever this year, as people who delayed getting care during the covid-19 pandemic have grown progressively sicker.

But there’s limited workforce to meet the demand. Both nationally and in Maine, staffing issues have plagued the EMS system for years. It’s intense work that takes a lot of training and offers low pay. The requirement in Maine and elsewhere that paramedics and emergency medical technicians be vaccinated against covid is another stress on the workforce.

Dinsmore and LeCaptain spend more than 20 hours a week working for Waldoboro on top of their full-time EMS jobs in other towns. It’s common in Maine for EMS staffers to work for multiple departments, because most EMS crews need the help — and Waldoboro may soon need even more of it.

The department has already lost one EMS worker who quit because of Maine’s covid vaccine mandate for health care workers, and may lose two more.

The stress of filling those vacancies keeps Town Manager Julie Keizer awake at night.

“So, we’re a 24-hour service,” Keizer said. “If I lose three people who were putting in 40 hours or over, that’s 120 hours I can’t cover. In Lincoln County, we already have a stressed system.”

The labor shortage almost forced Waldoboro to shut down ambulance service for a recent weekend. Keizer said she supports vaccination but believes Maine’s decision to mandate it threatens the ability of some EMS departments to function.

Maine is one of 10 states that require health care workers to get vaccinated against covid or risk losing their jobs. Along with Oregon, Washington and Washington, D.C., it also explicitly includes the EMTs and paramedics who respond to 911 calls in that mandate. Some ambulance crews say it’s making an ongoing staffing crisis even worse.

Two hundred miles north of Waldoboro, on the border with Canada, is Fort Fairfield, a town of 3,200. Deputy Fire Chief Cody Fenderson explained that two workers got vaccinated after the mandate was issued in mid-August, but eight quit.

“That was extremely frustrating,” Fenderson said.

Now Fort Fairfield has only five full-time staffers available to fill 10 slots. Its roster of per-diem workers all have full-time jobs elsewhere, many with other EMS departments that are also facing shortages.

“You know, anybody who does ambulances is suffering,” said Fenderson. “It’s tough. I’m not sure what we’re going to do, and I don’t know what the answer is.”

In Maine’s largest city, Portland, the municipal first-responder workforce is around 200 people, and eight are expected to quit because of the vaccine mandate, according to the union president for firefighters, Chris Thomson.

That may not seem like a significant loss, but Thomson said those are full-time positions and those vacancies will have to be covered by other employees who are already exhausted by the pandemic and working overtime.

“You know, the union encourages people to get their vaccine. I personally got the vaccine. And we’re not in denial of how serious the pandemic is,” Thomson said. “But the firefighters and the nurses have been doing this for a year and a half, and I think that we’ve done it safely. And I think the only thing that really threatens the health of the public is short staffing.”

Thomson maintains that unvaccinated staffers should be allowed to stay on the job because they’re experts in infection control and wear personal protective equipment such as masks and gloves.

But Maine’s public safety commissioner, Mike Sauschuck, said EMS departments also risk staff shortages if workers are exposed to covid and have to isolate or quarantine.

“Win-win scenarios are often talked about but seldom realized,” he said. “So sure, you may have a situation where staffing concerns are a reality in communities. But for us, we do believe the broader impact, the safer impact on our system is through vaccination.”

Some EMS departments in Maine have complied fully with the mandate, with no one quitting. Andrew Turcotte, the fire chief and director of EMS for the city of Westbrook, said all 70 members of his staff are now vaccinated. He doesn’t see the new mandate as being any different from the vaccine requirements to attend school or enter the health care field.

“I think that we all have not only a social responsibility but a moral one,” Turcotte said. “We chose to get into the health care field, and with that comes responsibilities and accountabilities. That includes ensuring that you’re vaccinated.”

Statewide numbers released last week show close to 97% of EMS workers in Maine have gotten vaccinated. But that varies by county: Rural Piscataquis and Franklin counties reported that 18% and 10% of EMS employees, respectively, were still unvaccinated as of mid-October.

Not all EMS departments have reported their vaccination rates to the state. Waldoboro is in Lincoln County, where only eight of 12 departments have reported their rates. Among those eight, the rate of noncompliance was just 1.6%.

But in small departments like Waldoboro, the loss of even one staff member can create a huge logistical problem. Over the past few months, Waldoboro’s EMS director, Richard Lash, started working extra long days to help cover the vacancies. He’s 65 and is planning to retire next year.

“I’ve told my town manager that we’ll do the best we can do. But, you know, I can’t continue to work 120 hours a week to fill shifts,” said Lash. “I’m getting old. And I just can’t keep doing that.”

This story is from a reporting partnership that includes Maine Public Radio, NPR and KHN.

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Científicos buscan la causa de una misteriosa inflamación en niños relacionada con covid

Como la mayoría de los niños con covid, Dante y Michael DeMaino no parecían tener síntomas graves.

Infectados a mediados de febrero, ambos perdieron los sentidos del gusto y del olfato. Dante, de 9 años, tuvo un día de fiebre baja. Michael, de 13, sintió un “cosquilleo en la garganta”, dijo su madre, Michele DeMaino, de Danvers, Massachusetts.

En una visita de seguimiento, “el pediatra auscultó corazón y pulmones, y todo parecía perfecto”, contó DeMaino.

Luego, a finales de marzo, Dante volvió a tener fiebre. Después de examinarlo, el médico dijo que probablemente su enfermedad no era “nada para preocuparse”, pero le pidió a DeMaino que lo llevara a urgencias si la fiebre subía a más de 40 grados Celsius.

Dos días después, Dante seguía con fiebre, dolor de cabeza y empezó a vomitar. Su madre lo llevó a urgencias, donde la fiebre subió a 40,5. En el hospital, los ojos de Dante se inflamaron, sus párpados se volvieron rojos, sus manos empezaron a hincharse y un sarpullido rojo brillante se extendió por su cuerpo.

En el hospital diagnosticaron a Dante con síndrome inflamatorio multisistémico infantil, o MIS-C, una complicación rara, asociada a covid-19, y potencialmente mortal, en la que un sistema inmunitario hiperactivo ataca el cuerpo del niño. Los síntomas —fiebre, dolor de estómago, vómitos, diarrea, ojos inyectados en sangre, sarpullido y mareos— suelen aparecer entre dos y seis semanas después de lo que suele ser una infección leve o incluso asintomática.

Más de 5,200 de los 6,2 millones de niños estadounidenses a los que se les ha diagnosticado covid han desarrollado MIS-C. Un 80% de los pacientes con MIS-C son tratados en unidades de cuidados intensivos, el 20% requiere ventilación mecánica y 46 han muerto.

A lo largo de la pandemia, el MIS-C ha seguido un patrón predecible, enviando a niños al hospital aproximadamente un mes después de una oleada de covid. Las unidades de cuidados intensivos pediátricos —que trataron a miles de pacientes jóvenes durante la aparición de la variante delta a finales de verano— luchan ahora por salvar al nuevo grupo de niños extremadamente enfermos.

El sur se ha visto especialmente afectado. En el Hospital Infantil Shawn Jenkins de la Universidad Médica de Carolina del Sur, por ejemplo, los médicos trataron en septiembre a 37 niños con covid y a nueve con MIS-C, la cantidad mensual más alta desde que comenzó la pandemia.

Los médicos no tienen forma de prevenir el MIS-C, porque todavía no saben exactamente qué lo causa, señaló el doctor Michael Chang, profesor de pediatría en el Children’s Memorial Hermann Hospital de Houston. Todo lo que los médicos pueden hacer es instar a los padres a vacunar a los niños que sean elegibles, y rodear a los más pequeños de personas vacunadas.

Dada la enorme magnitud de la pandemia, los científicos de todo el mundo buscan respuestas.

Aunque la mayoría de los niños que desarrollan MIS-C estaban sanos, el 80% tuvo complicaciones cardíacas. Las arterias coronarias de Dante se dilataron, lo que dificultó el bombeo de sangre del corazón y el suministro de nutrientes a sus órganos. Si no se trata rápidamente, el niño puede entrar en shock. Algunos pacientes desarrollan anomalías del ritmo cardíaco o aneurismas, cuando las paredes de las arterias se tapan y amenazan con reventar.

“Fue traumático”, contó DeMaino. “Me quedé con él en el hospital todo el tiempo”.

Historias como ésta plantean importantes cuestiones sobre las causas del MIS-C.

“Es el mismo virus y la misma familia, así que ¿por qué un niño contrae MIS-C y el otro no?”, se preguntó la doctora Natasha Halasa, del Instituto Vanderbilt sobre Infección, Inmunología e Inflamación.

Los médicos han mejorado a la hora de diagnosticar y tratar el MIS-C. La tasa de mortalidad ha descendido del 2,4% al 0,7% desde el comienzo de la pandemia. Los adultos también pueden desarrollar un síndrome inflamatorio post-covid, llamado MIS-A; que es aún más raro que el MIS-C, con una tasa de mortalidad siete veces mayor que la observada en niños.

Aunque el MIS-C es nuevo, los médicos pueden tratarlo con terapias utilizadas desde hace décadas para la enfermedad de Kawasaki, un síndrome pediátrico que también causa inflamación sistémica. Aunque los científicos nunca han identificado la causa de la enfermedad de Kawasaki, muchos sospechan que se desarrolla tras una infección.

Los investigadores del Boston Children’s Hospital, y otras instituciones, están buscando pistas en los genes de los niños.

En un estudio realizado en julio, investigadores identificaron variantes genéticas raras en tres de los 18 niños estudiados. Resulta significativo que todos los genes estén implicados en la “eliminación de los frenos” del sistema inmunitario, lo que podría contribuir a la hiperinflamación observada en el MIS-C, señaló la doctora Janet Chou, jefa de inmunología clínica del Boston Children’s, que dirigió el estudio.

Chou reconoce que su estudio —que encontró variantes genéticas en sólo el 17% de los pacientes— no resuelve el rompecabezas. Y plantea nuevas preguntas: si estos niños son genéticamente susceptibles a los problemas inmunitarios, ¿por qué no enfermaron gravemente a causa de infecciones infantiles anteriores?

Algunos investigadores afirman que el aumento de las tasas de MIS-C entre las minorías raciales y étnicas de todo el mundo —en Estados Unidos, Francia y el Reino Unido— puede deberse a la genética.

Otros señalan que las tasas de MIS-C son un reflejo de las mayores tasas de covid en estas comunidades, que han sido impulsadas por factores socioeconómicos como las condiciones de trabajo y de vida de alto riesgo.

“No sé por qué algunos niños lo desarrollan y otros no”, dijo el doctor Dusan Bogunovic, investigador de la Escuela de Medicina Icahn de Mount Sinai que ha estudiado las respuestas de los anticuerpos en el MIS-C. “¿Se debe a la genética o a la exposición ambiental? La verdad puede estar en algún punto intermedio”.

Un enemigo oculto y un intestino permeable

La mayoría de los niños con MIS-C dan negativo para las pruebas de covid, lo que sugiere que el organismo ya ha eliminado al nuevo coronavirus de la nariz y las vías respiratorias superiores.

Esto llevó a los médicos a suponer que el MIS-C era una enfermedad “post-infecciosa”, que se desarrollaba después que “el virus hubiera desaparecido por completo”, señaló el doctor Hamid Bassiri, especialista en enfermedades infecciosas pediátricas y codirector del programa de desregulación inmunológica del Hospital Infantil de Filadelfia.

Ahora, sin embargo, “están surgiendo pruebas de que tal vez no sea así”, dijo Bassiri.

Incluso si el virus ha desaparecido de la nariz del niño, podría estar al acecho —y diseminándose— en otras partes del cuerpo, indicó Chou. Esto podría explicar por qué los síntomas aparecen tanto tiempo después de la infección inicial del niño.

El doctor Lael Yonker observó que los niños con MIS-C son mucho más propensos a desarrollar síntomas gastrointestinales —como dolor de estómago, diarrea y vómitos— que los problemas respiratorios que suelen observarse en el covid agudo.

En algunos niños con MIS-C, el dolor abdominal ha sido tan intenso que los médicos los diagnosticaron erróneamente con apendicitis; algunos incluso fueron operados antes de que sus médicos se dieran cuenta del verdadero origen de su dolor.

Yonker, neumólogo pediátrico del Hospital Infantil MassGeneral de Boston, encontró recientemente pruebas de que el origen de esos síntomas podría ser el coronavirus, que puede sobrevivir en el intestino durante semanas después de desaparecer de las fosas nasales.

En un estudio publicado en mayo en The Journal of Clinical Investigation, Yonker y sus colegas demostraron que más de la mitad de los pacientes con MIS-C tenían material genético —llamado ARN— del coronavirus en sus heces.

El cuerpo descompone el ARN viral muy rápidamente, explicó Chou, por lo que es poco probable que el material genético de una infección por covid se encuentre todavía en las heces de un niño un mes después. Si se encuentra, lo más probable es que sea porque el coronavirus se ha instalado en un órgano, como el intestino.

Aunque el coronavirus puede prosperar en el intestino, es un terrible huésped.

En algunos niños, el virus irrita el revestimiento intestinal, creando brechas microscópicas que permiten que las partículas virales escapen al torrente sanguíneo, dijo Yonker.

Los análisis de sangre de los niños con MIS-C revelaron que tenían un alto nivel del antígeno espiga (o pico) del coronavirus, una importante proteína que permite al virus entrar en las células humanas. Los científicos han dedicado más tiempo a estudiar el antígeno de espiga que cualquier otra parte del virus. Es el objetivo de las vacunas contra covid, así como de los anticuerpos producidos naturalmente durante la infección.

“No vemos que el virus vivo se replique en la sangre”, señaló Yonker. “Pero las proteínas espiga se desprenden y se filtran a la sangre”.

Según Yonker, las partículas virales en la sangre podrían causar problemas que van más allá del malestar estomacal. Es posible que estimulen el sistema inmunitario en exceso.

En su estudio, Yonker cuenta como trató a un niño de 17 meses gravemente enfermo cuyo cuadro se agravó aún más a pesar de los tratamientos habituales. Recibió permiso para tratarlo con un fármaco experimental, larazotida, diseñado para curar los intestinos permeables. Y funcionó.

Yonker recetó larazotida a otros cuatro niños, entre ellos Dante, que también recibió un medicamento utilizado para tratar la artritis reumatoide. Mejoró.

Pero la mayoría de los niños con MIS-C mejoran, incluso sin medicamentos experimentales. Sin un grupo de comparación, no hay forma de saber si la larazotida funciona realmente. Por eso Yonker está inscribiendo a 20 niños en un pequeño ensayo clínico aleatorio de larazotida, que proporcionará pruebas más sólidas.

Soldados rebeldes

El doctor Moshe Arditi también ha establecido conexiones entre los síntomas de los niños y lo que podría estar causándolos.

Aunque los primeros médicos que trataron la MIS-C lo compararon con la enfermedad de Kawasaki —que también provoca ojos rojos, sarpullidos y fiebres altas—, Arditi señaló que la MIS-C se parece más al síndrome de shock tóxico, una afección potencialmente mortal causada por determinados tipos de bacterias estreptocócicas o estafilocócicas que liberan toxinas en la sangre. Ambos síndromes provocan fiebre alta, trastornos gastrointestinales, disfunción del músculo cardíaco, caída de la presión arterial y síntomas neurológicos, como dolor de cabeza y confusión.

El shock tóxico puede producirse tras un parto o la infección de una herida, aunque los casos más conocidos se produjeron en los años 70 y 80 en mujeres que utilizaron un tipo de tampón que ya no se usa.

Las toxinas liberadas por estas bacterias pueden desencadenar una reacción exagerada de los principales combatientes del sistema inmunitario, denominados células T, que coordinan la respuesta del sistema inmunitario, explicó Arditi, director de la división de enfermedades infecciosas pediátricas del Centro Médico Cedars-Sinai.

Las células T son tremendamente poderosas, por lo que el cuerpo normalmente las activa de forma precisa y controlada, dijo Bassiri. Una de las lecciones más importantes que deben aprender las células T es que deben dirigirse a los malos y dejar en paz a los civiles. De hecho, un sistema inmunitario sano suele destruir muchas células T que no pueden distinguir entre los gérmenes y el tejido sano para evitar las enfermedades autoinmunes.

En una respuesta típica a una sustancia extraña —conocida como antígeno—, el sistema inmunitario activa sólo alrededor del 0,01% de todas las células T, indicó Arditi.

Sin embargo, las toxinas producidas por ciertos virus y las bacterias que causan el shock tóxico contienen “superantígenos”, que eluden las salvaguardias normales del organismo y se adhieren directamente a las células T. Esto permite que los superantígenos activen entre el 20% y el 30% de las células T a la vez, generando un peligroso enjambre de glóbulos blancos y proteínas inflamatorias denominadas citoquinas, explicó Arditi.

Esta respuesta inflamatoria masiva provoca daños en todo el organismo, desde el corazón hasta los vasos sanguíneos y los riñones.

Aunque múltiples estudios han constatado que los niños con MIS-C tienen menos células T de lo normal, el equipo de Arditi ha encontrado un aumento explosivo de un subtipo de células T capaces de interactuar con un superantígeno.

Varios grupos de investigación independientes —entre los que se encuentran investigadores de la Escuela de Medicina de Yale, los Institutos Nacionales de la Salud (NIH) y la Universidad de Lyon en Francia— han confirmado los hallazgos de Arditi, sugiriendo que algo, muy probablemente un superantígeno, causó un enorme aumento de este subtipo de células T.

Aunque Arditi ha propuesto que partes de la proteína espiga del coronavirus podrían actuar como un superantígeno, otros científicos afirman que el superantígeno podría proceder de otros microbios, como las bacterias.

“Ahora se está buscando urgentemente la fuente del superantígeno”, afirmó la doctora Carrie Lucas, profesora de inmunobiología en Yale, cuyo equipo ha identificado cambios en las células inmunitarias y en las proteínas de la sangre de los niños con MIS-C.

Futuro incierto

Un mes después de que Dante saliera del hospital, los médicos le hicieron un ecocardiograma para ver si su corazón tenía daños persistentes.

Para alivio de su madre, su corazón había vuelto a la normalidad.

Hoy, Dante es un niño de 10 años lleno de energía que ha vuelto a jugar al hockey y al béisbol, a nadar y a patinar.

“Ha vuelto a realizar todas estas actividades”, dijo DeMaino, y contó que los médicos de Dante volvieron a examinar su corazón seis meses después de su enfermedad y volverán a hacerlo al cabo de un año.

Al igual que Dante, la mayoría de los niños que sobreviven al MIS-C parecen recuperarse completamente, según un estudio publicado en marzo en JAMA.

Estas recuperaciones tan rápidas sugieren que los problemas cardiovasculares relacionados con el MIS-C son el resultado de una “inflamación severa y un estrés agudo” más que de una enfermedad cardíaca subyacente, según los autores del estudio, denominado Overcoming COVID-19.

Aunque los niños que sobreviven a la enfermedad de Kawasaki tienen un mayor riesgo de sufrir problemas cardíacos a largo plazo, los médicos no saben cómo les irá a los supervivientes del MIS-C.

Los NIH y los Centros para el Control y la Prevención de Enfermedades han puesto en marcha varios ensayos a largo plazo para estudiar a los jóvenes pacientes de covid y sobrevivientes de MIS-C. Los investigadores estudiarán el sistema inmunitario de los niños para buscar pistas sobre la causa del MIS-C, examinarán sus corazones en busca de signos de daños a largo plazo y controlarán su salud a lo largo del tiempo.

DeMaino dijo que ella está mucho más preocupada por la salud de Dante que él mismo.

“No tiene ninguna preocupación en el mundo”, contó. “Yo estaba preocupada por la última cita con el cardiólogo, pero él me dijo: ‘Mamá, no tengo ningún problema para respirar. Me siento completamente bien'”.

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This story can be republished for free (details).

from Health Industry – Kaiser Health News

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