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In California Nursing Homes, Omicron Is Bad, but So Is the Isolation

Dina Halperin had been cooped up alone for three weeks in her nursing home room after her two unvaccinated roommates were moved out at the onset of the omicron surge. “I’m frustrated,” she said, “and so many of the nursing staff are burned out or just plain tired.”

The situation wasn’t terrifying, as it was in September 2020, when disease swept through the Victorian Post Acute facility in San Francisco and Halperin, a 63-year-old former English as a Second Language teacher, became severely ill with covid. She spent 10 days in the hospital and required supplemental oxygen. Since the pandemic began, 14 residents of the nursing home have died of covid, according to state figures.

Over time, Victorian Post Acute has gotten better at dealing with the virus, especially its milder omicron form, which accounted for 31 cases as of Jan. 27 but not a single illness serious enough to cause hospitalization, said Dan Kramer, a spokesperson for Victorian Post Acute. But the ongoing safety protocols at this and other nursing homes — including visitor restrictions and frequent testing of staff and residents — can be soul-killing. For the 1.4 million residents of the nation’s roughly 15,000 nursing homes, the rules have led to renewed isolation and separation.

“I’m feeling very restless,” Halperin said. She has Cushing’s syndrome, an autoimmune disease that caused tumors and a spinal fracture that left her mostly wheelchair-bound and unable to live independently. Although she has residual covid symptoms, including headaches and balance problems, Halperin, who has lived in the nursing home for nine years, is usually quite sociable. She volunteers in the dining room, helps other residents with their activities, and shops and runs errands during her frequent forays outside the building.

But covid infections are again spiking at nursing homes around the country. In California, 792 new nursing home cases were reported on Jan. 19, compared with fewer than 11 cases on Dec. 19, 2021. However, the death rates are not nearly as bad as they were during pre-vaccine covid surges. From Dec. 23, 2021, to Jan. 23, 2022, 217 nursing home residents died of covid in California. By contrast, in just the week from Christmas 2020 to New Year’s Day 2021, 555 people died at nursing homes in the state.

Those numbers, and others cited in this article, don’t filter out patients who entered hospitals for treatment of other conditions but tested positive for covid upon admission — a common occurrence during the omicron wave.

To keep nursing home residents out of overwhelmed hospitals, California public health officials have mandated masking and imposed strict vaccination and testing requirements for visitors and staffers at the homes, said Dr. Zachary Rubin, a medical epidemiologist with the Los Angeles County Department of Public Health. “Our approach is to prevent cases from coming into the facility, stop transmission once it gets into the facility, and to prevent serious outcomes,” he said.

Rubin acknowledged that some of these policies may seem like they’re doing more harm than good — but only temporarily, he hopes.

The omicron surge has created staffing shortages as nurses and aides call in sick, and the strict testing requirements have the effect of limiting visits by friends and relatives who provide crucial care and contact for some residents, bathing and grooming them, overseeing their diets and medications, and making sure they’re not being neglected.

Nationally, a federal mandate requires all workers in federally funded facilities to be fully vaccinated by Feb. 28. The deadline was extended to March 15 for 24 states that challenged the requirement in court. Last month, California issued a similar order, which also requires nursing home staffers to receive booster shots by Feb. 1.

However, while vaccination rates for staff members and residents are high in California (96% for staffers and 89% for residents), only 52% of nursing home workers and 68% of their residents in California have received boosters, according to Jan. 23 figures from the Centers for Disease Control and Prevention. At Victorian Post Acute, 95% of staff and 92% of residents had been vaccinated with boosters as of Jan. 27, Kramer said.

Across the state, many unvaccinated staff members claim religious exemptions. Others say they can’t get vaccinated at their workplaces and don’t have time to get shots on their own, said Deborah Pacyna, a spokesperson for the California Association of Health Facilities, which represents the nursing home industry in Sacramento.

“We’re going to have to deal with that as the deadline approaches. If they’re not boosted, does that mean they can’t work?” she asked. “That would be an extraordinary development.”

The state hasn’t indicated how it will enforce mandates, especially for boosters, said Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform.

Most nursing home visitors, as of Jan. 7, must be fully vaccinated — including boosters, if eligible — under California Department of Public Health requirements. Guests also must present a negative covid test taken within one or two days, depending on the type of test. The federal government is sending four rapid tests to families that request them, and the state of California has distributed 300,000 tests to nursing homes.

That’s “better than nothing,” said Pacyna, but it may not be enough for families that visit several times a week. Some experts think any policy that tends to restrict visitors sets the wrong priority.

“Limiting visitation is bad psychologically,” said Charlene Harrington, a professor emeritus in social and behavioral sciences at the University of California-San Francisco who has done extensive research on nursing homes. Numerous studies have shown that social isolation and loneliness can lead to depression, worsening dementia and cognitive decline, anxiety, a loss of the will to live — and increased risk of mortality from other causes.

Besides, Harrington said, most nursing home outbreaks are caused by infected staffers, who often work multiple jobs because of the low pay.

Maitely Weismann visits her 79-year-old mother, who has dementia and uses a wheelchair, at a Los Angeles residential facility several times a week. Her mother deteriorated considerably during the initial lockdown, and Weismann is doing her best to slow her mother’s decline, she said.

“It’s much harder to do this during the pandemic because there are so many barriers to entry,” said Weismann, co-founder of the advocacy group Essential Caregivers Coalition. “Family caregivers can’t actually tell if a loved one is doing OK through a screen, or a window, or a phone call.”

Responding to the critical health care staff shortages, the CDC issued emergency guidelines in December — California followed suit in January — that allow workers who have been exposed to or test positive for covid to return to work if they are asymptomatic.

It’s a short-term, last-resort measure, Rubin said. “It’s just not possible to adequately take care of people and do the daily activities of living if you don’t have a nurse or caregivers. You just can’t operate the place.”

On one recent day alone — Jan. 24 — more than 10,300 workers were out sick — which is roughly a tenth of the combined staff in California nursing homes. To deal with the crunch, said Pacyna, “we’re asking people to work extra hours, knowing that the peak is near and this isn’t going to last forever.”

In the meantime, families continue to worry about their loved ones. “When residents are isolated, they become completely dependent on the caregivers in the facility,” Weismann said. “But when staff stops coming to work, the system falls apart.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the 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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Medicare Patients Win the Right to Appeal Gap in Nursing Home Coverage

A three-judge federal appeals court panel in Connecticut has likely ended an 11-year fight against a frustrating and confusing rule that left hundreds of thousands of Medicare beneficiaries without coverage for nursing home care, and no way to challenge a denial.

The Jan. 25 ruling, which came in response to a 2011 class-action lawsuit eventually joined by 14 beneficiaries against the Department of Health and Human Services, will guarantee patients the right to appeal to Medicare for nursing home coverage if they were admitted to a hospital as an inpatient but were switched to observation care, an outpatient service.

The court’s decision applies only to people with traditional Medicare whose status was changed from inpatient to observation. A hospital services review team can make this change during or after a patient’s stay.

Observation care is a classification designed for patients who are not well enough to go home but still need the kind of care they can get only in a hospital. But it can have serious repercussions.

Without a three-day inpatient stay, beneficiaries are ineligible for Medicare’s nursing home benefit. So if they need follow-up care in a nursing home after leaving the hospital, they can face charges of about $290 a day, the average national cost of nursing home care, according to a 2021 survey. Also, since observation care is categorized as outpatient treatment — even if the patient is on a hospital ward — they can get stuck with significant copays under Medicare rules.

“You can appeal almost every issue affecting your Medicare coverage except this one, and that is unfair,” said Alice Bers, litigation director at the Center for Medicare Advocacy, which represented the patients in their lawsuit along with Justice in Aging, another advocacy group, and the California law firm of Wilson Sonsini Goodrich and Rosati.

Until Congress passed a law that took effect in 2017, hospitals weren’t required to tell patients whether they were receiving observation care and had not been admitted. Under that law, hospitals must provide written notice, but it does not trigger any right to appeal.

The Department of Justice, representing HHS and the Medicare program, tried numerous times to get the case dismissed, arguing that the decision to admit patients or classify them as “observation patients” was based on a doctor’s or hospital’s medical expertise. Patients had nothing to appeal because the government can’t change a decision it didn’t make, so no Medicare rule had been violated.

Doctors rejected that notion and have long complained that the Medicare rule undermined their clinical judgment and produced “absurd results” that can hurt patients. The American Medical Association and state medical societies filed legal papers in support of the patients challenging the rule, as did several other organizations, including AARP, the National Disability Rights Network, and the American Health Care Association, which represents nursing homes across the country.

But U.S. District Judge Michael Shea ruled against HHS in 2020, and estimated that hundreds of thousands of Medicare patients would be able to seek refunds for nursing home care and other costs that admitted patients don’t pay. The trial took place in 2019.

The government continued to back the rule, however, and asked a federal appeals court panel to reverse Shea’s decision — despite comments from then-chief of Medicare Seema Verma, who questioned these policies in a 2019 tweet, saying that “government doesn’t always make sense.”

On Jan. 25, the appeals court judges upheld Shea’s decision, agreeing that when hospitals switched a patient’s status they were following Medicare’s 2013 “two-midnight rule.” It requires hospitals to admit patients who are expected to stay through two midnights. The ruling applies to people in traditional Medicare.

“The decision to reclassify a hospital patient from an inpatient to one receiving observation services may have significant and detrimental impacts on plaintiffs’ financial, psychological, and physical well-being,” the judges wrote. “That there is currently no recourse available to challenge that decision also weighs heavily in favor of a finding that plaintiffs have not been afforded the process required by the Constitution.”

A DOJ spokesperson declined to comment on whether government lawyers would appeal the new ruling.

Three groups of Medicare patients who were switched from inpatient to observation status after Jan.1, 2009, will be able to file appeals for nursing home coverage and reimbursement for out-of-pocket costs. People currently in the hospital will be able to request an expedited appeal, and others who have recently incurred costs can file a standard appeal by following instructions in their Medicare Summary Notice. A plan for appealing older claims has not yet been arranged, said Bers. The latest details are available on the Center for Medicare Advocacy’s website. (The three-day inpatient hospital stay requirement is temporarily suspended due to the covid-19 pandemic.)

Observation status also causes trouble for people like Andrew Roney, 70, of Teaneck, New Jersey, who was caught unawares when he was switched from inpatient to observation status. He had Medicare’s Part A hospitalization coverage, which is free for most people 65 and older. But he didn’t sign up for Part B, which carries a monthly premium and covers outpatient services, including observation care, doctor visits, lab tests, and X-rays. He spent three days in a nearby hospital for an intestinal infection in 2016.

Roney, a freelance editor and substitute teacher, didn’t think he needed Part B and assumed Part A would cover his hospital stay. Instead, he was surprised to get a $5,000 bill because he was classified as an observation patient and was not admitted. Despite his best efforts, there was nothing he could do about it except to pay up.

“It came as a shock to the system,” said Roney, who testified in the 2019 trial. “I don’t want anybody else to go through that.” Although he had given up hope of getting his money back, he intends to file an appeal now that he can. “It’s a nice chunk of change.”

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KHN’s ‘What the Health?’: Record ACA Enrollment Puts Pressure on Congress

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

The Biden administration announced that 14.5 million Americans have signed up for health insurance under the Affordable Care Act for 2022. That’s a record, and several states are still enrolling people. But many millions of those newly insured could face significantly higher premiums for 2023 unless Congress extends the temporary subsidies it passed last year.

Meanwhile, lawmakers are again working to salvage parts of the president’s Build Back Better social spending bill that failed to garner enough votes to pass the Senate. Separately, lawmakers are looking to remake the federal public health apparatus to better prepare for the next pandemic.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico and the Johns Hopkins Bloomberg School of Public Health, Sarah Karlin-Smith of the Pink Sheet, and Anna Edney of Bloomberg News.

Among the takeaways from this week’s episode:

Replacing Supreme Court Justice Stephen Breyer, who announced his retirement this week, adds to an already long to-do list in the Senate. Lawmakers must still fund the government for the remainder of the fiscal year and find an acceptable compromise on President Joe Biden’s big social spending bill. Approving a Supreme Court justice in a 50-50 Senate will not be easy, but the realization that the replacement will not change the ideological balance on the court could take off some of the pressure.
As Democrats contemplate advancing a slimmed-down Build Back Better package, health provisions — including ones to lower the price of prescription drugs — seem near certain to make the cut. One reason: Democrats generally agree on them. Also, though, Democrats are likely to suffer in the midterm elections unless they manage to get something passed.
Meanwhile, Sens. Patty Murray (D-Wash.) and Richard Burr (R-N.C.), members of the Senate Committee on Health, Education, Labor, and Pensions, have put forth a new framework to upgrade the federal government’s public health apparatus for future pandemics. Their plan includes changes such as requiring Senate confirmation for the position of director of the Centers for Disease Control and Prevention, ramping up national health-related data collection, and shoring up the strategic national stockpile.
In its first full year, the Biden administration has had successes and failures dealing with the covid pandemic. Among the successes is the effective distribution of vaccines. One of its biggest failures, however, has been its inability to communicate to the public how the changing virus necessitated changed behaviors.
Anti-vaccine activists — who historically have held fringe positions on both the far left and far right — increasingly seem to be part of the GOP coalition. The concept is tied up in the movement to promote individual liberties. And it is starting to appear that the strength of the anti-vaccine movement will outlive the pandemic.

Also this week, Rovner interviews Diana Greene Foster of the Bixby Center for Global Reproductive Health at the University of California-San Francisco. She is the lead researcher of the “Turnaway Study,” which followed a thousand women who sought abortions for several years afterward to see how their lives turned out.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “After Miscarriages, Workers Have Few Guarantees for Time Off or Job-Based Help,” by Bryce Covert

Anna Edney: The AP’s “How a Kennedy Built an Anti-Vaccine Juggernaut amid COVID-19,” by Michelle R. Smith

Joanne Kenen: HuffPost’s “The Right’s War on Government Is Working and It Could Cost Lives,” by Jonathan Cohn

Sarah Karlin-Smith: The Column’s “Covid Isn’t a Human Being, It Doesn’t Care What You Think About It,” by Adam Johnson

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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Readers and Tweeters: Give Nurse Practitioners Their Due

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

The latest installment in: Hospital Billing is Totally Ridiculous. See also: High Deductibles are Badhttps://t.co/JAk1CfrEuN
— Rachel Patterson (@racheljpat) January 24, 2022

— Rachel Patterson, Washington, D.C.

In Respect to Nurse Practitioners

My dispute with this story (“Bill of the Month: The Doctor Didn’t Show Up, but the Hospital ER Still Charged $1,012,” Jan. 24) is not about the actual billing or details of the injustice suffered by the patient. Instead, I am appalled at the gross misrepresentation of the nurse practitioner (NP) profession. In a few instances, the article referred to the NP as “nurse.” NPs are highly trained advanced practice providers. Educated at the master’s or doctoral level, NPs undergo extensive training and possess the scope of practice to assess, diagnose, treat, and prescribe medications for a vast array of conditions. They carry expertise in clinical judgment that is held to the highest clinical standards. They are widely recognized and respected for their breadth of knowledge and skills.

This article incorrectly refers to the NP as “nurse” and, more insultingly, repeatedly suggests that the value of the NP’s assessment is insufficient. Using the quote from Adam Fox (“if they are not provided treatment”) leads readers to believe that the patient was not assessed by a competent health care provider. This is factually untrue. This misperception and misinformation undermine the inherent value and understanding of the NP profession.

Nurse practitioners exist to serve patients, their families, their communities, and the health care system by providing thorough, high-level, and evidenced-based care. This article missed the opportunity to educate the public about the indisputable value of NPs in a complex health care landscape.

— Gautham Iyer, lead nurse practitioner in the Department of Advanced Lung Disease & Lung Transplantation, UCSF School of Nursing; San Rafael, California

Problem with this is how the nurse practitioner was portraid. NP's have more school than MD's, prescribed meds, and know more about patients than doctors do like most nurses The Doctor Didn’t Show Up, but the Hospital ER Still Charged $1,012 https://t.co/1MisOURhJY #SmartNews
— Dan Matevia (@cruiser_dan) January 25, 2022

— Dan Matevia, Cincinnati

I found this piece deceptive. First, the care was rendered not just by a registered nurse at triage (standard procedure) but by a nurse practitioner, who was the medical service provider. The patient’s father did not seem to understand that, however limited and insufficient that may have seemed at the time. In Missouri, that type of provider may act independently from a physician to provide medical care in limited situations. In some states, they may act fully independently, including prescribing medication and doing procedures.

Secondly, comparing the charges of care rendered in an ER, which is open 24/7/365, to what a mechanic or pharmacy charges for service is ludicrous and insulting. On any given day, the cost of providing nursing care alone throughout the hospital, let alone the ER, is upward of 70% of the daily operating expense. Who should pay for that, I wonder?

I have no argument that the cost of care in hospitals is too high, especially in the ER, but we have a very imperfect system. It results in shifting costs from those whose bills are unpaid (roughly half of all ER visits) to those who can pay, by whatever insurance they do or do not have. Not a perfect idea, but that is the way it will be until there is a “better” system.

— Dr. Robert D. Greene, Palm Springs, California

The USA has the best healthcare money can buy – even when you don't get the healthcare you wanted, you still have to pay for it – Doctor Didn’t Show Up, but the Hospital ER Still Charged $1,012 – https://t.co/pDdzr2X2D1
— Ritesh Patel (@ritters90) January 24, 2022

— Ritesh Patel, Montclair, New Jersey

Nursing Homes’ Balancing Act

Rules regarding nursing home visitation are determined by state and federal regulators — not the providers (“Families Complain as States Require Covid Testing for Nursing Home Visits,” Jan. 20).

Neither we nor our mission-driven members advocate an unqualified return to “lockdown,” when visits were not allowed.

In following current Centers for Medicare & Medicaid Services guidance, nursing home staff members face a delicate balancing act. They welcome visitors in to preclude possible resident social isolation while, at the same time, fight to keep the highly transmissible covid-19 omicron variant out.

Keeping nursing home residents (who due to age and underlying health conditions are among the most vulnerable to covid), as well as the staff who care for them, safe from covid is a public health issue that requires concerted community effort. Everyone has a role to play. We urge everyone to get tested, vaccinated, and boosted before visiting a loved one in a nursing home. And once there, follow proper infection control and hygiene. Lastly, if you are sick, stay home.

As one of our nursing home member CEOs told Judith Graham, “We want visitors. We want them to bring their life, their love, and their joy. We don’t want them to bring infection.”

— Katie Smith Sloan, president and CEO of LeadingAge, Washington, D.C.

booster confusion https://t.co/KK8V0eEkQr
— Kate Yandell (@KateYandell) January 25, 2022

— Kate Yandell, Philadelphia

Extra Shots for the Immunocompromised

I just wanted to say thank you for your article on fourth covid shots for the immunocompromised (“Pharmacies Are Turning Away Immunocompromised Patients Seeking 4th Covid Shot,” Jan. 25). I would have had a terrible experience with this myself if not for a pharmacist at Harris Teeter who was willing to move heaven and earth to make it happen. As the U.S. covid response and prevailing attitudes continue to make me feel increasingly isolated and marginalized, writing like yours helps me feel seen.

— Julie Roy, Durham, North Carolina

Had so much anxiety before my 4th #CovidVaccine, but independent pharma was great & knew rules. Exhausting to have to keep fighting for our lives. 😞 @CDCgov @CDCDirector it IS part of your role to educate #immunocompromised #transplanttwitter https://t.co/kd5vcMgXJ9
— Tania Daniels (@TaniaDaniels3) January 25, 2022

— Tania Daniels, Los Angeles

A Heavy Lift: Leaving No Medicaid Patient Behind

Thank you so much for providing the story about how unreliable and ridiculous Medicaid transportation is (“Left Behind: Medicaid Patients Say Rides to Doctors Don’t Always Come,” Jan. 12). As a Medicaid patient, I’ve been left waiting hours, stranded at one point for four hours following an appointment. For me, it’s highly unsafe, as it is for any patient. The provider also stayed with me, as their office was closing for the day, and incurred their own additional expenses. But I’ve had other experiences of being loaded into cars with multiple other patients. It is not only an invasion of privacy but highly problematic for people like myself with multiple rare conditions. On top of that, when it comes to someone who is going to therapy or other appointments of personal natures with things like PTSD, it becomes a trigger having others there who shouldn’t be. It’s not OK under any circumstances and even when you request it not be they don’t abide. I’ve had vendors stop working with me because I require riding alone.

The best experience I have had is using Lyft. It doesn’t require advance notice. It doesn’t require anything but me and my phone. But it’s expensive. Medicaid riders need the flexibility to use Lyft on their phone through the Lyft app. Not through third-party services, because it doesn’t fix the issue when the third party is involved. They need to be able to be reimbursed for the ride or even not have to pay upfront, but given the ability to use a state benefit card as the form of payment on the app.

The ride companies who take the calls and schedule for Medicaid with the individual vendors often send wrong information to the ride providers, too, even after a patient enters it correctly. I’ve confirmed this with drivers in the past; I’d print a screenshot before I hit submit on the form. It was all accurate on my end. But the ride vendor found the ride scheduling company was a major problem. I also worked as an outpatient access specialist and saw it from the other side of the counter. It’s really bad. Patients waiting for four, five, or more hours after appointments for their ride home. Some crying in pain, some dealing with missing other treatments. And if you’ve got limited energy from diseases, it’s even worse. It’s dangerous.

— Ian Scheil, Rochester, New York

We really can’t walk and chew gum during this #pandemic, and it’s awful. These children deserve more. “No concerted government effort exists to help the estimated 140,000 children who have lost a parent — or even to identify them.” https://t.co/bmwdR7KPRc
— Dr. Beth S. Linas(she/her) (@bethlinas) December 1, 2021

— Dr. Beth S. Linas, Washington, D.C.

The Shadow Pandemic: Our Nation’s Pediatric Behavioral Health Crisis

As we near two years of being locked inside a worldwide pandemic, we approach the first anniversary of pretending impassive gestures like flipping a calendar from one year to the next will cure what ails us.

This time last year, we were ready to put 2020 behind us and looked forward to the promise of 2021. For children’s hospitals, 2021 has been more frustrating than its predecessor as the pandemic has accelerated a youth mental health crisis years in the making — one we cannot effectively manage without help.

On July 13, we sounded the alarm. We demonstrated that the demand for services far exceeds supply, explained how children’s hospitals are not designed to care for kids with mental health needs at scale, and illuminated the impact of the crisis on kids we are caring for and the dedicated health care professionals caring for them.

On Oct. 19, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association declared a national emergency in youth mental health, echoing our concerns and urging policymakers to take action. They pointed to a 45% increase in self-injury and suicide cases among 5- to 17-year-olds at children’s hospitals during the first six months of 2021, as well as more than 140,000 U.S. children having experienced the death of a primary or secondary caregiver during the pandemic, with children of color disproportionately impacted.

On Dec. 6, a new poll highlighted the pandemic’s outsize impact on anxiety and stress among children and adolescents. On Dec. 7, the U.S. Surgeon General issued an advisory on the youth mental health crisis, calling for “a swift and coordinated response to this crisis.”

We hope that will be the case — at both federal and state levels of government. Because in the meantime, children’s hospitals continue to see an overwhelming demand for mental health care. An unprecedented number of patients are seeking outpatient care for concerns such as anxiety, depression, disruptive behaviors, academic problems, and eating disorders. The resources needed to provide this care are grossly insufficient (“Watch: No Extra Resources for Children Orphaned by Covid,” Dec. 1).

While there is no easy fix to this crisis, we as health care providers are interested in joining policymakers and other key stakeholders to develop the best, most comprehensive policy package we can. Our children and families deserve no less from us.

— Trish Lollo, president of St. Louis Children’s Hospital; Steven Burghart, president of SSM Health Cardinal Glennon Children’s Hospital; Paul Kempinski, president of Children’s Mercy Kansas City; and Dr. Joseph Kahn, president of Mercy Kids

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Resistance to a Boston Hospital’s Expansion Centers on Rising Prices

A boisterous political battle over a proposed expansion by the largest and most expensive hospital system in Massachusetts is spotlighting questions about whether similar expansions by big health systems around the country drive up health care costs.

Mass General Brigham, which owns 11 hospitals in the state, has proposed a $2.3 billion expansion including a new 482-bed tower at its flagship Massachusetts General Hospital in Boston and a 78-bed addition to Brigham and Women’s Faulkner Hospital. The most controversial element, however, is a plan to build three comprehensive ambulatory care centers, offering physician services, surgery, and diagnostic imaging, in three suburbs west of Boston.

On Jan. 25, the state’s 11-member Health Policy Commission unanimously concluded that these expansions would drive up spending for commercially insured residents by as much as $90 million a year and boost health insurance premiums.

The commission also ordered Mass General Brigham to develop an 18-month “performance improvement plan” to slow its cost growth. The action, believed to be the first time in the country a hospital has been ordered to develop a plan to control costs, reflects concern about giant hospitals’ role in rising health care costs.

Other states, including California, Delaware, Oregon, Rhode Island, and Washington, have created or are considering commissions on health care costs with the authority to analyze the market impact of mergers and expansions. That’s happening because the traditional “determination of need” process for approving health facility expansions, which nearly three dozen states still have in place, has not been effective in the current era of health system giants, said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy.

The Mass General Brigham health system, which generates $15.7 billion in annual operating revenue, announced that the massive expansion would better serve its existing patients, including 227,000 who live outside Boston. Its leaders said the new facilities would not raise health spending in the state, where policymakers are alarmed that cost growth in 2019 hit 4.3%, exceeding the state’s target of 3.1%.

The hospitals’ cost-analysis report, submitted to the state last month, concluded that the system’s existing patients would pay lower prices at the new suburban sites than at its downtown locations. John Fernandez, president of Mass General Brigham Integrated Care, projected that prices at the new centers would be 25% less, and he said patients will not have to pay extra hospital “facility fees” at the new outpatient sites.

“We’re all going to have a tsunami of patients over the next 20 years given the aging population, and everyone has to step up to meet that demand,” he said in explaining the expansion.

But a well-funded coalition of competing hospitals, labor unions, and chambers of commerce argues that Mass General Brigham’s invasion of the Boston suburbs would spike total spending by drawing in patients from lower-priced physicians and hospitals. They cite the health system’s own planning projection, unearthed by the attorney general’s office in a November report, that the expansion would boost annual profits by $385 million.

“How could you be fooled?” said Dr. Eric Dickson, CEO of UMass Memorial Health Care, a safety-net health system serving the towns west of Boston that is part of the coalition of expansion opponents. “If you let the state’s most expensive system grow wildly, it will drive up the cost of care.”

The controversy signals a shift in the concerns about the cause of rapidly escalating health care costs. Up to now, state and federal policymakers examining how hospital system growth affects costs have largely focused on hospital mergers and purchases of physician practices. Studies have found that these deals significantly boost prices to consumers, employers, and insurers. State and federal regulators have stepped up antitrust scrutiny of mergers and acquisitions.

Deep-pocketed hospital systems increasingly are turning to solo expansion to gain a bigger share of the market. These expansions fall outside the legal authority of antitrust enforcers.

Health systems are building satellite ambulatory care centers to attract more well-insured patients and steer them to their own hospitals and other facilities, said Glenn Melnick, a health economist at the University of Southern California.

“The outcome is the same as a merger — capturing patients and keeping them,” he said. “That’s not necessarily good for consumers in terms of access to care or cost efficiency.”

Critics of Mass General Brigham’s plans also warn that the expansion would financially destabilize providers that heavily serve lower-income and minority residents because some of their more affluent patients would move to the new facilities. Those patients’ commercial insurance plans pay nearly three times what the state’s Medicaid program pays.

“It’s a very, very good business move for MGB,” said Dickson, whose system serves a large percentage of Medicaid patients. “But they know quite well this will impact our ability to care for vulnerable populations.”

The Health Policy Commission agreed with those opposing the expansion and said it would advise the state Public Health Council — which will decide on the three expansion applications by April — that the proposals are not consistent with the state’s goals for cost containment.

“Our strong assessment is this would substantially increase spending,” said Stuart Altman, a health policy professor at Brandeis University who chairs the commission. In addition, “there is a clear indication it would reduce revenues to those institutions we count on to provide services to lower-income and historically marginalized communities.”

In a written statement, Mass General Brigham ripped the commission’s findings as flawed. It also disagreed with the commission’s decision to require a cost-improvement plan but said it would work with the agency to address the challenge.

Under Massachusetts’ determination of need process, Mass General Brigham must show the Public Health Council that its expansion proposals would contribute to the state’s goals for cost containment, improved public health outcomes, and delivery system transformation.

The council has never blocked a project on cost grounds in its nearly 50-year history, said Dr. Paul Hattis, a former member of the Health Policy Commission. He argues that Massachusetts needs more explicit statutory power to decide whether health system expansions are good for the public, because he doesn’t think the council understands its own regulation.

A bill passed by the Massachusetts House of Representatives last fall would give the commission, which was created in 2012, greater authority to investigate the cost and market impact of such expansions. Its legislative fate is uncertain.

Upping the stakes in the Massachusetts expansion fight: Massachusetts General Hospital charges by far the highest prices in the state, and Brigham and Women’s Hospital isn’t far behind.

Patients with a Mass General Brigham primary care physician had the highest total per-member spending in 2019, nearly $700 per month, according to the Health Policy Commission. That was 45% higher than spending for patients served by doctors at Reliant, which is owned by UnitedHealth Group’s Optum unit. Average payments for major outpatient surgery at Massachusetts General and Brigham and Women’s were nearly twice as high as at the state’s lowest-paid high-volume hospital.

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CDC Tells Pharmacies to Give 4th Covid Shots to Immunocompromised Patients

The Centers for Disease Control and Prevention reached out to pharmacists Wednesday to reinforce the message that people with moderate to severe immune suppression are eligible for fourth covid shots.

The conference call came a day after KHN reported that immunocompromised people were being turned away by pharmacy employees unfamiliar with the latest CDC guidelines.

White House chief of staff Ron Klain tweeted Wednesday morning that “immune-compromised people should get the shots they need,” adding that the CDC “is going to send stronger messages to pharmacies to make sure this happens.”

Pharmacists who joined the call said it took place midday Wednesday, a few hours after Klain’s tweet.

The CDC “reiterated the recommendations, running through case examples,” said Mitchel Rothholz, chief of governance and state affiliates for the American Pharmacists Association, who joined the CDC call.

Rothholz said he “asked for a prepared document … that clearly laid out the recommendations … so we can clearly and consistently communicate the message. They said they would but don’t know how long that will take.”

The CDC recommends one additional shot for the 7 million American adults whose weak immune systems make them more vulnerable to covid infection and death. This group includes people with medical conditions that impair their immune response to infection, as well as people who take immune-suppressing drugs because of organ transplants, cancer, or autoimmune diseases. Although people with obesity or diabetes are at high risk of developing severe disease or dying from covid, they’re not considered immunocompromised.

For other people ages 5 or older, the CDC recommends a primary vaccine series of two doses of mRNA vaccine. Adults also may receive the one-dose Johnson & Johnson vaccine, which the CDC says may be safer for people who have had a severe allergic reaction to an mRNA vaccine.

Anyone older than 12 can get one booster dose to combat waning immunity five months after the last shot in their primary series, regardless of which vaccine they received. Vaccines are not yet authorized for children younger than 5.

The CDC first recommended fourth shots for immunocompromised people in October. The agency has been working to educate pharmacists and other health providers since then, said CDC spokesperson Kristen Nordlund. Those efforts included a conference call with health officials from every state that had thousands of participants, as well as an additional call to physicians. The CDC has streamlined its website with booster advice several times. In its guidance to pharmacists, the CDC notes that patients don’t need to provide proof that they are immunocompromised.

Alyson Smith, who was turned away from a Walgreens drugstore after booking a vaccine appointment online, said she was pleased that the CDC is trying to help.

“I appreciate that the CDC is listening to patient and physician concerns and hope they will examine their processes for clear messaging and comprehensive dissemination of information,” Smith said.

In a statement before the publication of KHN’s first story, Walgreens said it continuously updates its pharmacists on new vaccine guidance.

Some health care leaders said the CDC should have done a better job of publicizing its advice on booster shots for the immunocompromised.

The call with pharmacists “should have been done many weeks ago,” said Dr. Eric Topol, founder and director of the Scripps Research Translational Institute. “I’m glad that the White House team is finally pushing forward on this.”

Dr. Ameet Kini, a professor of pathology and laboratory medicine at Loyola University Chicago Stritch School of Medicine, said he hopes the large pharmacies that have been turning people away will issue news releases and update their websites “explicitly stating that they are offering fourth doses” to immunocompromised people. He said pharmacies also need to update their patient portals and provide “clear guidance for their pharmacists.”

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I Write About America’s Absurd Health Care System. Then I Got Caught Up in It.

I got a hurried voicemail from my pharmacist in Wisconsin the day before Thanksgiving letting me know my insurance was refusing to cover my insulin.

I had enough of the hormone that keeps me alive to last 17 days.

In my 10 years living with Type 1 diabetes, I’ve never really struggled to access insulin. But in my job reporting on the people left behind by our country’s absurdly complex health care system, I’ve written about how insulin’s steep cost leads to deadly rationing and about patients protesting to bring those prices down.

For the most part, though, I’ve been spared from the problems I cover. Maybe that’s why I waited over a week to call my new pharmacy in St. Louis, where I recently moved for this job with KHN.

I’d been waiting since September for an appointment with an endocrinologist in St. Louis; the doctor’s office couldn’t get me in until Dec. 23 and wouldn’t handle my prescriptions before then. When I finally called a pharmacy to sort this out, a pharmacist in St. Louis said my new employer-provided insurance wouldn’t cover insulin without something called a prior authorization. I’ve written about these, too. They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.

Doctors hate them. The American Medical Association has a website outlining proposed changes to the practice, while the insurance industry defends it as protecting patient safety and saving money. It feels like a lot of paperwork to confirm something we already know: Without insulin, I will die.

I knew right away the prior authorization would be a problem. Since it was a Saturday when I learned about the need for the authorization, my best option was to call my old endocrinologist’s practice that Monday morning and beg his staffers to fill out forms for their now former patient.

I had enough insulin to last seven days.

But late that afternoon, I got an automated message from the pharmacy about an insurance issue.

After spending 45 minutes on hold the next morning, I finally got through to the pharmacist, who said my insurer was still waiting for a completed prior authorization form from my physician. I called the doctor’s office to give a nudge.

Four days’ worth of insulin left.

The price of my prescription without insurance was $339 per vial of insulin, and I use about two vials per month. Normally, I pay a $25 copay. Without the prior authorization, though, I’m exposed to the list price of insulin, as is anyone with diabetes who lacks insurance, even if they live in one of the states with copay caps intended to rein in costs.

I called the pharmacy again on Thursday at 7:30 p.m., figuring it’d be less busy. I got right through to the pharmacist, who told me my insurer was still waiting on the prior authorization form. Friday morning, the diabetes nurse at my doctor’s office said she’d check on it and call me back.

I’d be out of insulin the next day.

By this time, I was live-tweeting my attempt to refill my prescription and started to get the kind of messages that are familiar to anyone in what’s known as the “diabetes online community.” People in Missouri offered me their surplus insulin. Some suggested I go to Walmart for $25 insulin, an older type I have no idea how to safely use.

My new strategy was to use one of the programs that insulin manufacturers started recently to help people get cheaper insulin. The very same day, the U.S. House Committee on Oversight and Reform’s Democrats released a report deriding these types of assistance programs as “tools to garner positive public relations, increase sales, and raise revenue.”

But before I tried that option, I heard back from the nurse who had called the pharmacy (she had spent 25 minutes on hold) and learned that my new insurance wouldn’t cover the brand of insulin I was using. The pharmacist was checking on a different brand.

Soon the pharmacist called: My insurance would cover the other brand. But the pharmacy might not have enough to fill my order. She said I should call a different branch of the chain. The first location I called was also out but pointed me to another one that had it.

With 12 hours’ worth of insulin left, I walked out of that third store with my medicine in hand.

It took 17 days and 20 phone calls. But I know I’m lucky. My insurance really is exceptional, recent events aside. My boss insisted that being alive was part of my job as I spent hours on the phone during the workday. And my job is to be persistent as I puzzle through the labyrinth of U.S. health care.

The time wasted by me, the pharmacists, the nurses and probably some insurance functionaries is astounding and likely both a cause and a symptom of the high cost of medical care. The problem is also much bigger than that.

Insulin is the single most important resource in my life, and this is what I had to do to get it. But I know not everyone has my good fortune. I’ve interviewed the loved ones of people with Type 1 diabetes who could not get insulin, and it’s not hard to imagine how my story could have ended just as tragically.

On Dec. 23, I finally saw my new doctor, who sent in a new prescription. That night, I got a message that my insurer was waiting on a prior authorization.

I had 17 days’ worth of insulin left.

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Justices Block Broad Worker Vaccine Requirement, Allow Health Worker Mandate to Proceed

The Supreme Court on Thursday blocked a key Biden administration covid-19 initiative — putting a stop, for now, to a rule requiring businesses with more than 100 workers to either mandate that employees be vaccinated against covid or wear masks and undergo weekly testing. The rule, which covers an estimated 80 million workers, took effect earlier this week.

At the same time, however, the justices said that a separate rule requiring covid vaccines for an estimated 10 million health workers at facilities that receive funding from Medicare and Medicaid could go forward. The justices removed a temporary halt imposed by a lower court late last year that affected health care facilities in half the states.

In emergency oral arguments held Jan. 7, a majority of the justices seemed dubious that the federal government, through the Occupational Safety and Health Administration, had broad enough authority to require vaccines or tests for the bulk of the nation’s private workforce, particularly for a threat that is not job-specific.

Said the unsigned majority opinion: “A vaccine mandate is strikingly unlike the workplace regulations that OSHA has typically imposed. A vaccination, after all, ‘cannot be undone at the end of the workday.’”

Three of the court’s conservatives — Justices Neil Gorsuch, Clarence Thomas and Samuel Alito — concurred with the decision in a signed opinion that laid out their concerns about OSHA’s authority. “The agency claims the power to force 84 million Americans to receive a vaccine or undergo regular testing,” they wrote. “By any measure, that is a claim of power to resolve a question of vast national significance. Yet Congress has nowhere clearly assigned so much power to OSHA.”

Liberals on the court — where anti-covid policies are even stricter than those up for debate in the case — were outraged at the majority decision, arguing that just because a threat exists outside the workplace as well as inside, that should not prevent the federal safety agency from regulating it.

Justices Stephen Breyer, Elena Kagan and Sonia Sotomayor wrote in a signed opinion, “When we are wise, we know not to displace the judgments of experts, acting within the sphere Congress marked out and under Presidential control, to deal with emergency conditions. Today, we are not wise.” In the second pair of cases also argued Jan. 7, the justices weighed whether the federal government could place conditions on payments for Medicare and Medicaid to help ensure the safety of the patients whose care is being underwritten.

The health worker rule, said the opinion, also unsigned, “fits neatly within the language of the statute. After all, ensuring that providers take steps to avoid transmitting a dangerous virus to their patients is consistent with the fundamental principle of the medical profession: first, do no harm.”

Four conservative justices — Thomas, Alito, Gorsuch and Amy Coney Barrett — dissented in the health worker case, arguing in a signed opinion that “to the extent the rule has any connection to the management of Medicare, and Medicaid, it is at most a ‘tangential’ one.”

President Joe Biden lamented the court’s decision on the rule for large workplaces. “As a result of the Court’s decision, it is now up to States and individual employers to determine whether to make their workplaces as safe as possible for employees, and whether their businesses will be safe for consumers during this pandemic by requiring employees to take the simple and effective step of getting vaccinated,” he said in a statement.

The OSHA rules are opposed by many business groups, led by the small business advocacy organization the National Federation of Independent Business. It argued that allowing the rules to take effect would leave businesses “irreparably harmed,” both by the costs of compliance and the possibility that workers would quit rather than accept the vaccine.

The challenge to the Medicare and Medicaid rules, by contrast, came mostly from states, rather than the hospitals, nursing homes and other facilities most directly affected. State officials charge that the rules would jeopardize the ability of health care providers, particularly those in rural areas, to retain enough staffers to care for patients.

The cases on the OSHA rule are National Federation of Independent Business v. Department of Labor and Ohio v. Department of Labor. The cases involving the CMS rule are Biden v. Missouri and Becerra v. Louisiana.

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Hospitales enfrentan más casos de covid en personas ya hospitalizadas, con menos personal

El 11 de enero, la Clínica Cleveland de Weston, en el sur de la Florida, estaba tratando a 80 pacientes con covid-19, 10 veces más que a fines diciembre. Casi la mitad fueron hospitalizados por otras razones médicas.

El aumento impulsado por la extremadamente infecciosa variante omicron abrumó al hospital de 206 camas: ahora tiene 250. El aumento de casos se produjo cuando el hospital ya enfrentaba una grave escasez de personal, con enfermeras y otros cuidadores ausentes por covid.

El desafío es encontrar espacio para tratar de manera segura a todos los pacientes con covid mientras se mantiene a salvo al personal y al resto de los pacientes, explicó el doctor Scott Ross, director médico.

“No es un problema de PPE”, dijo, refiriéndose a los equipos de protección personal como máscaras, “ni un problema de oxígeno, o de ventiladores. Es un problema de volumen y de asegurarnos de tener suficientes camas y cuidadores para los pacientes”.

A nivel nacional, los casos de covid y las hospitalizaciones están en sus niveles más altos desde que comenzó la pandemia. Sin embargo, a diferencia de los aumentos repentinos anteriores por covid, una gran parte de los pacientes con covid llegan al hospital por otras razones.

Las infecciones están exacerbando algunas condiciones médicas y dificultando la reducción de la propagación de covid dentro de las paredes del hospital, especialmente porque los pacientes se presentan en etapas más tempranas y más infecciosas de la enfermedad.

Aunque la variante omicron generalmente produce casos más leves, agregar la gran cantidad de estas hospitalizaciones “incidentales” a las causadas directamente por covid podría ser un punto de inflexión para un sistema de atención médica que tambalea a medida que continúa la batalla contra la pandemia.

El aumento de las tasas de covid en la comunidad también se traduce en un aumento de las infecciones entre los trabajadores de salud, lo que desequlibra más al ya abrumado sistema.

Los funcionarios y el personal de 13 sistemas hospitalarios de todo el país dijeron que la atención de pacientes infectados que necesitan otros servicios médicos es un desafío y, a veces, requiere protocolos diferentes.

El doctor Robert Jansen, director médico de Grady Health System, en Atlanta, Georgia, dijo que la tasa de infección en su comunidad no tenía precedentes. Grady Memorial Hospital pasó de 18 pacientes con covid el 1 de diciembre a 259 la semana del 3 de enero.

Aproximadamente del 80% al 90% de esos pacientes tienen covid como su diagnóstico principal o tienen una condición de salud, como enfermedad de células falciformes o insuficiencia cardíaca, que ha empeorado por covid, dijo Jansen.

Aunque menos de sus pacientes han desarrollado neumonía causada por covid que durante los picos más importantes a principios del año pasado, los líderes de Grady están lidiando con un gran número de trabajadores de salud con covid. En un momento, dijo Jansen, 100 enfermeras y otros 50 miembros del personal estaban ausentes por enfermedad.

En uno de los sistemas hospitalarios más grandes de Nueva Jersey, Atlantic Health System, donde aproximadamente la mitad de los pacientes con covid ingresaron por otras razones, no todos aquellos con covid incidental pueden trasladarse a las salas de covid, dijo el director ejecutivo Brian Gragnolati. Necesitan servicios especializados para sus otras afecciones, por lo que el personal del hospital toma precauciones especiales, como usar PPE de mayor nivel cuando trata a pacientes con covid en lugares como un ala cardíaca.

En el Hospital Jackson Memorial de Miami, donde aproximadamente la mitad de los pacientes con covid están allí principalmente por otros motivos de salud, a todos los pacientes internados por covid, ya sea que tengan síntomas o no, se los trata en una parte del hospital reservada para pacientes con la infección, dijo el doctor Hany Atallah, director médico.

Independientemente de si los pacientes son admitidos por covid, o con covid, aún ponen a prueba la capacidad del hospital para operar, dijo el doctor Alex Garza, jefe de incidentes de la Fuerza de Tareas Metropolitana contra la Pandemia de St. Louis, una colaboración de los sistemas de atención médica más grandes del área. Estimó que del 80% al 90% de los pacientes en los hospitales de la región están ahí por covid.

En Weston, Florida, la Clínica Cleveland también está teniendo dificultades para dar de alta a los pacientes con covid en hogares de adultos mayores o centros de rehabilitación porque muchos lugares no pueden atender a más pacientes con covid, dijo Ross.

El hospital también está teniendo dificultades para enviar a los pacientes a casa, por temor a que pongan en riesgo a las personas con las que viven.

Todo esto significa que hay una razón por la que los hospitales les dicen a las personas que se mantengan alejadas de la sala de emergencias a menos que sea realmente una emergencia, dijo el doctor Jeremy Faust, médico de emergencias en el Brigham and Women’s Hospital de Boston.

La gran cantidad de pacientes que se presentan y no saben que tienen covid durante este aumento aterrador, dijo Faust. A medida que llegan más casos incidentales a los hospitales, representan un mayor riesgo para el personal y otros pacientes del hospital porque generalmente se encuentran en una etapa más contagiosa de la enfermedad, antes de que comiencen los síntomas, dijo Faust.

En las anteriores oleadas de covid, las personas estaban siendo hospitalizadas en las fases media y posterior de la enfermedad.

En el análisis de datos federales de Faust, el 7 de enero mostró el segundo número más alto de casos de covid de “inicio en el hospital” desde que comenzó la pandemia. Pero estos datos representan solo a las personas que estuvieron en el hospital durante 14 días antes de dar positivo por covid, dijo Faust, por lo que es probable que se haya subestimado.

Una serie de investigación de KHN reveló múltiples lagunas en la supervisión del gobierno al responsabilizar a los hospitales por las altas tasas de pacientes con covid que fueron diagnosticados al ser admitidos, incluido que los sistemas de informes federales no registran públicamente los casos de covid contraídos en hospitales.

“Las personas en el hospital son vulnerables por muchas razones”, dijo el doctor Manoj Jain, especialista en enfermedades infecciosas en Memphis, Tennessee. “Todas sus enfermedades subyacentes existentes con múltiples condiciones médicas, todo eso los pone en un riesgo mucho mayor”.

La sala de emergencias en particular es una zona de peligro potencial en medio de la actual avalancha de casos, agregó Garza. Recomendó que los pacientes usen máscaras de alta calidad, como una KN95 o un respirador N95. Según The Washington Post, los Centros para el Control y la Prevención de Enfermedades (CDC) están sopesando si recomendar que todos los estadounidenses utilicen estas máscaras durante la crisis de omicron.

“Es física y matemáticas”, explicó Garza. “Si tienes mucha gente concentrada en un área y una carga viral alta, la probabilidad de que te expongas a algo así si no llevas la protección adecuada es mucho mayor”.

Si los pacientes no pueden tolerar una N95 durante todo un día, Faust dice que deben usarlas cuando están en contacto con el personal del hospital, los visitantes u otros pacientes.

El doctor Dallas Holladay, médico de medicina de emergencia del sistema de Servicios de Salud Samaritan de Oregon, dijo que debido a la escasez de enfermeras, más pacientes se agrupan en habitaciones de hospital. Esto aumenta su riesgo de infección.

El doctor Abraar Karan, becario de enfermedades infecciosas en Stanford, cree que todos los trabajadores de salud deberían tener el mandato de usar N95 para cada interacción con el paciente, no solo máscaras quirúrgicas, considerando el aumento en el riesgo de exposición a covid.

Pero en ausencia de mandatos de máscaras de mayor calidad para el personal, recomendó que los pacientes pidan a sus proveedores que usen un N95.

“¿Por qué deberíamos responsabilizar a los pacientes para que se protejan de los trabajadores de salud?”, se preguntó. “Es tan equivocado”.

Es posible que algunos trabajadores del hospital no sepan que se están enfermando e infectando. E incluso si lo saben, en algunos estados, incluidos Rhode Island y California, los que no presentan síntomas pueden ser llamados a trabajar nuevamente debido a la escasez de personal.

A Faust le gustaría ver una actualización de la capacidad de prueba para los trabajadores de salud y otros miembros del personal.

En Stanford, se recomiendan las pruebas periódicas, dijo Karan, y están disponibles para el personal. Pero esa es una excepción a la regla: Jain dijo que algunos hospitales se han resistido a las pruebas de rutina del personal, tanto por la fuga de recursos del laboratorio como por los posibles resultados.

“Los hospitales no quieren saber”, dijo. “Simplemente no tenemos el personal”.

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Watch and Listen: Examining the Risks of Covid’s Spread Within Hospitals

KHN Midwest correspondent Lauren Weber appeared on Newsy’s “Evening Debrief” program to discuss her recent investigative series on the risks of covid’s spread within hospitals.

The series, reported with Christina Jewett, documented how more than 10,000 patients were diagnosed with covid after being hospitalized for other medical conditions in 2020 — and how multiple gaps in government oversight fail to hold hospitals accountable for high rates of such infections. Patients and their loved ones have few options to seek improvements to infection control policies after states passed a raft of liability shield laws nationwide.

Weber also spoke on Washington, D.C., radio station WAMU’s “1A” about the issue, among other pandemic-related topics. Listen to the news roundup.

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Incidental Cases and Staff Shortages Make Covid’s Next Act Tough for Hospitals

The Cleveland Clinic in Weston, Florida, on Jan. 11 was treating 80 covid-19 patients — a tenfold increase since late December. Nearly half were admitted for other medical reasons.

The surge driven by the extremely infectious omicron variant helped push the South Florida hospital with 206 licensed beds to 250 patients. The rise in cases came as the hospital struggled with severe staff shortages while nurses and other caregivers were out with covid.

The challenge is finding room to safely treat all the covid patients while keeping staffers and the rest of patients safe, said Dr. Scott Ross, chief medical officer.

“It’s not a PPE issue,” he said, referring to personal protective equipment like masks, “nor an oxygen issue, nor a ventilator issue. It’s a volume issue and making sure we have enough beds and caregivers for patients.”

Nationally, covid cases and hospitalizations are at their highest levels since the pandemic began. Yet, unlike previous covid surges, large portions of the patients with covid are coming to the hospital for other reasons. The infections are exacerbating some medical conditions and making it harder to reduce covid’s spread within hospital walls, especially as patients show up at earlier, more infectious stages of the disease.

Although the omicron variant generally produces milder cases, adding the sheer number of these “incidental” hospitalizations to covid-caused hospitalizations could be a tipping point for a health care system that is reeling as the battle against the pandemic continues. Rising rates of covid in the community also translate to rising rates among hospital staffers, causing them to call out sick in record numbers and further stress an overwhelmed system.

Officials and staff at 13 hospital systems around the country said that caring for infected patients who need other medical services is challenging and sometimes requires different protocols.

Dr. Robert Jansen, chief medical officer at Grady Health System in Atlanta, said the infection rate in his community was unprecedented. Grady Memorial Hospital went from 18 covid patients on Dec. 1 to 259 last week.

Roughly 80% to 90% of those patients either have covid as their primary diagnosis or have a health condition — such as sickle cell disease or heart failure — that has been exacerbated by covid, Jansen said.

Although fewer of their patients have developed pneumonia caused by covid than during the major spikes early last year, Grady’s leaders are grappling with high numbers of health care workers out with covid. At one point last week, Jansen said, 100 nurses and as many as 50 other staff members were out.

In one of New Jersey’s largest hospital systems, Atlantic Health System, where about half the covid patients came in for other reasons, not all of those with incidental covid can be shifted into the covid wards, CEO Brian Gragnolati said. They need specialized services for their other conditions, so hospital staffers take special precautions, such as wearing higher-level PPE when treating covid patients in places like a cardiac wing.

At Miami’s Jackson Memorial Hospital, where about half the covid patients are there primarily for other health reasons, all patients admitted for covid — whether they have symptoms or not — are treated in a part of the hospital reserved for covid patients, said Dr. Hany Atallah, chief medical officer.

Regardless of whether patients are admitted for or with covid, the patients still tax the hospital’s ability to operate, said Dr. Alex Garza, incident commander of the St. Louis Metropolitan Pandemic Task Force, a collaboration of the area’s largest health care systems. He estimated that 80% to 90% of patients in the region’s hospitals are there because of covid.

In Weston, Florida, the Cleveland Clinic is also having a hard time discharging covid patients to nursing homes or rehabilitation facilities because many places aren’t able to handle more covid patients, Ross said. The hospital is also having difficulty sending patients home, out of concern they would put those they live with at risk.

All this means there’s a reason that hospitals are telling people to stay away from the ER unless it’s truly an emergency, said Dr. Jeremy Faust, an emergency medicine physician at Brigham and Women’s Hospital in Boston.

The sheer number of patients who are showing up and don’t know they have covid during this surge is frightening, Faust said. As more incidental cases pour into hospitals, they pose a greater risk to staffers and other hospital patients because they are typically at a more contagious stage of the disease — before symptoms begin, Faust said. In previous covid waves, people were being hospitalized in the middle and later phases of the illness.

In Faust’s analysis of federal data, Jan. 7 showed the second-highest number of “hospital onset” covid cases since the pandemic began, behind only an October 2020 outlier, he said. But this data accounts for only people who were in the hospital for 14 days before testing positive for covid, Faust said, so it’s likely an undercount.

A KHN investigative series revealed multiple gaps in government oversight in holding hospitals accountable for high rates of covid patients who didn’t have the diagnosis when they were admitted, including that federal reporting systems don’t publicly note covid caught in individual hospitals.

“People in the hospital are vulnerable for many reasons,” said Dr. Manoj Jain, an infectious disease specialist in Memphis, Tennessee. “All of their existing underlying illnesses with multiple medical conditions — all of that puts them at much greater risk.”

The ER in particular is a potential danger zone amid the current crush of cases, Garza said. He recommended that patients wear high-quality masks, like a KN95, or an N95 respirator. According to The Washington Post, the Centers for Disease Control and Prevention is weighing whether to recommend that all Americans upgrade their masks during the omicron surge.

“It’s physics and math,” Garza said. “If you’ve got a lot of people concentrated in one area and a high viral load, the probability of you being exposed to something like that if you’re not wearing adequate protection are much higher.”

If patients can’t tolerate an N95 for an entire day, Faust urges them to wear upgraded masks whenever they come into contact with hospital staffers, visitors or other patients.

Dr. Dallas Holladay, an emergency medicine physician for Oregon’s Samaritan Health Services system, said that because of nursing shortages, more patients are being grouped together in hospital rooms. This raises their infection risk.

Dr. Abraar Karan, an infectious diseases fellow at Stanford, believes all health care workers should be mandated to wear N95s for every patient interaction, not just surgical masks, considering the rise in covid-exposure risk.

But in the absence of higher-quality mask mandates for staffers, he recommended that patients ask that their providers wear an N95.

“Why should we be putting the onus on patients to protect themselves from health care workers when health care workers are not even going to be doing that?” he asked. “It’s so backwards.”

Some hospital workers may not know they are getting sick — and infectious. And even if they do know, in some states, including Rhode Island and California, health care workers who are asymptomatic can be called back to work because of staffing shortages.

Faust would like to see an upgrade of testing capacity for health care workers and other staff members.

At Stanford, regular testing is encouraged, Karan said, and tests are readily available for staffers. But that’s an exception to the rule: Jain said some hospitals have resisted routine staff testing — both for the lab resource drain and the possible results.

“Hospitals don’t want to know,” he said. “We just don’t have the staff.”

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Left Behind: Medicaid Patients Say Rides to Doctors Don’t Always Come

Tranisha Rockmore and her daughter Karisma waited at an Atlanta children’s hospital in July for their ride home.

Karisma had been at Children’s Healthcare of Atlanta to have her gastrostomy tube fixed, Rockmore said. The 4-year-old, who has several severe medical conditions, has insurance coverage from Medicaid, which provides transportation to and from nonemergency medical appointments through private vendors.

After being told that a ride would not be available for hours, Rockmore said, she finally gave up and called her sister to drive them home to the South Georgia town of Ashburn, more than 160 miles away.

She said it wasn’t the first time she had run into trouble with the Medicaid transportation service.

“Sometimes they don’t ever come,” said Rockmore, who doesn’t own a car. Many rides have been canceled recently, she said; the company told her it couldn’t find drivers. “Sometimes they make me feel like they don’t care if my child gets to the doctor or not.”

Rockmore’s remarks would no doubt resonate with the Medicaid beneficiaries, relatives and advocacy groups across the country upset about problems patients have getting transportation for medical appointments. Not only are some shuttle drivers no-shows, but some patients have been injured during rides because their wheelchairs were not properly secured, according to lawsuits filed in Georgia and other states.

States are required to set up transportation to medical appointments for adults, children and people with disabilities in the Medicaid health insurance program. Transportation brokers — such as Modivcare, which Rockmore used — have subcontracts with local providers, often small “mom and pop” operations, to shuttle patients to and from needed appointments, including for dialysis, adult day care, and mental health and treatment for substance use disorders.

It’s a lucrative business, with transportation management contracts that can be worth tens of millions of dollars for companies. The two companies that have contracts in Georgia have given extensively to political campaigns of elected officials in the state. The firms, Modivcare and Southeastrans, have also faced complaints, lawsuits and state government fines in Georgia and elsewhere. The two companies maintain, though, that the complaints relate to a tiny percentage of rides provided.

Medicaid nonemergency transportation “is absolutely a national challenge,’’ said Matt Salo, executive director of the National Association of Medicaid Directors. “This is something practically all the states we talk to are dealing with. I don’t think anyone has figured this out.”

Beth Holloway, 47, of Wharton, New Jersey, said she has had multiple problems with rides. “Sometimes they arrive late, other times not at all,” said Holloway, who has cerebral palsy and lives independently. “I’ve been stranded at doctors’ offices for hours, sometimes out in the elements.”

In Los Angeles, Rose Ratcliff and several other patients filed a lawsuit in 2017 against Modivcare, then known as LogistiCare; other local transportation brokers; and the insurers that run the state Medicaid program, known as Medi-Cal in California.

The pending suit alleges that Ratcliff and other patients like her missed crucial dialysis appointments and faced unsafe conditions during transport. It calls Modivcare the “broken link” in the Medicaid transportation chain and claims the company did not adequately respond to complaints from clients like Ratcliff.

Katherine Zerone, a spokesperson for Modivcare, said the company does not comment on pending litigation. In an initial legal response, it said the problems were linked to the independent transportation vendors and their employees, not Modivcare/LogistiCare.

After complaints were made about Southeastrans’ service across Indiana, the state appointed a special legislative commission to review the company’s performance. Indiana now publishes detailed complaint data for the Atlanta-based company each month.

In August, James Mills, a Bloomington man who uses a wheelchair, filed a lawsuit alleging that the company had violated the Americans with Disabilities Act and other civil rights laws by not providing a wheelchair-accessible vehicle to transport him to and from his appointments. The lawsuit alleges that because of the lack of wheelchair accommodation, Mills missed needed medical care and was even kicked off the patient lists of some of his local doctors.

“While we’re unable to comment on pending litigation, we’re aware of the matter and strongly disagree with the allegations,’’ said Christopher Lee, an attorney for Southeastrans, which operates in seven states and Washington, D.C.

Two decades ago, Georgia was one of the first states to start using transportation brokers to manage its Medicaid transportation program. The two longtime providers in the state — Modivcare and Southeastrans — will receive a total of $127.6 million from the state this fiscal year. They are paid a per-member monthly rate that averages $5.60 in Georgia, regardless of how many rides, if any, a Medicaid user takes. The state was expected to announce new contracts for Medicaid transportation this month.

Georgia assessed a total of $4.4 million in penalties to the two companies over the period from January 2018 to December 2020 for failing to pick up patients on time and other problems. However, the state Medicaid agency essentially gave them discounts, charging the two companies only $1.2 million during that period, according to state Department of Community Health letters obtained through an open records request. In extending the brokers’ contracts in the 2018 fiscal year, the state Medicaid agency agreed to cap damages at 25% of the assessed amount, Department of Community Health spokesperson Fiona Roberts said.

Modivcare said it’s the largest transportation broker nationally, controlling about 40% of the market. The publicly traded company based in Colorado provides Medicaid transportation in more than 20 states.

Modivcare and other companies say only a tiny fraction of the rides they provide lead to complaints. “Our first priority is safe and reliable transportation,” Zerone said. In Georgia, 99.8% of its trips are complaint-free, she said.

Andrew Tomys, Georgia state director for Southeastrans, said 99.9% of the trips his company services in the state are “free of valid complaints.”

Both Modivcare and Southeastrans say they investigate each complaint to determine whether it’s valid. In Georgia, Modivcare reported to the Department of Community Health more than 3,200 late rides or no-shows over a year out of around 2.3 million rides. Southeastrans reported just over 900 such problems out of around 1.4 million rides.

But patients and their advocates say that in many cases problems aren’t reported, or complaints are ignored.

Georgia should peg any new contracts to timely rides, ease of use for beneficiaries and the overall ride experience, said Melissa Haberlen DeWolf, policy director of the advocacy group Voices for Georgia’s Children.

In recent election cycles, Southeastrans and Modivcare — through its former corporate name LogistiCare — have been generous donors to Georgia Republicans, who have controlled state offices in the state for nearly two decades.

Southeastrans, as a company, has donated $126,000 to Georgia Republican campaigns and committees since 2017, according to documents on the Georgia Government Transparency and Campaign Finance Commission website.

Additionally, Southeastrans’ co-founder and CEO, Steve Adams, has given at least $86,000 to Georgia Republican candidates for state office and to the state Republican Party since 2017, according to state filings. During that same period, Adams donated $3,800 to two state Democratic candidates.

“As a minority-owned business headquartered in Georgia for over 20 years, Southeastrans and its owner have contributed to a diverse mix of local causes and organizations,” Lee said.

Modivcare, through LogistiCare, has given $48,350 to Georgia Republican candidates in state races since 2017, according to the Georgia Government Transparency and Campaign Finance Commission. It gave $750 to former Democratic state Rep. Pat Gardner, also according to the commission. Modivcare’s Zerone did not answer questions about the company’s political giving because she said it would be “competitive information.”

Such contributions can help companies buy access to government officials, said Paul S. Ryan, a vice president at the government watchdog group Common Cause.

“Anytime a special interest doing business with the government can make big contributions to public officials handing out contracts or making other government decisions, it’s a cause for concern,” he said. “Average, everyday Americans can’t buy the same influence.”

Tranisha Rockmore said she’s so fed up that she wants to get a car so she can avoid the transportation problems. “I’m to the point where I feel like they don’t care about my daughter,” she said. “You don’t just do people’s kids like that.”

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This story can be republished for free (details).

from Health Industry – Kaiser Health News

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