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Agotados por covid y por trabajar 80 horas a la semana, médicos residentes deciden sindicalizarse

En las primeras semanas de la pandemia, el doctor Lorenzo González, entonces residente de segundo año de medicina familiar en el Centro Médico Harbor-UCLA, trabajaba hasta 80 horas a la semana en la unidad de terapia intensiva. Siempre tenía miedo de contraer covid-19 y se sentía culpable por no tener tiempo suficiente para ayudar a su padre enfermo.

En abril de 2020, su padre, un jardinero jubilado, murió de insuficiencia cardíaca y pulmonar. González hizo el duelo solo. Su trabajo como médico en formación le exponía a un alto riesgo de contraer el virus, y no quería contagiar a su familia. El estrés económico también se apoderó de él al tener que hacer frente a los elevados costos del entierro.

Ahora, González reclama una mejor remuneración y prestaciones para los residentes que trabajan horarios agotadores en los hospitales públicos del condado de Los Angeles por lo que, según él, reciben menos de $18 la hora, mientras atienden a los pacientes más vulnerables del condado.

“Se están aprovechando de nuestro altruismo”, dijo González. Ahora es jefe de residentes de medicina familiar en Harbor-UCLA y presidente del Comité de Internos y Residentes (CIR), un sindicato nacional que representa a los médicos en prácticas y que forma parte del Sindicato Internacional de Empleados de Servicios (SEIU).

“Necesitamos que se reconozcan los sacrificios que hemos hecho”, señaló.

Los residentes son médicos recién recibidos, que han terminado la carrera de medicina, y deben pasar de tres a siete años de formación en hospitales universitarios antes de poder ejercer de forma independiente.

Bajo la supervisión de un médico profesor, los residentes examinan, diagnostican y tratan a los pacientes. Algunos buscan formación adicional en especialidades médicas como “fellows” (práctica de especialización).

Estos médicos en formación se están agrupando en California, y otros estados, para exigir mayores salarios y mejores beneficios y condiciones de trabajo, luego de la enorme presión vivida durante la pandemia.

Así, se suman a enfermeras y enfermeros, auxiliares de enfermería y otros trabajadores de salud que se están sindicalizando y amenazan con ir a la huelga, ya que la escasez de personal, el aumento del costo de la vida y la falta de uniformidad en el suministro de equipos de protección personal y vacunas contra covid les han llevado al límite.

Más de 1,300 residentes sindicalizados y otros médicos en formación de tres hospitales públicos del condado de Los Angeles, incluido el Harbor-UCLA, votarán el 30 de mayo si se declaran en huelga para pedir un aumento de salarios y de gastos de alojamiento, tras un mes de bloqueo de las negociaciones con el condado.

Desde marzo, los residentes de Stanford Health Care, la Facultad de Medicina Keck de la Universidad del Sur de California y el Centro Médico de la Universidad de Vermont se han sindicado.

“Los residentes siempre han trabajado horarios de locos, pero el estrés de la pandemia les afectó mucho”, explicó John August, director de la Facultad de Relaciones Industriales y Laborales de la Universidad de Cornell.

La Asociación de Escuelas de Medicina de Estados Unidos, un grupo que representa a los hospitales universitarios y a las facultades de medicina, no abordó directamente la tendencia a la sindicalización de los residentes, pero la jefa de atención sanitaria de la organización, la doctora Janis Orlowski, comunicó a través de un vocero que una residencia es un aprendizaje laboral, y que la función principal de un residente es formarse.

Los residentes cobran como aprendices mientras estudian, se forman y trabajan, dijo Orlowski, y la asociación trabaja para garantizar que reciban una formación y un apoyo eficaces.

David Simon, vocero de la Asociación de Hospitales de California, no quiso hacer comentarios. Pero remitió a un estudio publicado en JAMA Network Open, en septiembre, en el que se mostraba que los residentes de cirugía en programas sindicados no reportaban menores tasas de agotamiento que los de los programas no sindicados.

Según el sindicato nacional, hasta el momento ningún nuevo grupo sindical ha alcanzado ningún acuerdo. Pero algunos de los más antiguos han conseguido mejoras en los salarios, las prestaciones y las condiciones de trabajo. El año pasado, un sindicato de residentes de la Universidad de California-Davis consiguió subvenciones para la vivienda y permisos parentales pagos.

Con más de 20,000 miembros, el CIR/SEIU representa a uno de cada siete médicos en formación en Estados Unidos. Su directora ejecutiva, Susan Naranjo, dijo que antes de la pandemia se organizaba un nuevo grupo sindical cada año, y que en el último año y medio se han unido ocho.

Las condiciones de trabajo de los residentes ya habían sido objeto de escrutinio mucho antes de la pandemia.

El salario medio de los residentes en Estados Unidos en 2021 era de $64,000, según MedScape, un sitio web de noticias para médicos, y los residentes pueden trabajar hasta 24 horas en un turno, pero no más de 80 horas a la semana.

Aunque una encuesta cuyos resultados se publicaron el año pasado encontró que el 43% de los residentes se sentían compensados adecuadamente, los que se están sindicalizando dicen que los salarios son demasiado bajos, especialmente teniendo en cuenta la carga de trabajo de los residentes, su deuda de préstamos estudiantiles y el aumento del costo de vida.

La tasa salarial afecta de manera desproporcionada a los residentes de comunidades de bajos ingresos y de color, afirmó González, porque tienen menos ayuda financiera de la familia para subvencionar su educación médica y para pagar otros gastos.

Sin embargo, al tener poco control sobre el lugar en el que se forman —a los graduados de escuelas de medicina se les asigna su residencia mediante un algoritmo—, individualmente, los residentes tienen un poder de negociación limitado con los hospitales.

Para los residentes sindicalizados que buscan ser escuchados, los aumentos salariales y los beneficios, como los estipendios de vivienda, son a menudo la prioridad, dijo Naranjo.

Los pacientes merecen médicos que no estén agotados y preocupados por el estrés financiero, dijo la doctora Shreya Amin, “fellow” de endocrinología en el Centro Médico de la Universidad de Vermont. A Amin le sorprendió que la institución se negara a reconocer al sindicato de residentes, teniendo en cuenta los sacrificios personales que hicieron durante la pandemia.

Si un hospital no reconoce voluntariamente a un sindicato, el CIR puede solicitar que la Junta Nacional de Relaciones Laborales administre una elección. El sindicato nacional lo hizo en abril, y con una mayoría de votos certificada, la sección de Vermont puede ahora comenzar la negociación colectiva, señaló Naranjo.

Annie Mackin, vocera del centro médico, declaró en un correo electrónico que está orgullosa de sus residentes por haber prestado una atención excepcional durante la pandemia y respeta su decisión de afiliarse a un sindicato. Mackin no quiso referirse a las preocupaciones de los residentes sobre las condiciones de trabajo.

La doctora Candice Chen, profesora de políticas de salud en la Universidad George Washington, cree que los Centros de Servicios de Medicare y Medicaid (CMS) también tienen cierta responsabilidad en las condiciones de trabajo de los residentes. Dado que la agencia paga a los hospitales universitarios para que formen a los residentes, debería responsabilizar a los centros de cómo los tratan, dijo.

Y el Consejo de Acreditación para la Educación Médica de Postgrado, que establece las normas laborales y educativas para los programas de residencia, se está moviendo en la dirección correcta con nuevos requisitos como la licencia familiar pagada, agregó, pero necesita hacer más.

Está por verse hasta dónde llegarán estos sindicatos para conseguir sus objetivos.

Las huelgas son poco frecuentes entre los médicos. La última huelga del CIR fue en 1975, la realizaron los residentes de 11 hospitales de Nueva York.

Naranjo aseguró que una huelga sería el último recurso para sus miembros en el condado de Los Angeles, pero culpó al condado de retrasar y cancelar continuamente las sesiones de negociación. Entre sus demandas, el sindicato pide que el condado iguale el aumento salarial concedido a los miembros del SEIU 721, un sindicato que representa a otros empleados del condado, y que se conceda un subsidio de vivienda de $10,000.

Las encuestas realizadas a los miembros del sindicato han revelado que la mayoría de los médicos residentes del condado de Los Angeles dicen trabajar 80 horas a la semana, según Naranjo.

Una vocera del Departamento de Servicios de Salud del condado de Los Angeles, Coral Itzcalli, agradeció a su “heroica” fuerza de trabajo de primera línea por proporcionar “la mejor atención de su clase” y reconoció la importante carga que la pandemia ha supuesto para sus vidas personales y profesionales. Dijo que el Consejo de Acreditación para la Educación Médica de Postgrado establece los límites de horas y que la mayoría de los médicos en formación dicen trabajar “significativamente menos” de 80 horas a la semana.

Jesús Ruiz, vocero de la Oficina Ejecutiva del condado de Los Angeles, que gestiona las negociaciones laborales, indicó por correo electrónico que el condado espera llegar a un “contrato justo y fiscalmente responsable” con el sindicato.

Se espera que los resultados de la votación sobre la huelga se anuncien el 31 de mayo, según comunicó el sindicato.

Esta historia fue producida 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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Burned Out by Covid and 80-Hour Workweeks, Resident Physicians Unionize

In the early weeks of the pandemic, Dr. Lorenzo González, then a second-year resident of family medicine at Harbor-UCLA Medical Center, ran on fumes, working as many as 80 hours a week in the ICU. He was constantly petrified that he would catch the covid-19 virus and guilt-ridden for not having enough time to help his ailing father.

In April 2020, his father, a retired landscaper, died of heart and lung failure. González mourned alone. His job as a doctor-in-training put him at high risk of catching the virus, and he didn’t want to inadvertently spread it to his family. Financial stress also set in as he confronted steep burial costs.

Now, González is calling for better pay and benefits for residents who work grueling schedules at Los Angeles County’s public hospitals for what he said amounts to less than $18 an hour — while caring for the county’s most vulnerable patients.

“They’re preying on our altruism,” González said of the hospitals. He is now chief resident of family medicine at Harbor-UCLA and president of the Committee of Interns and Residents, a national union that represents physician trainees and that is part of the Service Employees International Union.

“We need acknowledgment of the sacrifices we’ve made,” he said.

Residents are newly minted physicians who have finished medical school and must spend three to seven years training at established teaching hospitals before they can practice independently. Under the supervision of a teaching physician, residents examine, diagnose, and treat patients. Some seek additional training in medical specialties as “fellows.”

These trainees are banding together in California and other states to demand higher wages and better benefits and working conditions amid intensifying burnout during the pandemic. They join nurses, nursing assistants, and other health care workers who are unionizing and threatening to strike as staffing shortages, the rising cost of living, and inconsistent supplies of personal protective equipment and covid vaccines have pushed them to the brink.

More than 1,300 unionized residents and other trainees at three L.A. County public hospitals, including Harbor-UCLA, will vote May 30 on whether to strike for a bump in their salaries and housing stipends, after a monthslong negotiation deadlock with the county. Since March, residents at Stanford Health Care, Keck School of Medicine at the University of Southern California, and the University of Vermont Medical Center have unionized.

“Residents were always working crazy hours, then the stress of the pandemic hit them really hard,” said John August, a director at Cornell University’s School of Industrial and Labor Relations.

The Association of American Medical Colleges, a group that represents teaching hospitals and medical schools, did not address the unionization trend among residents directly, but the organization’s chief health care officer, Dr. Janis Orlowski, said through a spokesperson that a residency is a working apprenticeship and that a resident’s primary role is to be trained.

Residents are paid as trainees while they are studying, training, and working, Orlowski said, and the association works to ensure that they receive effective training and support.

David Simon, a spokesperson for the California Hospital Association, declined to comment. But he forwarded a study published in JAMA Network Open in September showing that surgery residents in unionized programs did not report lower rates of burnout than those in nonunionized programs.

So far, none of the new chapters have negotiated their first contracts, the national union said. But some of the longer-standing ones have won improvements in pay, benefits, and working conditions. Last year, a resident union at the University of California-Davis secured housing subsidies and paid parental leave through its first contract.

With more than 20,000 members, CIR represents about 1 in 7 physician trainees in the U.S. Executive Director Susan Naranjo said that before the pandemic one new chapter organized each year and that eight have joined in the past year and a half.

Residents’ working conditions had come under scrutiny long before the pandemic.

The average resident salary in the U.S. in 2021 was $64,000, according to Medscape, a physician news site, and residents can work up to 24 hours in a shift but no more than 80 hours per week. Although one survey whose results were released last year found that 43% of residents felt they were adequately compensated, those who are unionizing say wages are too low, especially given residents’ workload, their student loan debt, and the rising cost of living.

The pay rate disproportionately affects residents from low-income communities and communities of color, González said, because they have less financial assistance from family to subsidize their medical education and to pay for other costs.

But with little control over where they train — medical school graduates are matched to their residency by an algorithm — individual residents have limited negotiating power with hospitals.

For unionizing residents seeking a seat at the table, wage increases and benefits like housing stipends are often at the top of their lists, Naranjo said.

Patients deserve doctors who aren’t exhausted and preoccupied by financial stress, said Dr. Shreya Amin, an endocrinology fellow at the University of Vermont Medical Center. She was surprised when the institution declined to recognize the residents’ union, she said, considering the personal sacrifices they had made to provide care during the pandemic.

If a hospital does not voluntarily recognize a union, CIR can request that the National Labor Relations Board administer an election. The national union did so in April, and with a certified majority vote, the Vermont chapter can now begin collective bargaining, Naranjo said.

Annie Mackin, a spokesperson for the medical center, said in an email that it is proud of its residents for delivering exceptional care throughout the pandemic and respects their decision to join a union. Mackin declined to address residents’ workplace concerns.

Dr. Candice Chen, an associate professor of health policy at George Washington University, believes that the federal Centers for Medicare & Medicaid Services also bears some responsibility for residents’ working conditions. Because the agency pays teaching hospitals to train residents, it should hold the facilities accountable for how they treat them, she said. And the Accreditation Council for Graduate Medical Education, which sets work and educational standards for residency programs, is moving in the right direction with new requirements like paid family leave, she added, but needs to do more.

How far these unions will go to achieve their goals is an open question.

Strikes are rare among doctors. The last CIR strike was in 1975, by residents at 11 hospitals in New York.

Naranjo said a strike would be the last resort for its L.A. County members but blamed the county for continuously delaying and canceling bargaining sessions. Among its demands, the union is calling for the county to match the wage increase granted to members of SEIU 721, a union that represents other county employees, and for a $10,000 housing allowance.

The union’s member surveys have found that most L.A. County residents report working 80 hours a week, Naranjo said.

A spokesperson for L.A. County’s Department of Health Services, Coral Itzcalli, thanked its “heroic” front-line workforce for providing “best-in-class care” and acknowledged the significant toll that the pandemic has taken on their personal and professional lives. She said limits on hours are set by the Accreditation Council for Graduate Medical Education and that most trainees report working “significantly less” than 80 hours a week.

Jesus Ruiz, a spokesperson for the L.A. County Chief Executive Office, which manages labor negotiations for the county, said via email that the county hopes to reach a “fair and fiscally responsible contract” with the union.

Results of the strike vote are expected to be announced May 31, the union 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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‘An Arm and a Leg’: Private Equity Is Everywhere in Health Care. Really.

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When a listener wrote to us about a pricey colonoscopy quote, we got curious. It turns out, a few years back, investors identified gastroenterology as their next hot-ticket item.

Private equity companies are the house-flippers of the investment world, and they’ve found their way into many areas of our lives. Now, they’re at gastroenterologists’ offices, too, hoping to change the way these doctors do business and make a quick buck selling the practice down the road.

In this episode of the podcast, we find out why these doctors are selling their practices to private equity to begin with, and what it could mean for the quality and cost of your health care.

Here’s a transcript.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

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Novavax Missed Its Global Moonshot but Is Angling to Win Over mRNA Defectors

Novavax hitched its wagon to the global coronavirus pandemic. Before most Americans truly grasped the scope of the danger, the small Maryland biotech startup had secured $1.6 billion in U.S. funding for its covid vaccine. Its moonshot goal: delivering 2 billion shots to the world by mid-2021.

Although the U.S. commitment eventually expanded to $1.8 billion, hardly any Novavax shots have found arms due to manufacturing issues, and most of the world has moved on. Novavax stock has plummeted from $290 a share in February 2021 to around $50 recently.

The FDA finally appears poised to authorize the company’s vaccine, however. If it does, Novavax would target the tens of millions of Americans who are not vaccinated against covid-19 or would benefit from boosters but have avoided mRNA vaccines because of health concerns or conspiracy theories about their dangers.

In clinical trials, Novavax’s two-dose vaccine has worked well and had few safety problems. It appears to cause fewer unpleasant reactions — fever, chills, and exhaustion — associated with mRNA vaccines produced by Moderna and Pfizer-BioNTech.

Novavax also relies on a more time-tested technology, using recombinant proteins grown in cell cultures. An influenza vaccine produced much the same way as Novavax’s shot has been on the market in the United States for nearly a decade.

“I do think there is a minority group who would take a protein vaccine over an mRNA vaccine,” said Dr. Kathleen Neuzil, director of the Center for Vaccine Development and Global Health at the University of Maryland. She was a researcher in a major U.S. trial of the Novavax vaccine, which found it 100% effective at preventing anything worse than mild covid.

With the FDA’s authorization, Novavax’s product would be the first vaccine produced in India for U.S. consumption. Novavax turned to the Serum Institute of India, a seasoned manufacturer that makes vaccines for poor countries, when its subcontractor in Texas, Fujifilm Diosynth Biotechnologies, stopped producing the vaccine last summer after it was dinged by FDA inspectors for inadequate contamination control, missing records, and other problems.

Founded in 1987, Novavax has never marketed a vaccine in the United States. It has boasted about the potential of a secret proprietary ingredient, Matrix-M, an immune system booster derived from Chilean soapbark trees. Those who’ve observed the company’s string of failures over the past decade see its June 7 FDA advisory committee meeting as the last chance to market its covid vaccine here, although it has obtained more than $2 billion in contracts with the U.S. government and nonprofit organizations.

Pharma giants Sanofi and GSK are jointly developing a similar vaccine. European Union reviewers began an examination of the drugmakers’ vaccine in March, and the companies expect to request an FDA review “in coming weeks,” Sanofi spokesperson Sally Bain said.

Even with FDA authorization, Novavax may be too late. While its vaccine is licensed in 41 countries and at least 42 million doses have been distributed, the world is overstocked with covid vaccine.

“They are applying for an emergency authorization” from the FDA, said Manon Cox, a vaccine industry consultant and the former CEO of Protein Sciences Corp., which made a similar vaccine. “What’s the emergency?”

Demand for covid vaccines is sluggish everywhere. About 13 million doses of the Novavax vaccine had been distributed in European Union countries as of mid-April, but fewer than 200,000 were administered. Distribution of the vaccine has been negligible since then.

Gavi, a nongovernmental organization, has suspended a 2021 agreement to buy at least 350 million Novavax doses for the COVAX program, which distributes vaccines at a deep discount to poor countries.

The U.S. market, however, shows promise for Novavax’s shot as an alternative to mRNA vaccines, especially now that the FDA has limited the use of a fourth vaccine, made by Johnson & Johnson, because of a serious though rare safety risk.

“The anti-vaxxers have been getting more and more aggressive about mRNA vaccine safety, including in recent months claiming these vaccines cause AIDS,” said John Moore, a professor of microbiology and immunology at Weill Cornell Medicine. “It’s all utter BS. But some people do buy into this garbage.”

Neuzil said the Novavax shot could prove more durable than the mRNA shots, whose capacity to prevent infection seems to fade after several months, although they are effective at keeping people out of the hospital.

“Realistically, there probably aren’t that many unvaccinated people who will now decide to take Novavax,” Moore said. “Being unvaccinated is mostly down to politics, not science, sadly.”

Most of the demand would be for boosters. But the FDA has indicated Novavax’s shots would be authorized initially as a first dose, not a booster, John Trizzino, Novavax’s chief commercial officer, told KHN in an interview. FDA officials also have bruited the possibility of requiring vaccine manufacturers to modify their shots by this fall to target the omicron variant.

Novavax has data showing its shot effectively boosts people who received mRNA vaccines, Trizzino said. And although the company is skeptical about the need to modify its shot, Novavax recently began testing an omicron-targeted vaccine and expects results in late summer, he said.

It’s surprising that Novavax should face this quandary now. The company announced May 9 that it had made its first-ever quarterly profit, of $203 million on $586 million in vaccine sales.

Novavax expects revenue of $4 billion to $5 billion this year in global sales, Trizzino said, noting “this is not just a pandemic question, it’s an ongoing vaccination question.” At an April 6 meeting, federal officials strongly suggested that covid vaccination will become an annual recommendation, like the flu shot.

“We were slightly behind providing supply into the pandemic period, unfortunately,” Trizzino said, “but there’s going to be at least some kind of annual revaccination.”

Trizzino said the company was negotiating with U.S. officials on how much of the remainder of its $1.8 billion contract would pay for shots as opposed to research. Beyond the contract, Novavax can charge the U.S. government a higher per-unit price for additional vaccine, he said.

The Biden administration’s budget contains no mention of further Novavax contracts, but if federal purchases end, Novavax could sell on the commercial market. Medicare officials have set the price for covid vaccines at about $60 per dose — approximately three times what Novavax has been getting from the U.S. and European government buyers, Trizzino said.

The company has come a long way from its first product, a microscopic fat particle designed to encase vaccines that instead was employed in skin care products and Girl Scout cookies, according to “The First Shots,” an account by journalist Brendan Borrell. Novavax spent hundreds of millions to develop a vaccine against respiratory syncytial virus, an infection that is especially harmful to babies and the elderly, but the product failed in 2016, after the company brushed aside a design feature originating in the National Institutes of Health laboratory of Dr. Barney Graham. That feature, which involves shaping the viral protein to allow the immune system to better recognize it, is now a key part of all the U.S. covid vaccines, including the Novavax shot.

In 2019, Novavax sold its vaccine production facility and laid off all but about 100 employees. A year later it was revived by Operation Warp Speed, the massive public-private effort to produce covid vaccines.

To make its shot, the company genetically alters an insect virus called a baculovirus to produce covid proteins in moth cells. The system was developed by Gale Smith, first at Protein Sciences Corp., which used it to license an influenza vaccine. Sanofi in 2017 bought Protein Sciences and its vaccine.

Smith, who has worked at Novavax since 2003, saw the moth cell system as a safer, faster alternative to traditional methods of growing vaccine viruses in eggs or monkey and dog kidney cell cultures, which were prone to contamination with potentially dangerous viruses. Baculoviruses don’t grow in people.

But the baculovirus system is messy, according to Kevin Gilligan, a senior consultant at Biologics Consulting Group in Alexandria, Virginia, and a former federal pandemic preparedness official. The product of the moth cell bioreactors can be a sticky mixture of cellular debris, and insect and viral proteins.

“It’s a whole soup of all kinds of things,” Cox said. “You go through a purification process and hopefully end up with that 90-plus percent pure protein you want.”

According to one report, some lots produced at the Texas plant were only 70% pure. So Novavax turned to the Serum Institute of India, one of several companies in the U.S., Asia, and Europe with which it had signed manufacturing agreements in 2020.

In the meantime, Novavax’s executives reaped record payouts in 2020. CEO Stanley Erck got $48 million, mostly in stocks and bonuses, while Trizzino and others got payouts of $20 million or more each. Over the past year, company executives cashed out stocks worth more than $150 million.

Shareholders have sued Novavax over sagging stock prices following missed deadlines for its vaccine.

In June 2021 Novavax hired a leading process engineer, Indresh Srivastava, from Sanofi. The company’s manufacturing problems are “well past us,” Trizzino said.

In an unusual twist, while U.S. taxpayers may come to rely on the Indian version of a vaccine they heavily funded, another Indian company, Biological E, is making a vaccine invented by Peter Hotez, Maria Elena Bottazzi, and colleagues at Baylor College of Medicine. Their only government funding was a $400,000 NIH grant, Hotez said, and Baylor is giving the shot away to companies that will make it cheaply in lower-income countries.

About 45 million doses of the vaccine have been administered so far to Indian teens — with a cost to the Indian government of $1.86 per shot.

KHN correspondent Rachana Pradhan contributed to this report.

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No Prison Time for Tennessee Nurse Convicted of Fatal Drug Error

RaDonda Vaught, a former Tennessee nurse convicted of two felonies for a fatal drug error, whose trial became a rallying cry for nurses fearful of the criminalization of medical mistakes, will not be required to spend any time in prison.

Davidson County criminal court Judge Jennifer Smith on Friday granted Vaught a judicial diversion, which means her conviction will be expunged if she completes a three-year probation.

Smith said that the family of the patient who died as a result of Vaught’s medication mix-up suffered a “terrible loss” and “nothing that happens here today can ease that loss.”

“Miss Vaught is well aware of the seriousness of the offense,” Smith said. “She credibly expressed remorse in this courtroom.”

The judge noted that Vaught had no criminal record, has been removed from the health care setting, and will never practice nursing again. The judge also said, “This was a terrible, terrible mistake and there have been consequences to the defendant.”

As the sentence was read, cheers erupted from a crowd of hundreds of purple-clad protesters who gathered outside the courthouse in opposition to Vaught’s prosecution.

Vaught, 38, a former nurse at Vanderbilt University Medical Center in Nashville, faced up to eight years in prison. In March she was convicted of criminally negligent homicide and gross neglect of an impaired adult for the 2017 death of 75-year-old patient Charlene Murphey. Murphey was prescribed Versed, a sedative, but Vaught inadvertently gave her a fatal dose of vecuronium, a powerful paralyzer.

Charlene Murphey’s son, Michael Murphey, testified at Friday’s sentencing hearing that his family remains devastated by the sudden death of their matriarch. She was “a very forgiving person” who would not want Vaught to serve any prison time, he said, but his widower father wanted Murphey to receive “the maximum sentence.”

“My dad suffers every day from this,” Michael Murphey said. “He goes out to the graveyard three to four times a week and just sits out there and cries.”

Vaught’s case stands out because medical errors ― even deadly ones ― are generally within the purview of state medical boards, and lawsuits are almost never prosecuted in criminal court.

The Davidson County district attorney’s office, which did not advocate for any particular sentence or oppose probation, has described Vaught’s case as an indictment of one careless nurse, not the entire nursing profession. Prosecutors argued in trial that Vaught overlooked multiple warning signs when she grabbed the wrong drug, including failing to notice Versed is a liquid and vecuronium is a powder.

Vaught admitted her error after the mix-up was discovered, and her defense largely focused on arguments that an honest mistake should not constitute a crime.

During the hearing on Friday, Vaught said she was forever changed by Murphey’s death and was “open and honest” about her error in an effort to prevent future mistakes by other nurses. Vaught also said there was no public interest in sentencing her to prison because she could not possibly re-offend after her nursing license was revoked.

“I have lost far more than just my nursing license and my career. I will never be the same person,” Vaught said, her voice quivering as she began to cry. “When Ms. Murphey died, a part of me died with her.”

At one point during her statement, Vaught turned to face Murphey’s family, apologizing for both the fatal error and how the public campaign against her prosecution may have forced the family to relive their loss.

“You don’t deserve this,” Vaught said. “I hope it does not come across as people forgetting your loved one. … I think we are just in the middle of systems that don’t understand one another.”

Prosecutors also argued at trial that Vaught circumvented safeguards by switching the hospital’s computerized medication cabinet into “override” mode, which made it possible to withdraw medications not prescribed to Murphey, including vecuronium. Other nurses and nursing experts have told KHN that overrides are routinely used in many hospitals to access medication quickly.

Theresa Collins, a travel nurse from Georgia who closely followed the trial, said she will no longer use the feature, even if it delays patients’ care, after prosecutors argued it proved Vaught’s recklessness.

“I’m not going to override anything beyond basic saline. I just don’t feel comfortable doing it anymore,” Collins said. “When you criminalize what health care workers do, it changes the whole ballgame.”

Vaught’s prosecution drew condemnation from nursing and medical organizations that said the case’s dangerous precedent would worsen the nursing shortage and make nurses less forthcoming about mistakes.

The case also spurred considerable backlash on social media as nurses streamed the trial through Facebook and rallied behind Vaught on TikTok. That outrage inspired Friday’s protest in Nashville, which drew supporters from as far as Massachusetts, Wisconsin, and Nevada.

Among those protesters was David Peterson, a nurse who marched Thursday in Washington, D.C., to demand health care reforms and safer nurse-patient staffing ratios, then drove through the night to Nashville and slept in his car so he could protest Vaught’s sentencing. The events were inherently intertwined, he said.

“The things being protested in Washington, practices in place because of poor staffing in hospitals, that’s exactly what happened to RaDonda. And it puts every nurse at risk every day,” Peterson said. “It’s cause and effect.”

Tina Vinsant, a Knoxville nurse and podcaster who organized the Nashville protest, said the group had spoken with Tennessee lawmakers about legislation to protect nurses from criminal prosecution for medical errors and would pursue similar bills “in every state.”

Vinsant said they would pursue this campaign even though Vaught was not sent to prison.

“She shouldn’t have been charged in the first place,” Vinsant said. “I want her not to serve jail time, of course, but the sentence doesn’t really affect where we go from here.”

Janis Peterson, a recently retired ICU nurse from Massachusetts, said she attended the protest after recognizing in Vaught’s case the all-too-familiar challenges from her own nursing career. Peterson’s fear was a common refrain among nurses: “It could have been me.”

“And if it was me, and I looked out that window and saw 1,000 people who supported me, I’d feel better,” she said. “Because for every one of those 1,000, there are probably 10 more who support her but couldn’t come.”

Nashville Public Radio’s Blake Farmer contributed to this report.

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Travel Nurses See Swift Change of Fortunes as Covid Money Runs Dry

Tiffanie Jones was a few tanks of gas into her drive from Tampa, Florida, to Cheyenne, Wyoming, when she found out her travel nurse contract had been canceled.

Jones, who has been a nurse for 17 years, caught up with a Facebook group for travel nurses and saw she wasn’t alone. Nurses had reported abruptly losing jobs and seeing their rates slashed as much as 50% midcontract.

“One lady packed up her whole family and was canceled during orientation,” she said.

Many career nurses like Jones turned to travel gigs during the pandemic, when hospitals crowded with covid-19 patients urgently needed the help. Some travelers — who made double, sometimes triple, what staff registered nurses earned — gathered on TikTok and other social media platforms to celebrate payday, share tips on how to calculate net income from contracts, and boast about how much they were taking home weekly. So great was their good fortune that federal and state lawmakers considered capping their pay, mobilizing nurses in protest.

The tide has swiftly turned. As covid hospitalization rates stabilize, at least for now, and federal and state covid relief funding dries up, travel nurse contracts that were plentiful and lucrative are vanishing. And after the pressure cooker of the past two-plus years led to staff turnover and a rash of early retirements, hospitals nationwide are focused on recruiting full-time nurses.

Nationally, demand for registered nurse travelers dropped by a third in the month leading up to April 10, according to data from staffing agency Aya Healthcare, although openings have rebounded slightly in recent weeks.

When Oregon’s governor declared the pandemic emergency over April 1, state-level covid relief money evaporated. Oregon Health & Science University Hospital in Portland lost funding for close to 100 travel nurses. That, along with lower covid rates and more full-time hires, has led to “a bursting of the bubble,” said Dr. John Hunter, CEO of OHSU Health.

The health system had about 50 contractors of all kinds before the pandemic, compared with 450 at its height, when patients, many in need of close monitoring, flooded in and turned the hospital’s recovery room into an intensive care unit.

“It has been very expensive,” Hunter said. But things are turning around, he said, and in recent weeks the hospital has negotiated contract rates with its travel nurse agency down as much as 50%.

Staff nurses make far less than their traveling counterparts. Rates for a new staff nurse at Northeastern Vermont Regional Hospital in St. Johnsbury, for example, start at $30 an hour — plus benefits and extra for night shifts. At the pandemic peak, the hospital paid staffing agencies about $175 an hour for each travel nurse. The rate remains well over $100 an hour, but the hospital is trying to negotiate it down. Because the hospital pays the agency directly, how much nurses pocket is unclear, said CEO Shawn Tester.

For some travel nurses, the abrupt drop in pay has been a shock. Since December, registered nurse Jessica Campbell had extended her 13-week contract at an Illinois hospital without any hiccups. In early April, a week into Campbell’s latest contract, her recruiter said that her rate would drop by $10 an hour and that she could take it or leave it.

“I ended up accepting it because I felt like I had no other option,” Campbell said.

The situation for some travel nurses has gotten so bad that a law firm in Kansas City, Missouri, said it is considering legal action against more than 35 staffing agencies. Austin Moore, an attorney at Stueve Siegel Hanson, said some agencies are “breaching their contracts” and in other cases “committing outright fraud” through bait-and-switch maneuvers on travel nursing contracts.

The firm opened an investigation in March, drawing comments from hundreds of nurses, Moore said. “Our phones are ringing off the hook,” he said. “Nobody has experienced it like this — historically, contracts have been honored.”

Stephen Dwyer, senior vice president and chief legal and operating officer of the American Staffing Association, the trade group that represents the travel nurse staffing industry, said in an emailed statement that “as market conditions change, hospitals and other healthcare facilities may change the terms of travel nurse contracts.”

“For rate reductions or contract cancellations that take place mid-assignment, staffing companies often recommend advance notice,” he said.

Moore said that the fine print can vary but that when a staffing agency cancels a contract at the last minute or gives a nurse one or two days to consider a lower rate, the agency is often breaching a contract. According to the contracts, the loss should fall to the agency, not the nurses, when a hospital requests a lower rate, Moore added.

Pay rates have always fluctuated seasonally as the demand for nurses to plug staffing holes at hospitals changes, said XueXia Bruton, an ICU nurse based in Houston. She has traveled since 2018, drawn to the flexibility and financial freedom, and has no plans to return to staff nursing. Along the way, Bruton has cataloged her experiences on TikTok and Instagram, telling her more than 91,000 followers that, for instance, “it may make more sense to wait to take a contract until rates go back up.”

“It was very hard across the board during covid when cases were really high,” Bruton said. “We were all burned out and exhausted, so it was important to be able to take as much time off as needed.”

Bruton saw crisis rates as high as $10,000 a week. Travel nurse rates now average about $3,100, according to online hiring marketplace Vivian Health. Still that’s higher than before the pandemic, and well above what a typical staff nurse makes.

Last year was particularly profitable for staffing agencies. Cross Country Healthcare, one of the few publicly traded companies that staff travel nurses and other health care workers, posted a profit of $132 million in 2021, compared with a loss of $13 million the previous year and even bigger losses in 2019. Then-CEO Kevin Clark called the company’s 2021 financial results a “historic milestone for both revenue and profitability.”

Big profits across the nurse staffing industry have drawn the attention of lawmakers, including U.S. Rep. Peter Welch (D-Vt.), who said he feared that private equity firms that were buying up staffing agencies were charging exorbitant fees during the pandemic, a pattern reported on by Stat. In January, Welch and U.S. Rep. Morgan Griffith (R-Va.) wrote the White House a letter requesting an investigation of possible “anticompetitive activity” by staffing agencies after receiving reports that they were “vastly inflating price, by two, three or more times pre-pandemic rates.”

Some travel nurses are returning to full-time gigs, drawn by hefty incentives and stability. Jones, whose contract in Wyoming was canceled in early March, considered a staff nurse position in Montana — swayed in part by a $10,000 starting bonus. But she ended up in a travel nurse contract in rural Kansas, where the pay is better than a staff job’s would be but not quite what she’d gotten used to during the pandemic.

Jones said her traveling stint raised a big question: How much is a nurse worth?

On the road, Jones said, she “could breathe financially for the first time in years,” at times making almost double what she made as a staff nurse.

“It’s a tough profession,” she said. “We love doing it, but we have bills to pay, too.”

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Medicare Surprise: Drug Plan Prices Touted During Open Enrollment Can Rise Within a Month

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

A recent analysis by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the Medicare website warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, Chiquita Brooks-LaSure, the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a study Dusetzina co-authored for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the Health Insurance Counseling and Advocacy Program. They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every two weeks.

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

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States Watching as Massachusetts Takes Aim at Hospital Building Boom and Costs

A Massachusetts health cost watchdog agency and a broad coalition including consumers, health systems, and insurers helped block the state’s largest — and most expensive — hospital system in April from expanding into the Boston suburbs.

Advocates for more affordable care hope the decision by regulators to hold Mass General Brigham accountable for its high costs will usher in a new era of aggressive action to rein in hospital expansions that drive up spending. Their next target is a proposed $435 million expansion by Boston Children’s Hospital.

Other states, including California and Oregon, are paying close attention, eyeing ways to emulate Massachusetts’ decade-old system of monitoring health care costs, setting a benchmark spending rate, and holding hospitals and other providers responsible for exceeding their target.

The Massachusetts Health Policy Commission examines hospital-specific data and recommends to the state Department of Public Health whether to approve mergers and expansions. The commission also can require providers and insurers to develop a plan to reduce costs, as it’s doing with MGB.

“The system is working in Massachusetts,” said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy, who stressed the importance of the state’s robust data-gathering and analysis program. “The focus on providing transparency around health costs has been really helpful. That’s what all states want to do. I don’t know if other states will adopt the Massachusetts model. But we’re hearing increased interest.”

With its many teaching hospitals, Massachusetts historically has been among the states with the highest per capita health care costs, though its spending has moderated in recent years as state officials have taken aim at the issue.

On April 1, MGB, an 11-hospital system that includes the famed Massachusetts General Hospital, unexpectedly withdrew its proposal for a $223.7 million outpatient care expansion in the suburbs after being told by state officials it wouldn’t be approved.

That expansion would have increased annual spending for commercially insured residents by as much as $28 million, driving up insurance premiums and shifting patients away from lower-priced competitors, according to the commission.

This marked the first time in decades that the state health department used its authority to block a hospital expansion because it undercut the state’s goals to control health costs.

Other parts of MGB’s $2.3 billion expansion plan also met resistance.

The health department staff recommended approving MGB’s proposal to build a 482-bed tower at its flagship Massachusetts General Hospital and a 78-bed addition at Brigham and Women’s Faulkner Hospital. But they urged rejecting a request for 94 additional beds at MGH.

The department’s Public Health Council, whose members are mostly appointed by the governor, is scheduled to vote on those recommendations May 4.

The health policy commission, which works independently of the public health department but provides advice, has also required MGB to submit an 18-month cost-control plan by May 16, because its prices and spending growth have far exceeded those of other hospital systems. That was a major reason the growth in state health spending hit 4.3% in 2019, exceeding the commission’s target of 3.1%.

This is the first time a state agency in Massachusetts or anywhere else in the country has ordered a hospital to develop a plan to control its costs, Hensley-Quinn said.

MGB’s $2.3 billion expansion plan and its refusal to acknowledge its high prices and their impact on the state’s health costs have united a usually fractious set of stakeholders, including competing hospitals, insurers, employers, labor unions, and regulators. They also were angered by MGB’s lavish advertising campaign touting the consumer benefits of the expansion.

Their fight was bolstered by a report last year from state Attorney General Maura Healey that found that the suburban outpatient expansion would increase MGB annual profits by $385 million. The nonprofit MGB reported $442 million in operating income in 2021.

The Massachusetts Association of Health Plans opposed the MGB outpatient expansion.

The well-funded coalition warned that the expansion would severely hurt local hospitals and other providers, including causing job losses. The consumer group Health Care for All predicted the shift of patients to the more expensive MGB sites would lead to higher insurance premiums for individuals and businesses.

“Having all that opposition made it pretty easy for [the Department of Public Health] to do the right thing for consumers and cost containment,” said Lora Pellegrini, CEO of the health plan association.

Republican Gov. Charlie Baker, who has made health care cost reduction a priority and who leaves office next January after eight years, didn’t want to see the erosion of the state’s pioneering system of global spending targets, she said.

“What would it say for the governor’s legacy if he allowed this massive expansion?” she added. “That would render our whole cost-containment structure meaningless.”

MGB declined to comment.

Massachusetts’ aggressive action examining and blocking a hospital expansion comes after many states have moved in the opposite direction. In the 1980s, most states required hospitals to get state permission for major projects under “certificate of need” laws. But many states have loosened or abandoned those laws, which critics say stymied competition and failed to control costs.

The Trump administration recommended that states repeal those laws and leave hospital expansion projects up to the free market.

But there are signs the tide is turning back to more regulation of hospital building.

Several states have created or are considering creating commissions similar to the one in Massachusetts with the authority and tools to analyze the market impact of expansions and mergers. Oregon, for example, recently passed a law empowering a state agency to review health care mergers and acquisitions to ensure they maintain access to affordable care.

Despite the defeat of MGB’s outpatient expansion, Massachusetts House Speaker Ron Mariano, a Democrat, said the state’s cost-control model needs strengthening to prevent hospitals from making an end run around it. A bill he backed that passed the House would give the commission and the attorney general’s office a bigger role in evaluating the cost impact of expansions. The Senate hasn’t taken up the bill.

“Hospital expansion is the biggest driver in the whole medical expense kettle,” he said.

Meanwhile, cost-control advocates are eager to see how MGB proposes to control its spending, and how the Health Policy Commission responds.

“Unless MGB somehow agrees to limit increases in its supranormal pricing, like a five-year price freeze across the system, I don’t know that the [plan] will accomplish anything,” said Dr. Paul Hattis, a former commission member.

Hattis and others are also waiting to see how the state rules on a bid by Boston Children’s Hospital, another high-priced provider, to build new outpatient facilities in the suburbs.

“For those of us on the affordability side, it’s like the sheriffs rediscovered their badge and realized they really could say no,” he said. “That’s a message to other states that they also should constrain their larger provider systems, and to the systems that they can no longer do whatever they please.”

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