Aneesh Chopra: It’s the people problem that remains at the core of cyberattacks

Cybersecurity will continue to be a major issue for providers in the year ahead. According to CareJourney President Aneesh Chopra, the most common factors putting providers at risk are their employees and being unable to track data flow.

Mayo Clinic, Microsoft, Cerner join coalition to provide digital access to Covid-19 vaccine records

A group of organizations have come together to work on a solution that will provide digital access to Covid-19 vaccination records. As the country eyes a challenging transition to the new normal, a verifiable vaccine record will be necessary to ensure individual and community safety.

YouTube teams up with providers, healthcare groups to combat health misinformation

The video-sharing giant is partnering with providers and groups, like Mayo Clinic and the American Public Health Association, to create evidence-based health content. YouTube has also added CVS Health’s former chief community health officer to lead those efforts.

Epic v Cerner v Meditech v Allscripts: Who is winning Canada’s EHR Battle?

EHR, EMR

Meditech continues to hold the largest EMR market share in Canada, but it is losing customers — mostly to Epic, which has seen a rapid rise in popularity, a new KLAS report shows. The report delves into market share data and customer satisfaction insights to assess EMR vendors’ positions in the Canadian market.

Analysis Examines the Implications of Price Transparency for Providers and Patients as New Rules Go into Effect

A new KFF analysis examines how new federal rules on price transparency for health services may affect patient decision-making and market pricing. As of January 1, 2021, the United States Department of Health and Human Services requires that hospitals publish payer-negotiated rates for common services on their websites. A second set of rules, which requiresMore

Feeling Left Out: Private Practice Doctors, Patients Wonder When It’s Their Turn for Vaccine

Dr. Andrew Carroll — a family doctor in Chandler, Arizona — wants to help his patients get immunized against covid, so he paid more than $4,000 to buy an ultra-low-temperature freezer from eBay needed to store the Pfizer vaccine.

But he’s not sure he’ll get a chance to use it, given health officials have so far not said when private doctor’s offices will get vaccine.

“I’m really angry,” said Carroll.

Not only are doctors having trouble getting vaccine for patients, but many of the community-based physicians and medical staff that aren’t employed by hospitals or health systems also report mixed results in getting inoculated. Some have had their shots, yet others are still waiting, even though health workers providing direct care to patients are in the Centers for Disease Control and Prevention’s top-priority group.

Many of these doctors say they don’t know when — or if — they will get doses for their patients, which will soon become a bigger issue as states attempt to vaccinate more people.

“The reason that’s important is patients trust their doctors when it comes to the vaccine,” said Carroll, who has complained on social media that his county hasn’t yet released plans on how primary care doctors will be brought into the loop.

Collectively, physicians in the county could vaccinate thousands of patients a day, he said, and might draw some who would otherwise be hesitant if they had to go to a large hospital, a fairground or another central site.

His concern comes as, nationally, the rollout of the vaccine is off to a slower start than expected, lagging far behind the initial goal of giving 20 million doses before the new year.

But Dr. Jen Brull, a family practice doctor in Plainville, Kansas, said her rural area has made good progress on the first phase of vaccinations, crediting close working relationships formed well before the pandemic.

This fall, before any doses became available, the local hospital, the health department and physician offices coordinated a sign-up list for medical workers who wanted the vaccine. So, when their county, with a population of 5,000, got its first 70 doses, they were ready to go. Another 80 doses came a week later.

“We’ll be able to vaccinate almost all the health care-associated folks who wanted it in the county” Brull said recently

Gaps in the Rollout

But that’s not the case everywhere.

Dr. Jason Goldman, a family doctor in Coral Gables, Florida, said he was able to get vaccinated at a local hospital that received the bulk of vaccines in his county and oversaw distribution.

In the weeks since, however, he said several of his front-line staff members still “don’t have access to the vaccine.”

Additionally, “a tremendous number” of patients are calling his office because Florida has relaxed distribution guidelines to include anyone over age 65, Goldman said, asking when they can get the vaccine. He’s applied to officials about distributing the vaccines through his practice but has heard nothing back.

Patients “are frustrated that they do not have clear answers and that I am not being given clear answers to provide them,” he said. “We have no choice but to direct them to the health department and some of the hospital systems.”

Another troubling point for Goldman, who served as a liaison between the American Academy of Family Physicians and the expert panel drawing up the CDC distribution guidelines, is the tremendous variation in how those recommendations are being implemented in the states.

The CDC recommends several phases, with front-line health care workers and nursing home residents and staff in the initial group. Then, in the second part of that phase, come people over 75 and non-health care front-line workers, which could include first responders, teachers and other designated essential workers.

States have the flexibility to design their own rollout schedule and priority groups. Florida, for example, is offering doses to anyone 65 and up. In some counties, older folks were told vaccines were available on a first-come, first-served basis, a move that has resulted in long lines.

“To say right now, 65-plus, when you haven’t even appropriately vaccinated all the health care workers, is negating the phasing,” said Goldman. “There needs to be a national standard. We have those guidelines. We need to come up with some oversight.”

On Thursday, the American Hospital Association echoed that concern in a letter to Health and Human Services Secretary Alex Azar. Hospitals — along with health departments and large pharmacy chains — are doing the bulk of the vaccinations.

Calling for additional coordination by federal officials, the letter outlined what it would take to reach the goal of vaccinating 75% of Americans by the end of May: 1.8 million vaccinations every day. Noting there are 64 different rollout plans from states, cities and other jurisdictions, the letter asked whether HHS has “assessed whether these plans, taken as a whole, are capable of achieving this level of vaccination?”

Making It Work

Lack of direct national support or strategy means each county is essentially on its own, with success or failure affected by available resources and the experience of local officials. Most state and local health departments are underfunded and are under intense pressure because of the surging pandemic.

Still, the success of vaccination efforts depends on planning, preparation and clear communication.

In Lorain County, Ohio, population 310,000, local officials started practicing in October, said Mark Adams, deputy health commissioner. They set up mass vaccination clinics for influenza to study what would be needed for a covid vaccination effort. How many staff? What would the traffic flow be like? Could patients be kept 6 feet apart?

“That gave us an idea of what is good, what is bad and what needs to change,” said Adams, who has had previous experience coordinating mass vaccination efforts at a county level.

So, when the county got its first shipment of 500 doses Dec. 21, Adams had his plan ready. He called the fire chiefs to invite all emergency medical technicians and affiliated personnel to an ad hoc vaccination center set up at a large entertainment venue staffed by his health department. Upon arrival, people were greeted at the door and directed to spaced-apart “lanes” where they would get their shots, then to a monitoring area where they could wait for 15 minutes to make sure they didn’t have a reaction.

Right after Christmas, another 400 doses arrived — and the makeshift clinic opened again. This time, doses went to community-based physicians, dentists and other hands-on medical practitioners, 600 of whom had previously signed up. (Hospital workers and nursing home staff and residents are getting their vaccinations through their own institutions.)

As they move into the next phase — recipients include residents over 80, people with developmental disorders and school staff — the challenges will grow, he said. The county plans a multipronged approach to notify people when it’s their turn, including use of a website, the local media, churches, other organizations and word-of-mouth.

Adams shares the concerns of medical providers nationwide: He gets only two days’ notice of how many doses he’s going to receive and, at the current pace of 400 or 500 doses a week, it’s going to take a while before most residents in the county have a chance to get a shot, including the estimated 33,000 people 65 and older.

With 10 nurses, his clinic can inject about 1,200 people a day. But many other health professionals have volunteered to administer the shots if he gets more doses.

“If I were to run three clinics, five days a week, I could do 15,000 vaccinations a week,” Adams said. “With all the volunteers, I could do almost six clinics, or 30,000 a week.”

Still, for those in the last public group, those age 18 and up without underlying medical conditions, “it could be summer,” Adams said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospitals’ Rocky Rollout of Covid Vaccine Sparks Questions of Fairness

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Last week, after finishing inoculations of some front-line hospital staff, Jupiter Medical Center was left with 40 doses of precious covid vaccine. So, officials offered shots to the South Florida hospital’s board of directors and their spouses over age 65.

But that decision sparked outrage among workers left unvaccinated, including those at one of the hospital’s urgent care clinics, or who believe the hospital was currying favor with wealthy insiders before getting all its staffers protected, according to a hospital employee who spoke on the condition of not being named.

The move also prompted dozens of calls from donors looking to get vaccinated.

The hospital received 1,000 doses of the Moderna vaccine two days before Christmas, fewer than half of what it requested from the state to cover its workforce. Officials prioritized delivering the vaccine to front-line medical workers who requested it, performing inoculations on Christmas Eve or the holiday weekends.

Patti Patrick, a hospital vice president, said the hospital acted appropriately in its offerings of the vaccine, which has a short shelf life once vials are opened. Neither she nor other administrators who don’t work directly with patients were included in this first round of shots.

“This was a simple way to move 40 doses very quickly” before it spoiled, she said.

She added that all front-line staff from the health system, including the clinics, were given the opportunity to get the shots.

Jupiter is not the only hospital in the nation facing questions about its handling of the vaccines. The initial rollout — aimed at health care workers and nursing home residents — has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.

In some hospitals, administrators and other personnel who have no contact with patients or face no risk at work from the virus are getting shots, while patients — and even front-line staff — who are at heightened risk for covid complications are being passed by. Some administrators who have been working remotely throughout the pandemic have been vaccinated, especially at hospitals that decided to allocate doses by age group rather than exposure risk.

Although states and federal health groups laid out broad guidelines on how to prioritize who gets the vaccine, in practice what’s mattered most was who controlled the vaccine and where the vaccine distribution was handled.

Stanford Health Care in California was forced to rework its priority list after protests from front-line doctors in training who said they had been unfairly overlooked while the vaccine was given to faculty who don’t regularly see patients. (Age was the important factor in the university’s algorithm.)

Members of Congress have called for an investigation following media reports that MorseLife Health System, a nonprofit that operates a nursing home and assisted living facility in West Palm Beach, Florida, vaccinated donors and members of a country club who donated thousands of dollars to the health company.

At least three other South Florida hospital systems — Jackson Health, Mount Sinai Medical Center and Baptist Health — have offered vaccines to donors in advance of the general public, while administering the shots to front-line employees, The Miami Herald reported.

Like Jupiter Medical, the hospitals insist that those offered shots were 65 and older, as prioritized by state officials.

Staffing Problems at Hospitals

An advisory board to the Centers for Disease Control and Prevention designated hospitals and nursing homes to get covid vaccines first because their workers and residents were considered at highest risk, and most states have followed that recommendation. But in many cases, the health institutions have found demand from staffers, some of whom are leery of the voluntary shot, is less than anticipated.

In addition, the arrival of promised shipments has been unpredictable. While the federal government approved the first covid vaccine on Dec. 14, some hospitals did not receive allotments until after Christmas.

That was the case at Hendry Regional Medical Center in Clewiston, Florida, which got 300 doses from the state. The hospital vaccinated 30 of its 285 employees between Dec. 28 and Jan. 5, said R.D. Williams, its chief executive officer. Some employees preferred to wait until after New Year’s weekend out of concern about side effects, he said.

The vaccine has been reported to commonly cause pain at the injection site and sometimes produce fever, lethargy or headache. The reactions generally last no more than a few days.

“I’m happy with how it’s going so far,” Williams said. “I know many of our employees want to be vaccinated, but I don’t see it as a panacea that they have to have it today,” he said, noting that staffers already have masks and gloves to protect themselves from the virus.

The hospital is also trying to coordinate vaccination schedules so 10 people at a time get the shot to ensure none of the medication is wasted after the multidose vials are thawed. Once vaccine is thawed, it must be used within hours to retain its effectiveness.

As of Jan. 6, Howard University Hospital in Washington, D.C., had vaccinated slightly more than 900 health workers since its first doses arrived Dec. 14. It has received 3,000 doses.

Success has been limited by reluctance among workers to get a vaccine and a lack of personnel trained to administer it, CEO Anita Jenkins said.

“We still have a hospital to run and have patients in the hospital with heart attacks and other conditions, and we don’t have additional staff to run the vaccine clinics,” she said.

While some hospitals offer the vaccine only to front-line workers who interact with patients, Howard makes it available to everyone, including public relations staff, cafeteria workers and administrators. Jenkins defended the move because, she said, it’s the best way to protect the entire hospital.

She noted such employees as information technology personnel who don’t see patients may be around doctors and nurses who do. “Working in a hospital, almost everyone runs into patients just walking down the hallway,” she said.

At Eisenhower Health, a nonprofit hospital based in Rancho Mirage, California, 2,300 of the 5,000 employees have been vaccinated.

“Our greatest challenge has been managing the current patient surge and staffing demands in our acute and critical care areas while also trying to ensure we have adequate staffing resources to operate the vaccine clinics,” said spokesperson Lee Rice.

A Non-System of Inequitable Distribution

Arthur Caplan, a bioethicist at NYU Langone Medical Center in New York City, said hospitals should not be inoculating board members ahead of hospital workers unless those people have a crucial role in running the hospital.

“That seems, to me, jostling to the head of the line and trying to reward those who may be potential donors,” he said. But he acknowledged that the hospitals’ vaccination systems are not always rational or equitable.

Covid vaccines need to get out as quickly as possible, he added, but hospitals can give them only to people they are connected with.

Caplan noted he was vaccinated at an NYU outpatient site last week, even though his primary care doctor hadn’t yet gotten the vaccine because his clinic had not received any doses.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Andy Slavitt at JPM: Biden unlikely to pick ‘divisive’ fights on healthcare

In a wide-ranging discussion at J.P. Morgan’s Annual Healthcare Conference, former CMS Administrator Andy Slavitt talked about the future of the ACA, telehealth and Medicare Advantage with a Democrat-led House, Senate and presidency.

Kaiser Permanente to analyze CDC’s Covid-19 vaccine data, identify bad reactions

The CDC has engaged the California-based health system’s Vaccine Study Center to conduct an analysis of its Covid-19 vaccine data with the aim of pinpointing adverse events and reactions. The collaboration will continue for the next three years.

Health Workers Unions See Surge in Interest Amid Covid


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The nurses at Mission Hospital in Asheville, North Carolina, declared on March 6 — by filing the official paperwork — that they were ready to vote on the prospect of joining a national union. At the time, they were motivated by the desire for more nurses and support staff, and to have a voice in hospital decisions.

A week later, as the covid-19 pandemic bore down on the state, the effort was put on hold, and everyone scrambled to respond to the coronavirus. But the nurses’ long-standing concerns only became heightened during the crisis, and new issues they’d never considered suddenly became urgent problems.

Staffers struggled to find masks and other protective equipment, said nurses interviewed for this story. The hospital discouraged them from wearing masks one day and required masks 10 days later. The staff wasn’t consistently tested for covid and often not even notified when exposed to covid-positive patients. According to the nurses and a review of safety complaints made to federal regulators, the concerns persisted for months. And some nurses said the situation fueled doubts about whether hospital executives were prioritizing staff and patients, or the bottom line.

By the time the nurses held their election in September — six months after they had filed paperwork to do so — 70% voted to unionize. In a historically anti-union state with right-to-work laws and the second-least unionized workforce in the country, that margin of victory is a significant feat, said academic experts who study labor movements.

That it occurred during the pandemic is no coincidence.

For months now, front-line health workers across the country have faced a perpetual lack of personal protective equipment, or PPE, and inconsistent safety measures. Studies show they’re more likely to be infected by the coronavirus than the general population, and hundreds have died, according to reporting by KHN and The Guardian.

Many workers say employers and government systems that are meant to protect them have failed.

Research shows that health facilities with unions have better patient outcomes and are more likely to have inspections that can find and correct workplace hazards. One study found New York nursing homes with unionized workers had lower covid mortality rates, as well as better access to PPE and stronger infection control measures, than nonunion facilities.

Recognizing that, some workers — like the nurses at Mission Hospital — are forming new unions or thinking about organizing for the first time. Others, who already belong to a union, are taking more active leadership roles, voting to strike, launching public information campaigns and filing lawsuits against employers.

“The urgency and desperation we’ve heard from workers is at a pitch I haven’t experienced before in 20 years of this work,” said Cass Gualvez, organizing director for Service Employees International Union-United Healthcare Workers West in California. “We’ve talked to workers who said, ‘I was dead set against a union five years ago, but covid has changed that.’”

In response to union actions, many hospitals across the country have said worker safety is already their top priority, and unions are taking advantage of a difficult situation to divide staff and management, rather than working together.

Labor experts say it’s too soon to know if the outrage over working conditions will translate into an increase in union membership, but early indications suggest a small uptick. Of the approximately 1,500 petitions for union representation posted on the National Labor Relations Board website in 2020, 16% appear related to the health care field, up from 14% the previous year.

In Colorado, SEIU Local 105 health care organizing director Stephanie Felix-Sowy said her team is fielding dozens of calls a month from nonunion workers interested in joining. Not only are nurses and respiratory therapists reaching out, but dietary workers and cleaning staff are as well, including several from rural parts of the state where union representation has traditionally been low.

“The pandemic didn’t create most of the root problems they’re concerned about,” she said. “But it amplified them and the need to address them.”

A nurse for 30 years, Amy Waters had always been aware of a mostly unspoken but widespread sentiment that talking about unions could endanger her job. But after HCA Healthcare took over Mission Health in 2019, she saw nurses and support staff members being cut and she worried about the effect on patient care. Joining National Nurses United could help, she thought. During the pandemic, her fears only worsened. At times, nurses cared for seven patients at once, despite research indicating four is a reasonable number.

In a statement, Mission Health said it has adequate staffing and is aggressively recruiting nurses. “We have the beds, staffing, PPE supplies and equipment we need at this time and we are well-equipped to handle any potential surge,” spokesperson Nancy Lindell wrote. The hospital has required universal masking since March and requires staff members who test positive to stay home, she added.

Although the nurses didn’t vote to unionize until September, Waters said, they began acting collectively from the early days of the pandemic. They drafted a petition and sent a letter to administrators together. When the hospital agreed to provide advanced training on how to use PPE to protect against covid transmission, it was a small but significant victory, Waters said.

“Seeing that change brought a fair number of nurses who had still been undecided about the union to feel like, ‘Yeah, if we work together, we can make change,’” she said.

Old Concerns Heightened, New Issues Arise

Even as union membership in most industries has declined in recent years, health workers unions have remained relatively stable. Experts say it’s partly because of the focus on patient care issues, like safe staffing ratios, which resonate widely and have only grown during the pandemic.

At St. Mary Medical Center outside Philadelphia, short staffing led nurses to strike in November. Donna Halpern, a nurse on the cardiovascular and critical care unit, said staffing had been a point of negotiation with the hospital since the nurses joined the Pennsylvania Association of Staff Nurses and Allied Professionals in 2019. But with another surge of covid cases approaching, the nurses decided not to wait any longer to take action, she said.

A month later, officials with Trinity Health Mid-Atlantic, which owns the hospital, announced a tentative labor agreement with the union. The contract “gives nurses a voice in discussions on staffing while preserving the hospital’s right and authority to make all staffing decisions,” the hospital said in a statement.

In Colorado, where state inspection reports show understaffing led to a patient death at a suburban Denver hospital, SEIU Local 105 has launched a media campaign about unsafe practices by the hospital’s parent company, HealthOne. The union doesn’t represent HealthOne employees, but union leaders said they felt compelled to act after repeatedly hearing concerns.

In a statement, HealthOne said staffing levels are appropriate across its hospitals and it is continuing to recruit and hire staff members.

Covid is also raising entirely new issues for workers to organize around. At the forefront is the lack of PPE, which was noted in one-third of the health worker deaths catalogued by KHN and The Guardian.

Nurses at Albany Medical Center in New York picketed on Dec. 1 with signs demanding PPE and spoke about having to reuse N95 masks up to 20 times.

The hospital told KHN it follows federal guidelines for reprocessing masks, but intensive care nurse Jennifer Bejo said it feels unsafe.

At MultiCare Indigo Urgent Care clinics in Washington state, staff members were provided only surgical masks and face shields for months, even when performing covid tests and seeing covid patients, said Dr. Brian Fox, who works at the clinics and is a member of the Union of American Physicians and Dentists. The company agreed to provide N95 masks after staffers went on a two-day strike in November.

MultiCare said it found another vendor for N95s in early December and is in the process of distributing them.

PPE has also become a rallying point for nonunion workers. At a November event handing out PPE in El Paso, Texas, more than 60 workers showed up in the first hour, said SEIU Texas President Elsa Caballero. Many were not union members, she said, but by the end of the day, dozens had signed membership cards to join.

Small Successes, Gradual Movement

Organized labor is not a panacea, union officials admit. Their members have faced PPE shortages and high infection rates throughout the pandemic, too. But collective action can help workers push for and achieve change, they said.

National Nurses United and the National Union of Healthcare Workers said they’ve each seen an influx in calls from nonmembers, but whether that results in more union elections is yet to be seen.

David Zonderman, an expert in labor history at North Carolina State University, said safety concerns like factory fires and mine collapses have often galvanized collective action in the past, as workers felt their lives were endangered. But labor laws can make it difficult to organize, he said, and many efforts to unionize are unsuccessful.

Health care employers, in particular, are known to launch aggressive and well-funded anti-union campaigns, said Rebecca Givan, a labor studies expert at Rutgers university. Still, workers might be more motivated by what they witnessed during the pandemic, she said.

“An experience like treating patients in this pandemic will change a health care worker forever,” Givan said, “and will have an impact on their willingness to speak out, to go on strike and to unionize if needed.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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An Urban Hospital on the Brink Vs. the Officials Sworn to Save It

Illinois and Chicago officials are trying to figure out how to stop a private company from closing a money-losing urban hospital in a poor, underserved Chicago neighborhood.

Trinity Health, a national Catholic tax-exempt chain, wants to close Mercy Hospital and Medical Center on Chicago’s Near South Side by May 31. Last month, in an unusual move, the Illinois Health Facilities & Services Review Board unanimously denied Trinity permission to close the 412-bed facility, which predominantly serves Black and other minority patients on Medicaid.

The board members said they feared the closure would limit access to care for nearly 60,000 South Side residents, forcing them to travel nearly 7 miles to the closest facility with an emergency room, intensive care unit and birthing center. It also would cost the community about 2,000 hospital jobs.

Urban hospitals in low-income areas of Los Angeles, Philadelphia, San Francisco, Washington, D.C., and other cities and suburbs face similar financial squeezes. Inner-city facilities like Mercy struggle to survive on lean payment rates from Medicaid and to compete with financially robust hospitals that mostly serve well-paying, privately insured patients.

So far, no one has come up with a politically and financially viable solution for strengthening safety-net health providers in low-income urban communities. “The sad fact is market location is everything,” said Lawton Robert Burns, a professor of health care management at the University of Pennsylvania, who studied the controversial closure of Hahnemann University Hospital in Philadelphia in 2019. “No offense to poor people, but there are economic factors that hospitals can’t control.”

But it is far from clear that a government board can stop a hospital from going out of business. “It’s really difficult in a capitalist country to tell a private company you have to continue to lose money,” said Dr. Linda Rae Murray, a member of the health facilities board and former Trinity Health board member who teaches health policy at the University of Illinois-Chicago.

Trinity, which operates 92 hospitals in 22 states, seems determined to push forward with its plans to close the hospital. It has deep pockets, with $31.9 billion in total assets. It reported revenue of $18.8 billion last year, and a profit of 2.3% in the most recent quarter. Trinity executives told the health facilities board in December that Mercy loses nearly $39 million a year and that they could not find any buyers for the hospital — Chicago’s oldest, chartered in 1852. They also reminded the board that state lawmakers rejected Mercy’s 2019 $1 billion proposal to merge with three other South Side hospitals and build a new hospital facility and several new clinics with $520 million in state aid.

Trinity declined to make anyone available for an interview for this article.

Trinity has said it will try again to get approval to shut Mercy at the facilities review board’s Jan. 26 meeting. It has offered to replace the hospital with a $13 million clinic offering just diagnostic and urgent care — but no primary care physician services. Critics of that proposal say the clinic, while helpful, would not be an adequate replacement for the hospital because it would not provide access to the full range of needed services.

“We can’t have these mega-hospital companies that are getting a property tax exemption for providing charity care closing a safety-net hospital in the middle of a pandemic,” said former Illinois Gov. Pat Quinn, a Democrat who spearheaded a 2013 deal to save Roseland Hospital, another embattled facility on Chicago’s South Side. “I’d tell the Trinity executives, ‘You’re not doing this to Chicago. We’ll work with you to put together a bigger deal.’”

The obvious long-term solution is richer Medicaid funding for safety-net hospitals, effective partnerships between public and private providers and firm commitments by financially strong hospital companies, including academic medical centers, to expand services in low-income communities. For instance, some say state and local officials should prod Trinity to use the resources of its Loyola University Medical Center in west suburban Chicago to bolster Mercy.

Hospitals are required to get a certificate of need for closure from the facilities review board, according to a new state law. But state officials’ actions are limited when seeking to enforce a decision to keep a facility open.

The state could levy a fine of up to $10,000 for not complying with the board’s decision, plus an additional $10,000 a month while the hospital continues to operate. But that’s a trivial amount for a big company like Trinity.

The state also could halt Medicaid and other public payments to Mercy. But that would be counterproductive, hastening the hospital’s demise since nearly half of Mercy’s inpatient revenue and 35% of its outpatient revenue comes from Medicaid, according to state data.

A final source of leverage is in Trinity’s ownership of three other hospitals in the Chicago area: Loyola, Gottlieb Memorial Hospital and MacNeal Hospital. The state could threaten Trinity’s property-tax exemption as a charitable organization. That’s an approach favored by Quinn, who cited a previous legal challenge to the tax-exempt status of the Carle Foundation Hospital in Urbana, Illinois.

No matter what the state does, Trinity can find ways to shut down Mercy. It could argue that even as Mercy is meeting the state requirement to continue to treat patients, it must close critical services like the emergency department or the birthing center because it lacks funding or staff to maintain adequate quality of care, said Juan Morado Jr., a Chicago health care lawyer who formerly served as general counsel for the facilities review board. The new law permits closing only one hospital department every six months.

While the state presses to keep the hospital open, Mercy also could suffer from attrition. When there’s talk of closing a hospital, physicians, nurses and other staffers may start leaving for other jobs. Whether Trinity seeks to refill positions is critical.

“There are things the owner can do to trickle the hospital down to nothing,” said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center in Chicago, who opposes shuttering Mercy. “There is a drip, drip, drip of negativity, and at some point people vote with their feet.”

The Chicago area has been through a similar battle recently. Pipeline Health, a private-equity investment firm, bought Westlake Hospital in suburban Melrose Park and two other local hospitals from hospital chain Tenet Healthcare in 2019. Pipeline quickly announced it was closing Westlake, a 230-bed hospital — even though it had promised the state it would keep it open for at least two years.

That controversial move prompted the Illinois legislature to give the facilities review board new authority to deny permission for future hospital closures, which the board lacked for Westlake.

Yet, the Westlake saga may point to a better solution for Mercy. In early 2020, the state and federal governments renovated the Westlake facility so it could be used as an overflow site for covid-19 patients. It wasn’t needed, but the updates led to strong interest from companies in purchasing and reopening the hospital, particularly for behavioral health inpatient services.

State Rep. Kathleen Willis, a Democrat who co-sponsored the 2019 bill to let the facilities review board say no to hospital closures, said a deal to buy and reopen Westlake likely will be announced within the next few weeks.

Any deal to save Mercy likely will require more money from Trinity, more commitment from other providers to offer a full range of hospital and medical services in the area, and significant increases in state and federal funding.

“Every hospital CEO has to worry about the bottom line of their business,” Ansell said. “But big organizations like Trinity need to come up with a better solution than the wholesale shutdown of an anchor institution that will leave communities bereft.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Northwell offers Whole Foods employees access to primary care services through new partnership

A subsidiary of Northwell Health is partnering with Whole Foods Market to offer its New York-based employees access to seven primary care locations. The supermarket chain’s employees will not be subject to a deductible or co-pay.

One Ambulance Ride Leads to Another When Packed Hospitals Cannot Handle Non-Covid Patients


This story also ran on U.S. News & World Report. It can be republished for free.

Keely Connolly thought she would be safe once the ambulance arrived at Hutchinson Regional Medical Center in Kansas.

She was having difficulty breathing because she’d had to miss a kidney dialysis treatment a few days earlier for lack of child care. Her potassium was dangerously high, putting her at risk of a heart attack. But she trusted she would be fine once she was admitted and dialysis was begun.

She panicked when a nurse told her that no beds were available and that she would have to be transferred — possibly more than 450 miles away to Denver. She had heard a rumor about a dialysis patient who died waiting for a bed at a hospital in Wichita, about an hour down the road.

“‘I don’t want to die in the ER,’” Connolly, 32, recalled thinking. “I just wanted them to fix me, but then the woman came in and said, ‘There are no beds.’ I got really scared and I didn’t know if they had time to get me anywhere else.”

When a bed was finally located 65 miles away in Salina, Connolly, who has kidney failure, was relieved but worried: How long would she be gone? Who would care for her young daughter? How would she get home? What would it all cost?

Connolly was caught in a situation experts have warned about since the beginning of the coronavirus pandemic: Covid-19 patients are overwhelming hospitals, squeezing space and staff needed to treat emergencies like Connolly’s.

While it has happened in pockets throughout the country since the spring, the pressure on hospitals is widespread now — reaching into both urban and rural communities at an alarming pace, even as local officials and citizens continue to slam public health departments and pandemic guidelines. Traveling nurses are hard to come by as their services are in high demand nationwide and their pay has escalated beyond the reach of some smaller hospitals.

“This is the first time since I have been here that we’ve had a scenario where multiple hospitals, for longer periods of time, are experiencing some kind of shortages,” said Cindy Samuelson, a senior vice president of the Kansas Hospital Association.

And it got worse after Connolly’s emergency in mid-November. The 14-day rolling average positive test rate in Reno County, where Hutchinson is the county seat, reached 46% on Dec. 22, though it has since come down to 24% as of Jan. 4, said D.J. Gering, data analyst for the Reno County Health Department. The results did not include inmates from the Hutchinson Correctional Center, the local state prison.

By Oct. 1, four covid deaths had been recorded in the county of about 62,000. By Jan. 4, the death toll since the pandemic began had jumped to 105. For comparison, Gering said, Reno County had 19 deaths attributed to pneumonia and influenza combined in all of 2019.

Hospitalizations at the 190-licensed-bed Hutchinson Regional Medical Center increased 800% from mid-October to mid-December then started to temper at the end of the month, said Chuck Welch, vice president of Hutchinson Regional Medical System.

“I hate to be overly optimistic until we are well past the possible holiday surge from Christmas and New Year’s,” he said in an email.

Operating between 90% and 95% capacity, the hospital is providing care to patients with a multitude of needs and still has room to expand. The problem, Welch said, has been staffing.

Competing for traveling nurses and specialists against larger hospitals to backfill positions open from sick or quarantining staffers has been challenging. When the hospital has been faced with increasing numbers of covid patients seeking emergency care, handling “normal” emergencies like Connolly’s has been much more difficult, Welch said.

While staffers work to transfer patients as close to home as possible, with so many hospitals in Kansas beyond capacity, it has become more common than before to transfer as far away as Colorado and Nebraska. Such transfers require medical flights, which are typically not covered by insurance and can cost patients upward of $50,000, Welch said.

“It is collateral damage,” he said. “It is something that has sort of been lost out of the narrative of these folks where everybody is relieved when we find them a bed. Everybody forgets about the downstream impact of the cost of those transports.”

Connolly recovered after three days in the Salina hospital. But the question still looms about the costs for her emergency care. Connolly had left her job as a corrections officer at the prison in September because coronavirus cases began to spike inside. Without her employer-sponsored health insurance, Connolly now relies on Medicaid and Medicare Part A, which means she is responsible for more out-of-pocket costs for things like pharmaceuticals and ambulance services.

Connolly worries so much about her finances that she’s been too scared to look at her recent ambulance bills. Being a single parent, living with kidney failure and undergoing dialysis during a pandemic are her primary concerns.

As with many underlying conditions, covid-19 appears to pose an extra risk for people with kidney failure and patients undergoing dialysis, said Dr. Alan Kliger, a nephrologist at Yale University and co-chair of the American Society of Nephrology’s COVID-19 Response Team.

Data from New York and Europe early in the pandemic showed that about 1 in 5 dialysis patients who acquired covid died, he said. However, the complication and mortality rates have fallen in recent months, according to unpublished survey data from members of the nephrology society, Kliger said.

“It’s still a high risk,” he said.

For Connolly, the pandemic has also complicated her three-times-a-week 3½-hour dialysis schedule. For example, when her daughter’s kindergarten class was told to quarantine for 14 days after an in-class exposure to the virus, she had to scramble to find babysitters so she could attend dialysis.

“I don’t want too many people to watch her because of covid,” Connolly said of her daughter, adding that she is lucky the girl’s father is supportive. But he can’t always step in, which means if Connolly can’t find a sitter, she may have to skip or reschedule dialysis.

Connolly wants to get another job. But living in a county where so many refuse to wear masks and some elected leaders accuse the health department of providing false information about covid testing rates and statistics makes her afraid to be in public more than necessary.

“I want to work,” she said. “I had a good job. I served my community. The reality of knowing how bad it is at the hospital — I have seen it firsthand. And now I am out and seeing people without masks and I am thinking, ‘If I get this and I have to go back, I may not leave the hospital next time.’”

The reality, said Kliger, Welch and others, is that while the virus runs rampant, hospitals will struggle to keep up, which potentially endangers medical staffers and anyone needing hospital care — and the virus will continue to spread as long as people refuse to wear masks and disregard scientifically sound guidelines.

Connolly said she would love to see more empathy for people who have underlying health concerns like her from those resisting safety measures such as masks.

“Even if they think that it doesn’t work, what if it does? What if it could? I don’t really understand how wearing a mask is going to take so much out of your day, compared to someone who is immunocompromised and gets sick,” said Connolly. “Or you lose your grandma, or your parent. That’s going to affect your life a lot longer than wearing a mask for a little while.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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How UCLA Health incorporated telehealth into its triage protocol

In response to the spike in demand for virtual care services amid the Covid-19 pandemic, UCLA Health developed telehealth-specific triage protocols to ensure their patients are getting care through the appropriate medium — whether in person or via a video visit. Here’s how they did it.

In Los Angeles and Beyond, Oxygen Is the Latest Covid Bottleneck

As Los Angeles hospitals give record numbers of covid patients oxygen, the systems and equipment needed to deliver the life-sustaining gas are faltering.

It’s gotten so bad that Los Angeles County officials are warning paramedics to conserve it. Some hospitals are having to delay releasing patients as they don’t have enough oxygen equipment to send home with them.

“Everybody is worried about what’s going to happen in the next week or so,” said Cathy Chidester, director of the L.A. County Emergency Medical Services Agency.

Oxygen, which makes up 21% of the Earth’s air, isn’t running short. But covid damages the lungs, and the crush of patients in hot spots such as Los Angeles, the Navajo Nation, El Paso, Texas, and in New York last spring have needed high concentrations of it. That has stressed the infrastructure for delivering the gas to hospitals and their patients.

The strain in those areas is caused by multiple weak links in the pandemic supply chain. In some hospitals that pipe oxygen to patients’ rooms, the massive volume of cold liquid oxygen is freezing the equipment needed to deliver it, which can block the system.

“You can completely — literally, completely — shut down the entire hospital supply if that happens,” said Rich Branson, a respiratory therapist with the University of Cincinnati and editor-in-chief of the journal Respiratory Care.

There is also pressure on the availability of both the portable cylinders that hold oxygen and the concentrators that pull oxygen from the air. And in some cases, vendors that supply the oxygen have struggled to get enough of the gas to hospitals. Even nasal cannulas, the tubing used to deliver oxygen, are now running low.

“It’s been nuts, absolutely nuts,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor based in El Paso. He provides oxygen to several temporary hospitals set up specifically to treat people with covid.

In November, he said, he was answering calls in the middle of the night from contractors worried about oxygen supplies. At one point, when the company’s usual supplier fell through, they were hauling oxygen from Houston, which is a more than 10-hour drive each way.

Branson has been sounding the alarm about logistical limitations on critical care since the SARS pandemic nearly 20 years ago, when he and others surveyed experts about the specific equipment and infrastructure needed during a future pandemic. Oxygen was near the top of the list.

Oxygen as Cold as Neptune

Last spring, New York, New Jersey and Connecticut faced a challenge similar to what is now unfolding in Los Angeles, said Robert Karcher, a vice president of contract services for Acurity, a group purchasing organization that worked with many hospitals during that surge.

To take up less space, oxygen is often stored as a liquid around minus 300 degrees Fahrenheit, about as cold as the surface of Neptune. But as covid patients filling ICUs were given oxygen through ventilators or nasal tubes, some hospitals began to see ice form over the equipment that converts liquid oxygen into a gas.

When a hospital draws more and more liquid oxygen from those tanks, the super-cold liquid can seep further into the vaporizing coils where liquid oxygen turns to gas.

Branson said some ice is normal, but a lot of ice can cause valves on the device to freeze in place. And the ice can restrict airflow in the pipes sending the oxygen into patients’ rooms, Karcher said. To combat this, hospitals could switch to a backup vaporizer if they had one, hose down iced vaporizers or move patients to cylinder-delivered oxygen. But that puts additional strain on the hospitals’ cylinder oxygen supply, as well as the medical gas supplier, Karcher said.

Hospitals in New York began to panic in the spring because the icing of the vaporizer was much greater than they had seen before, he added. It got so bad, he said, that some hospitals worried they’d have to close their ICUs.

“They thought they were in imminent danger of their tank piping shutting down,” he said. “We came pretty close in a couple of our hospitals. It was a rough few weeks.”

The strain on Los Angeles health care infrastructure could be worse given the now-common treatment of putting patients on oxygen using high-flow nasal cannulas. That requires more of the gas pumped at a higher rate than with ventilators.

“I don’t know of any system that is really set to triple patient volumes — or 10 times the oxygen delivery,” Chidester said of the L.A. County hospitals. “They’re having a hard time keeping up.”

The Oxygen Shortage Doom Loop

In and around Los Angeles, the Army Corps of Engineers has so far surveyed 11 hospitals for freezing oxygen pipe issues. The hospitals are a mix of older facilities and smaller suburban hospitals seeing such high demand amid skyrocketing cases in the area, said Mike Petersen, a Corps spokesperson.

One of the worst examples he saw included pipes that looked like a home freezer that had not been defrosted in some time.

The problem gets worse for hospitals that have had to convert regular hospital rooms to intensive care units. ICU pipes are bigger than those leading to other parts of a hospital. When rooms get repurposed as pop-up ICUs, the pipes can simply be too narrow to deliver the oxygen that covid patients need. And so, Chidester said, the hospitals switch to large cylinders of oxygen. But vendors are having a hard time refilling those quickly enough.

Even smaller cylinders and oxygen concentrators are in short supply amid the surge, she said. Those patients who could be sent home with an oxygen cylinder are left stuck in a hospital waiting for one, taking up a much-needed bed.

‘Extreme Rurality’

In early December, doctors serving the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to get oxygen to patients both in the hospital and recovering at home.

“We’ve never reached capacity before — until now,” said Dr. Loretta Christensen, chief medical officer for the Navajo Area Indian Health Service, in mid-December. Its hospitals serve a patient population in the southwestern U.S. that’s spread across an area bigger than West Virginia.

The buildings are aging, and they aren’t built to house a large number of critical patients, said Christensen. As the number of patients on high-flow oxygen climbed, several facilities started to notice their oxygen flow weaken. They thought something was broken, but when engineers took a look, Christensen said, it became clear the system was just not able to provide the amount of high-flow oxygen patients needed.

She said a hospital in Gallup, New Mexico, put in new filters to maximize oxygen flow. After delays from snowy weather, a hospital serving the northern part of the Navajo Nation managed to hook up a second oxygen tank to boost capacity.

But medical facilities in the area are always a little on edge.

“Honestly, we worry about supply a lot out here because — and I call it extreme rurality — you just can’t get something tomorrow,” said Christensen. “It’s not like being in an urban area where you can say, ‘Oh, I need this right now.’”

Because of the small size of certain hospitals and the difficulty of getting to some of them, Christensen said, Navajo facilities aren’t attractive to big vendors, so they rely on local vendors, which may prove more vulnerable to supply chain hiccups.

Tséhootsooí Medical Center in Fort Defiance, Arizona, has at times had to keep patients in the hospital and transfer incoming patients to other facilities because it couldn’t get the oxygen cylinders needed to send recovering patients home.

Tina James-Tafoya, covid incident commander at Fort Defiance Indian Hospital Board, which runs the center, said at-home oxygen is out of the question for some patients. Oxygen concentrators require electricity, which some patients don’t have. And for patients who live in hogans, homes often heated with a wood stove, the use of oxygen cylinders is a hazard.

“It’s really interesting and eye-opening for me to see that something that seems so simple like oxygen has so many different things tied to it that will hinder it getting to the patient,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Push for better patient outcomes drives new standard of care [Sponsored]

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In this webinar on Feb. 10,healthcare experts from Desert Oasis Healthcare and iRhythm Technologies will discuss how Zio monitors, designed to be worn for longer duration than holter monitors, represent a new standard of care in remote cardiac monitoring.

States threaten to crackdown on providers amid Covid-19 vaccine distribution

In an effort to ensure the efficient and orderly distribution of the Covid-19 vaccine, governors from New York, California and Florida are warning that they will take action against providers who are conducting vaccinations too slowly or healthcare workers who undercut priority guidelines.

Children’s Hospitals Grapple With Wave of Mental Illness

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Krissy Williams, 15, had attempted suicide before, but never with pills.

The teen was diagnosed with schizophrenia when she was 9. People with this chronic mental health condition perceive reality differently and often experience hallucinations and delusions. She learned to manage these symptoms with a variety of services offered at home and at school.

But the pandemic upended those lifelines. She lost much of the support offered at school. She also lost regular contact with her peers. Her mother lost access to respite care — which allowed her to take a break.

On a Thursday in October, the isolation and sadness came to a head. As Krissy’s mother, Patricia Williams, called a mental crisis hotline for help, she said, Krissy stood on the deck of their Maryland home with a bottle of pain medication in one hand and water in the other.

Before Patricia could react, Krissy placed the pills in her mouth and swallowed.

Efforts to contain the spread of the novel coronavirus in the United States have led to drastic changes in the way children and teens learn, play and socialize. Tens of millions of students are attending school through some form of distance learning. Many extracurricular activities have been canceled. Playgrounds, zoos and other recreational spaces have closed. Kids like Krissy have struggled to cope and the toll is becoming evident.

Government figures show the proportion of children who arrived in emergency departments with mental health issues increased 24% from mid-March through mid-October, compared with the same period in 2019. Among preteens and adolescents, it rose by 31%. Anecdotally, some hospitals said they are seeing more cases of severe depression and suicidal thoughts among children, particularly attempts to overdose.

The increased demand for intensive mental health care that has accompanied the pandemic has worsened issues that have long plagued the system. In some hospitals, the number of children unable to immediately get a bed in the psychiatric unit rose. Others reduced the number of beds or closed psychiatric units altogether to reduce the spread of covid-19.

“It’s only a matter of time before a tsunami sort of reaches the shore of our service system, and it’s going to be overwhelmed with the mental health needs of kids,” said Jason Williams, a psychologist and director of operations of the Pediatric Mental Health Institute at Children’s Hospital Colorado.

“I think we’re just starting to see the tip of the iceberg, to be honest with you.”

Before covid, more than 8 million kids between ages 3 and 17 were diagnosed with a mental or behavioral health condition, according to the most recent National Survey of Children’s Health. A separate survey from the Centers for Disease Control and Prevention found 1 in 3 high school students in 2019 reported feeling persistently sad and hopeless — a 40% increase from 2009.

The coronavirus pandemic appears to be adding to these difficulties. A review of 80 studies found forced isolation and loneliness among children correlated with an increased risk of depression.

“We’re all social beings, but they’re [teenagers] at the point in their development where their peers are their reality,” said Terrie Andrews, a psychologist and administrator of behavioral health at Wolfson Children’s Hospital in Florida. “Their peers are their grounding mechanism.”

Children’s hospitals in New York, Colorado and Missouri all reported an uptick in the number of patients who thought about or attempted suicide. Clinicians also mentioned spikes in children with severe depression and those with autism who are acting out.

The number of overdose attempts among children has caught the attention of clinicians at two facilities. Andrews from Wolfson Children’s said the facility gives out lockboxes for weapons and medication to the public — including parents who come in after children attempted to take their life using medication.

Children’s National Hospital in Washington, D.C., also has experienced an uptick, said Dr. Colby Tyson, associate director of inpatient psychiatry. She’s seen children’s mental health deteriorate due to a likely increase in family conflict — often a consequence of the chaos caused by the pandemic. Without school, connections with peers or employment, families don’t have the opportunity to spend time away from one another and regroup, which can add stress to an already tense situation.

“That break is gone,” she said.

The higher demand for child mental health services caused by the pandemic has made finding a bed at an inpatient unit more difficult.

Now, some hospitals report running at full capacity and having more children “boarding,” or sleeping in emergency departments before being admitted to the psychiatric unit. Among them is the Pediatric Mental Health Institute at Children’s Hospital Colorado. Williams said the inpatient unit has been full since March. Some children now wait nearly two days for a bed, up from the eight to 10 hours common before the pandemic.

Cincinnati Children’s Hospital Medical Center in Ohio is also running at full capacity, said clinicians, and had several days in which the unit was above capacity and placed kids instead in the emergency department waiting to be admitted. In Florida, Andrews said, up to 25 children have been held on surgical floors at Wolfson Children’s while waiting for a spot to open in the inpatient psychiatric unit. Their wait could last as long as five days, she said.

Multiple hospitals said the usual summer slump in child psychiatric admissions was missing last year. “We never saw that during the pandemic,” said Andrews. “We stayed completely busy the entire time.”

Some facilities have decided to reduce the number of beds available to maintain physical distancing, further constricting supply. Children’s National in D.C. cut five beds from its unit to maintain single occupancy in every room, said Dr. Adelaide Robb, division chief of psychiatry and behavioral sciences.

The measures taken to curb the spread of covid have also affected the way hospitalized children receive mental health services. In addition to providers wearing protective equipment, some hospitals like Cincinnati Children’s rearranged furniture and placed cues on the floor as reminders to stay 6 feet apart. UPMC Western Psychiatric Hospital in Pittsburgh and other facilities encourage children to keep their masks on by offering rewards like extra computer time. Patients at Children’s National now eat in their rooms, a change from when they ate together.

Despite the need for distance, social interaction still represents an important part of mental health care for children, clinicians said. Facilities have come up with various ways to do so safely, including creating smaller pods for group therapy. Kids at Cincinnati Children’s can play with toys, but only with ones that can be wiped clean afterward. No cards or board games, said Dr. Suzanne Sampang, clinical medical director for child and adolescent psychiatry at the hospital.

“I think what’s different about psychiatric treatment is that, really, interaction is the treatment,” she said, “just as much as a medication.”

The added infection-control precautions pose challenges to forging therapeutic connections. Masks can complicate the ability to read a person’s face. Online meetings make it difficult to build trust between a patient and a therapist.

“There’s something about the real relationship in person that the best technology can’t give to you,” said Robb.

For now, Krissy is relying on virtual platforms to receive some of her mental health services. Despite being hospitalized and suffering brain damage due to the overdose, she is now at home and in good spirits. She enjoys geometry, dancing on TikTok and trying to beat her mother at Super Mario Bros. on the Wii. But being away from her friends, she said, has been a hard adjustment.

“When you’re used to something,” she said, “it’s not easy to change everything.”

If you have contemplated suicide or someone you know has talked about it, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospital Prices Just Got a Lot More Transparent. What Does This Mean for You?

Hospitals face the new year with new requirements to post price information they have long sought to obscure: the actual prices negotiated with insurers and the discounts they offer their cash-paying customers.

The move is part of a larger push by the Trump administration to use price transparency to curtail prices and create better-informed consumers. Yet there is disagreement on whether it will do so.

As of Jan. 1, facilities must publicly post on their websites prices for every service, drug and supply they provide. Next year, under a separate rule, health insurers must take similar steps. A related effort to force drugmakers to list their prices in advertisements was struck down by the courts.

With the new hospital rule, consumers should be able to see the tremendous variation in prices for the exact same care among hospitals and get an estimate of what they will be charged for care — before they seek it.

The new data requirements go well beyond the previous rule of requiring hospitals to post their “chargemasters,” hospital-generated list prices that bear little relation to what it costs a hospital to provide care and that few consumers or insurers actually pay.

Instead, under the new rule put forward by the Trump administration, “these are the real prices in health care,” said Cynthia Fisher, founder and chairman of Patient Rights Advocate, a group that promotes price transparency.

Here’s what consumers should know:

What’s the Scope of the Intel?

Each hospital must post publicly online — and in a machine-readable format easy to process by computers — several prices for every item and service they provide: gross charges; the actual, and most likely far lower, prices they’ve negotiated with insurers, including de-identified minimum and maximum negotiated charges; and the cash price they offer patients who are uninsured or not using their insurance.

In addition, each hospital must make available, in a “consumer-friendly format,” the specific costs for 300 common and “shoppable” services, such as having a baby, getting a joint replacement, having a hernia repair or undergoing a diagnostic brain scan.

Those 300 bundles of procedures and services must total all costs involved — from the hardware used to the operating room time, to drugs given and the fees of hospital-employed physicians — so patients won’t have to attempt the nearly impossible job of figuring it out themselves.

Hospitals can mostly select which services fall into this category, although the federal government has dictated 70 that must be listed — including certain surgeries, diagnostic tests, imaging scans, new patient visits and psychotherapy sessions.

Will Prices Be Exact?

No. At best, these are ballpark figures.

Other factors influence consumers’ costs, like the type of insurance plan a patient has, the size and remaining amount of the annual deductible, and the complexity of the medical problem.

An estimate on a surgery, for example, might prove inexact. If all goes as expected, the price quoted likely will be close. But unexpected complications could arise, adding to the cost.

“You’ll get the average price, but you are not average,” said Gerard Anderson, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health who studies hospital pricing.

Tools to help consumers determine in advance the amount of deductible they’ll owe are already available from many insurers. And experts expect the additional information being made available this month will prompt entrepreneurs to create their own apps or services to help consumers analyze the price data.

For now, though, the hospital requirements are a worthy start, say experts.

“It’s very good news for consumers,” said George Nation, a professor of law and business at Lehigh University who studies hospital pricing. “Individuals will be able to get price information, although how much they are going to use it will remain to be seen.”

Will Consumers Use This Info? Who Else Might?

Zack Cooper, an associate professor of public health and economics at Yale, doubts that the data alone will make much of a difference for most consumers.

“It’s not likely that my neighbor — or me, for that matter — will go on and look at prices and, therefore, dramatically change decisions about where to get care,” he said.

Some cost information is already made available by insurers to their enrollees, particularly out-of-pocket costs for elective services, “but most people don’t consult it,” he added.

That could be because many consumers carry types of insurance in which they pay flat-dollar copayments for such things as doctor visits, drugs or hospital stays that have no correlation to the underlying charges.

Still, the information may be of great interest to the uninsured and to the increasing number of Americans with high-deductible plans, in which they are responsible for hundreds or even thousands of dollars in costs annually before the insurer begins picking up the bulk of the cost.

For them, the negotiated rate and cash discount information may prove more useful, said Nation at Lehigh.

“If I have a $10,000 deductible plan and it’s December and I’m not close to meeting that, I may go to a hospital and try to get the cash price,” said Nation.

Employers, however, may have a keen interest in the new data, said James Gelfand, senior vice president at the ERISA Industry Committee, which lobbies on behalf of large employers that offer health insurance to their workers. They’ll want to know how much they are paying each hospital compared with others in the area and how well their insurers stack up in negotiating rates, he said.

For some employers, he said, it could be eye-opening to see how hospitals cross-subsidize by charging exorbitant amounts for some things and minimal amounts for others.

“The rule puts that all into the light,” said Gelfand. “When an employer sees these ridiculous prices, for the first time they will have the ability to say no.” That could mean rejecting specific prices or the hospital entirely, cutting it out of the employer plan’s insurance network. But, typically, employers can’t or won’t limit workers’ choices by outright cutting a hospital from an insurance network.

More likely, they may use the information to create financial incentives to use the lowest-cost facilities, said Anderson at Johns Hopkins.

“If I’m an employer, I’ll look at three hospitals in my area and say, ‘I’ll pay the price for the lowest one. If you want to go to one of the other two, you can pay the difference,’” said Anderson.

Will Price Transparency Reduce Overall Health Spending?

Revealing actual negotiated prices, as this rule requires, may push the more expensive hospitals in an area to reduce prices in future bargaining talks with insurers or employers, potentially lowering health spending in those regions.

It could also go the other way, with lower-cost hospitals demanding a raise, driving up spending.

Bottom line: Price transparency can help, but the market power of the various players might matter more.

In some places, where there may be one dominant hospital, even employers “who know they are getting ripped off” may not feel they can cut out a big, brand-name facility from their networks, no matter the price, said Anderson.

Is the Rule Change a Done Deal?

The hospital industry went to court, arguing that parts of the rule go too far, violating their First Amendment rights and also unfairly forcing hospitals to disclose trade secrets. That information, the industry said, can then be used against them in negotiations with insurers and employers.

But the U.S. District Court for the District of Columbia disagreed with the hospitals and upheld the rule, prompting an appeal by the industry. On Dec. 29, the U.S. Court of Appeals for the District of Columbia affirmed that lower-court decision and did not block the rule.

In a written statement last week, the American Hospital Association’s general counsel cited “disappointment” with the ruling and said the organization is “reviewing the decision carefully to determine next steps.”

Apart from the litigation, the American Hospital Association plans to talk with the incoming Biden administration “to try to persuade them there are some elements to this rule and the insurer rule that are tricky,” said Tom Nickels, an executive vice president of the trade group. “We want to be of help to consumers, but is it really in people’s best interest to provide privately negotiated rates?”

Fisher thinks so: “Hospitals are fighting this because they want to keep their negotiated deals with insurers secret,” she said. “What these rules do is give the American consumer the power of being informed.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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46 hospitals file suit to reverse HHS bad debt policy

A group of hospitals have sued HHS Secretary Alex Azar, arguing he should reverse a policy that prevents hospitals from getting reimbursed for Medicare-related bad debts pending at outside collection agencies. The policy has raised hospital debt payments by about $1.35 million, the lawsuit claims.

Behind the scenes: How health systems, EHR vendors will give patients unprecedented access to their data

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Health systems and EHR vendors have been working for months to comply with the ONC’s final rule on interoperability and information blocking that goes into effect in April and is expected to grant patients unprecedented access to their health information. Here is a look at some of the issues they contended with.

Children’s Hospitals Are Partly to Blame as Superbugs Increasingly Attack Kids

COLUMBIA, Mo. — A memory haunts Christina Fuhrman: the image of her toddler Pearl lying pale and listless in a hospital bed, tethered to an IV to keep her hydrated as she struggled against a superbug infection.

“She survived by the grace of God,” Fuhrman said of the illness that struck her oldest child in this central Missouri city almost five years ago. “She could’ve gone septic fast. Her condition was near critical.”

Pearl was fighting Clostridium difficile, or C. diff, a type of antibiotic-resistant bacteria known as a superbug. A growing body of research shows that overuse and misuse of antibiotics in children’s hospitals — which health experts and patients say should know better — helps fuel these dangerous bacteria that attack adults and, increasingly, children. Doctors worry that the covid pandemic will only lead to more overprescribing.

A study published in the journal Clinical Infectious Diseases in January found that 1 in 4 children given antibiotics in U.S. children’s hospitals are prescribed the drugs inappropriately — the wrong types, or for too long, or when they’re not necessary.

Dr. Jason Newland, a pediatrics professor at Washington University in St. Louis who co-authored the study, said that’s likely an underestimate because the research involved 32 children’s hospitals already working together on proper antibiotic use. Newland said the nation’s 250-plus children’s hospitals need to do better.

“It’s irresponsible,” Fuhrman added. Coupled with parents begging for antibiotics in pediatricians’ offices, it’s “just creating a monster.”

Using antibiotics when they’re not needed is a long-standing problem, and the pandemic “has thrown a little bit of gas on the fire,” said Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School.

Although fears of covid-19 mean fewer parents are taking their children to doctors’ offices and some have skipped routine visits for their kids, children are still getting antibiotics through telemedicine visits that don’t allow for in-person exams. And research shows more than 5,000 children infected with the coronavirus were hospitalized between late May and late September. If symptoms point toward a bacterial infection on top of the coronavirus, Schleiss said, doctors sometimes prescribe antibiotics, which don’t work on viruses, until tests rule out bacteria.

At the same time, Newland said, the demands of caring for covid patients take time away from what are known as “stewardship” programs aimed at measuring and improving how antibiotics are prescribed. Often such efforts involve continuing education courses for health care professionals on how to use antibiotics safely, but the pandemic has made those more difficult to host.

“There’s no doubt: We’ve seen some extra use of antibiotics,” Newland said. “The impact of the pandemic on antibiotic use will be significant.”

Habits Drive Superbug Growth

Antibiotic resistance occurs through random mutation and natural selection. Those bacteria most susceptible to an antibiotic die quickly, but surviving germs can pass on resistant features, then spread. The process is driven by prescribing habits that lead to high levels of antibiotic use.

A March study in the journal Infection Control & Hospital Epidemiology found that the rates of antibiotic use on patients at 51 children’s hospitals ranged from 22% to 52%. Some of those medications treated actual bacterial infections, but others were given in hopes of preventing infections or when doctors didn’t know what was causing a problem.

“I hear a lot about antibiotic use for the ‘just in case’ scenarios,” said Dr. Joshua Watson, director of the antimicrobial stewardship program at Nationwide Children’s Hospital in Ohio. “We underestimate the downsides.”

Newland said each specialty in medicine has its own culture around antibiotic use. Many surgeons, for example, routinely use antibiotics to prevent infection after operations.

Outside of hospitals, doctors have long been criticized for prescribing antibiotics too often for ailments such as ear infections, which can sometimes go away on their own or can be caused by viruses that antibiotics won’t counter.

Dr. Shannon Ross, an associate professor of pediatrics and microbiology at the University of Alabama at Birmingham, said not all doctors have been taught how to use antibiotics correctly.

“Many of us don’t realize we’re doing it,” she said of overuse. “It’s sort of not knowing what you’re doing until someone tells you.”

All this drives the growth of numerous superbugs in the very population served by these hospitals. Numerous studies, including one published in the Journal of Pediatrics in March, cite the rise among kids of C. diff, which causes gastrointestinal problems. A 2017 study in the Journal of the Pediatric Infectious Diseases Society found that cases of a certain type of multidrug-resistant Enterobacteriaceae rose 700% in American children in just eight years. And a steady stream of research points to the stubborn prevalence in kids of the better-known MRSA, or methicillin-resistant Staphylococcus aureus.

Superbug infections can be extremely difficult — and sometimes impossible — to treat. Doctors often must turn to strong medicines with side effects or give drugs intravenously.

“It’s getting more and more worrisome,” Ross said. “We have had patients we have not been able to treat because we’ve had no antibiotics available” that could kill the germs.

Doctors say the world is nearing a “post-antibiotic era,” when antibiotics no longer work and common infections can kill.

A Monster Unleashed

Superbugs spawned by antibiotic overuse put everyone at risk.

Like her daughter, Fuhrman also suffered through a C. diff infection, getting sick after taking antibiotics following a root canal in 2012. While killing harmful germs, antibiotics can also destroy those that protect against infection. Fuhrman cycled in and out of the hospital for months. When she finally got better, she tried to avoid using antibiotics and never gave them to her daughter.

That’s because antibiotics affect your microbiome by wiping out bad germs and the good germs that protect your body against infections.

Pearl’s first symptoms of C. diff arose about three years later, at around 20 months old. Fuhrman noticed her daughter was having lots of bowel movements. The mom eventually found pus and blood in her daughter’s stools. One day, Pearl was so pale and weak that Fuhrman took her to the emergency room. She was discharged, then spiked a fever and returned to the hospital.

Doctors treated Pearl with Flagyl, a broad-spectrum antibiotic. But two days after the last dose, she went downhill. The infection had returned. She recovered only after going to the Mayo Clinic in Rochester, Minnesota, for a fecal microbiota transplantation, in which she received healthy donor stool from her dad through a colonoscopy.

Since her family’s ordeal, Fuhrman has been trying to raise awareness of superbugs and antibiotic overuse. She serves on the board of the Peggy Lillis Foundation, a C. diff education and advocacy organization, and has testified before a presidential advisory committee in Washington, D.C., about superbugs and antibiotic stewardship.

In March, the Centers for Medicare & Medicaid Services began requiring all hospitals to document that they have antibiotic stewardship programs.

One approach, Schleiss said, is to restrict antibiotics by “saving our most magic bullets for the most desperate situations.” Another is to stop antibiotics at, say, 72 hours, after reassessing whether patients need them. Meanwhile, doctors are calling for more research into antibiotic use in children.

Fuhrman said hospitals must do all they can to stop superbug infections. The stakes are enormous, she said, pointing toward Pearl, now a 7-year-old first grader who likes to wear a pink hair bow and paint her tiny fingernails a rainbow of pastel colors.

“Antibiotics are great, but they have to be used wisely,” Fuhrman said. “The problem of superbugs is here. It’s in our backyard now, and it’s just getting worse.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘Last Responders’ Brace for Surge in Covid Deaths Across US

Funeral director Kevin Spitzer has been overwhelmed with covid-related deaths in the small city of Aberdeen, South Dakota.

He and his two colleagues at the Spitzer-Miller Funeral Home have been working 12-15 hours a day, seven days a week, to keep up with the demand in the community of 26,000. The funerals are sparsely attended, which would have been unthinkable before the pandemic.

“We had a funeral for a younger man one recent Saturday, and not 20 people came, because most everyone was just afraid,” he said.

As covid-19 has spread from big cities to rural communities, it has stressed not only hospitals, but also what some euphemistically call “last responders.” The crush has overwhelmed morgues, funeral homes and religious leaders, required ingenuity and even changed the rituals of honoring the dead.

Officials in many smaller cities and towns learned from seeing the overflow of bodies during last spring’s first wave of covid deaths in places such as Detroit, where nurses at Detroit Medical Center Sinai-Grace Hospital alerted the media to bodies accumulating in hospital storage rooms. They watched as New York hospitals and funeral homes marshaled refrigerated trucks to store bodies. More than 600 bodies of people who died in the spring covid surge remain in freezer trucks on the Brooklyn waterfront because officials can’t find next of kin, or relatives are also sick or unable to pay for burial.

People like Dr. Robert Kurtzman, Montana’s chief medical examiner, took heed. Last spring, he worked with funeral directors and others to study the state’s morgue capacity. After looking at covid projections, the state arranged with the Montana National Guard to have 13 refrigerated semitrucks ready to dispatch anywhere in the state.

“We are already in a precarious position, and the projections present a scary proposition,” he said. “We need to be ready for worst-case scenarios.”

Chad Towner, CEO of St. Joseph Health System, which has two hospitals in northern Indiana, ordered two refrigerated semitrailers in April. For a time, things were relatively quiet. But the pandemic has hit.

“I told a friend who was a covid doubter that if my wife needed a bed today, I could not arrange one. That’s the dire situation we face here,” Towner said. “All our competitors in the area are in the same boat, and we’re working together instead of competing.”

Although the freezer trucks have not yet been needed, he worries that the sharp increase in cases, and those anticipated from holiday gatherings, will make last-resort measures necessary.

“We recently had four deaths in one afternoon,” said Towner. “A priest approached me to say he’d been asked to provide last rites to three patients in one hour.”

Moving bodies from the hospital morgue is a slower process than usual, he said. “Morticians and funeral homes are overflowing as well. Families that are sick or quarantined at the time of the loved one’s death often can’t work with us on a transfer, meaning bodies are here longer. The entire system is stressed to the tipping point,” said Towner.

Private enterprise has created a solution for smaller communities. In Bozeman, Montana, a specialty truck company has retrofitted trailers that can be pulled by an SUV or a pickup.

Acela Truck Co. has already sold hundreds of the pull-behind refrigerated units created in response to the covid pandemic. They range from 9 to 53 feet and have racks that each hold four body trays. “We’re very busy and have orders in all of the lower 48 states,” said CEO David Ronsen. Acela has partnered with Mopec, a Michigan autopsy supply company, to help sell and deliver the new product.

Billings Clinic in Montana also anticipated a flood of deaths last spring by reserving a semitrailer for delivery, if needed. The clinic, which has just two morgue spaces, has dealt with 80 covid deaths, including seven on the weekend after Thanksgiving.

Chief Nursing Officer Laurie Smith said the hospital is at capacity, despite adding beds by converting office space and building an addition. The hospital, which currently has 335 beds, so far has handled the additional deaths through what she calls a “sad partnership” with funeral homes, which have been quickly picking up bodies the hospital cannot store.

The hospital does its best to allow relatives to say goodbye, but that often involves family members standing at an interior window outside the patient’s room, using a computer tablet to communicate their last words.

That is just one way in which the rituals of grieving have changed during the covid pandemic.

Typical congregational hymns are pretty much gone, as are choirs.

“We are using mostly recordings, sometimes a soloist,” said Spitzer.

Funeral home directors who pride themselves on spending time comforting grieving families say they are so busy that some days they have to rush out from one funeral to begin the next one.

“Families are being robbed of the whole funeral rite experience and losing the support of having friends and family around them,” said Shauna Kjos-Miotke of Fiksdal Funeral Home in Webster, South Dakota.

Native communities have not only been among the hardest hit with covid illnesses and deaths, but their grieving rituals have been among the most seriously disrupted.

“Normally a funeral is a two- or three-day process with hundreds of people,” said Josiah Hugs, a Crow tribal member who is the outreach coordinator for Billings Urban Indian Health and Wellness Center. “Now there is no time to tell stories about the person, not a lot of singing and praying. I’ve been to three recent covid funerals, and everything was at the burial site, with maybe 30 people sitting in their cars and not getting out.”

Covid has even affected body disposal. A survey by the National Funeral Directors Association found that more than half of their members reported increased cremation rates due to covid. The NFDA also found that half its members have clients who have postponed services to hold a memorial later.

In the largely impoverished Hidalgo County, a Texas border area, county officials began using covid funds to help cover the burial costs for struggling families. Then they begin hearing of the emotional costs, including the anguish of videoconferenced funerals, such as for a family that had lost a husband, a mother and an aunt in one month. They wondered if there would be interest in an alternative way to honor the dead.

“We sent out a social media post asking if anyone wanted to post a photograph of a relative who died of covid if we created a county memorial page,” said county spokesperson Carlos Sanchez, who himself barely survived a bout with covid in July. “Within minutes, we got more than 20 emails. Several sent photos of multiple relatives. They want them to be remembered.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Report: Covid-19 hospitalizations spiked amid falling operating margins in November

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How Cerner plans to bolster rural hospitals’ telehealth efforts amid the pandemic and beyond

In a wide-ranging interview with MedCity News, Cerner CommunityWorks President Mitchell Clark discussed the healthcare challenges facing rural communities amid the Covid-19 pandemic and the company’s new free offering that aims to support rural telehealth.

NHS doctors ‘scrabbling’ to get vaccine amid alarm at Covid variant

Many medics ‘frustrated’ about low priority given to frontline staff at high risk of infection

Frontline NHS staff have been denied the Pfizer/BioNTech vaccine, leaving doctors alarmed and “scrabbling” to get immunised.

A new survey reveals that almost two-thirds of medics who responded to it have still not had the vaccine, half believe its delivery to the NHS frontline has been “ad hoc” and a third have no idea when they will be offered it. They fear the government’s decision to prioritise over-80s and care home staff above health workers has left them at risk of catching the disease, especially given the emergence of the coronavirus variant, which is 70% more transmissable.

Continue reading…

Provider groups, hospitals file motion to stop CMS from enforcing price transparency rule

The American Hospital Association and several other entities, including some hospitals, filed an emergency motion to block CMS from enforcing the hospital price transparency rule set to take effect Jan. 1. Provider groups are arguing that complying with the rule would shift focus away from pandemic-related efforts.

Why Covid Antibody Drugs Go Unused as Need Soars

While such treatments are promising, their use has been slowed by testing lags, overwhelmed hospitals and a perception the therapies are only for well-connected people.

Covid Antibody Drugs Go Unused as Need Soars

While such treatments are promising, their use has been slowed by testing lags, overwhelmed hospitals and a perception the therapies are only for well-connected people.

Why Covid Antibody Drugs Go Unused as Need Soars

While such treatments are promising, their use has been slowed by testing lags, overwhelmed hospitals and a perception the therapies are only for well-connected people.

As the Terror of COVID Struck, Health Care Workers Struggled to Survive. Thousands Lost the Fight.


This story also ran on The Guardian. It can be republished for free.

Workers at Garfield Medical Center in suburban Los Angeles were on edge as the pandemic ramped up in March and April. Staffers in a 30-patient unit were rationing a single tub of sanitizing wipes all day. A May memo from the CEO said N95 masks could be cleaned up to 20 times before replacement.

Patients showed up COVID-negative but some still developed symptoms a few days later. Contact tracing took the form of texts and whispers about exposures.

By summer, frustration gave way to fear. At least 60 staff members at the 210-bed community hospital caught COVID-19, according to records obtained by KHN and interviews with eight staff members and others familiar with hospital operations.

The first to die was Dawei Liang, 60, a quiet radiology technician who never said no when a colleague needed help. A cardiology technician became infected and changed his final wishes — agreeing to intubation — hoping for more years to dote on his grandchildren.

Few felt safe.

Ten months into the pandemic, it has become far clearer why tens of thousands of health care workers have been infected by the virus and why so many have died: dire PPE shortages. Limited COVID tests. Sparse tracking of viral spread. Layers of flawed policies handed down by health care executives and politicians, and lax enforcement by government regulators.

All of those breakdowns, across cities and states, have contributed to the deaths of more than 2,900 health care workers, a nine-month investigation by over 70 reporters at KHN and The Guardian has found. This number is far higher than that reported by the U.S. government, which does not have a comprehensive national count of health care workers who’ve died of COVID-19.

The fatalities have skewed young, with the majority of victims under age 60 in the cases for which there is age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective equipment.

Many of the deaths occurred in New York and New Jersey, and significant numbers also died in Southern and Western states as the pandemic wore on.

Workers at well-funded academic medical centers — hubs of policymaking clout and prestigious research — were largely spared. Those who died tended to work in less prestigious community hospitals like Garfield, nursing homes and other health centers in roles in which access to critical information was low and patient contact was high.

Garfield Medical Center and its parent company, AHMC Healthcare, did not respond to multiple calls or emails regarding workers’ concerns and circumstances leading to the worker deaths.

So as 2020 draws to a close, we ask: Did so many of the nation’s health care workers have to die?

New York’s Warning for the Nation

The seeds of the crisis can be found in New York and the surrounding cities and suburbs. It was the region where the profound risks facing medical staff became clear. And it was here where the most died.

As the pandemic began its U.S. surge, city paramedics were out in force, their sirens cutting through eerily empty streets as they rushed patients to hospitals. Carlos Lizcano, a blunt Queens native who had been with the New York City Fire Department (FDNY) for two decades, was one of them.

He was answering four to five cardiac arrest calls every shift. Normally he would have fielded that many in a month. He remembered being stretched so thin he had to enlist a dying man’s son to help with CPR. On another call, he did chest compressions on a 33-year-old woman as her two small children stood in the doorway of a small apartment.

“I just have this memory of those kids looking at us like, ‘What’s going on?’”

After the young woman died, Lizcano went outside and punched the ambulance in frustration and grief.

The personal risks paramedics faced were also grave.

More than 40% of emergency medical service workers in the FDNY went on leave for confirmed or suspected coronavirus during the first three months of the pandemic, according to a study by the department’s chief medical officer and others.

In fact, health care workers were three times more likely than the general public to get COVID-19, other researchers found. And the risks were not equally spread among medical professions. Initially, CDC guidelines were written to afford the highest protection to workers in a hospital’s COVID-19 unit.

Yet months later, it was clear that the doctors initially thought to be at most risk — anesthesiologists and those working in the intensive care unit — were among the least likely to die. This could be due to better personal protective equipment or patients being less infectious by the time they reach the ICU.

Instead, scientists discovered that “front door” health workers like paramedics and those in acute-care “receiving” roles — such as in the emergency room — were twice as likely as other health care workers to be hospitalized with COVID-19.

For FDNY’s first responders, part of the problem was having to ration and reuse masks. Workers were blind to an invisible threat that would be recognized months later: The virus spread rapidly from pre-symptomatic people and among those with no symptoms at all.

In mid-March, Lizcano was one of thousands of FDNY first responders infected with COVID-19.

At least four of them died, city records show. They were among the 679 health care workers who have died in New York and New Jersey to date, most at the height of the terrible first wave of the virus.

“Initially, we didn’t think it was this bad,” Lizcano said, recalling the confusion and chaos of the early pandemic. “This city wasn’t prepared.”

Neither was the rest of the country.

An Elusive Enemy

The virus continued to spread like a ghost through the nation and proved deadly to workers who were among the first to encounter sick patients in their hospital or nursing home. One government agency had a unique vantage point into the problem but did little to use its power to cite employers — or speak out about the hazards.

Health employers had a mandate to report worker deaths and hospitalizations to the Occupational Safety and Health Administration.

When they did so, the report went to an agency headed by Eugene Scalia, son of conservative Supreme Court Justice Antonin Scalia who died in 2016. The younger Scalia had spent part of his career as a corporate lawyer fighting the very agency he was charged with leading.

Its inspectors have documented instances in which some of the most vulnerable workers — those with low information and high patient contact — faced incredible hazards, but OSHA’s staff did little to hold employers to account.

Beaumont, Texas, a town near the Louisiana border, was largely untouched by the pandemic in early April.

That’s when a 56-year-old physical therapy assistant at Christus Health’s St. Elizabeth Hospital named Danny Marks called in sick with a fever and body aches, federal OSHA records show.

He told a human resources employee that he’d been in the room of a patient who was receiving a breathing treatment — the type known as the most hazardous to health workers. The CDC advises that N95 respirators be used by all in the room for the so-called aerosol-generating procedures. (A facility spokesperson said the patient was not known or suspected to have COVID at the time Marks entered the room.)

Marks went home to self-isolate. By April 17, he was dead.

The patient whose room Marks entered later tested positive for COVID-19. And an OSHA investigation into Marks’ death found there was no sign on the door to warn him that a potentially infected patient was inside, nor was there a cart outside the room where he could grab protective gear.

The facility did not have a universal masking policy in effect when Marks went in the room, and it was more than likely that he was not wearing any respiratory protection, according to a copy of the report obtained through a public records request. Twenty-one more employees contracted COVID by the time he died.

“He was a beloved gentleman and friend and he is missed very much,” Katy Kiser, Christus’ public relations director, told KHN.

OSHA did not issue a citation to the facility, instead recommending safety changes.

The agency logged nearly 8,700 complaints from health care workers in 2020. Yet Harvard researchers found that some of those desperate pleas for help, often decrying shortages of PPE, did little to forestall harm. In fact, they concluded that surges in those complaints preceded increases in deaths among working-age adults 16 days later.

One report author, Peg Seminario, blasted OSHA for failing to use its power to get employers’ attention about the danger facing health workers. She said issuing big fines in high-profile cases can have a broad impact — except OSHA has not done so.

“There’s no accountability for failing to protect workers from exposure to this deadly virus,” said Seminario, a former union health and safety official.

More ‘Lost on the Frontline’ Stories

Desperate for Safety Gear

There was little outward sign this summer that Garfield Medical Center was struggling to contain COVID-19. While Medicare has forced nursing homes to report staff infections and deaths, no such requirement applies to hospitals.

Yet as the focus of the pandemic moved from the East Coast in the spring to Southern and Western states, health care worker deaths climbed. And behind the scenes at Garfield, workers were dealing with a lack of equipment meant to keep them safe.

Complaints to state worker-safety officials filed in March and April said Garfield Medical Center workers were asked to reuse the same N95 respirator for a week. Another complaint said workers ran out of medical gowns and were directed to use less-protective gowns typically provided to patients.

Staffers were shaken by the death of Dawei Liang. And only after his death and a rash of infections did Garfield provide N95 masks to more workers and put up plastic tarps to block a COVID unit from an adjacent ward. Yet this may have been too late.

The coronavirus can easily spread to every corner of a hospital. Researchers in South Africa traced a single ER patient to 119 cases in a hospital — 80 among staff members. Those included 62 nurses from neurology, surgical and general medical units that typically would not have housed COVID patients.

By late July, Garfield cardiac and respiratory technician Thong Nguyen, 73, learned he was COVID-positive days after he collapsed at work. Nguyen loved his job and was typically not one to complain, said his youngest daughter, Dinh Kozuki. A 34-year veteran at the hospital, he was known for conducting medical tests in multiple languages. His colleagues teased him, saying he was never going to retire.

Kozuki said her father spoke up in March about the rationing of protective gear, but his concerns were not allayed.

The PPE problems at Garfield were a symptom of a broader problem. As the virus spread around the nation, chronic shortages of protective gear left many workers in community-based settings fatally exposed. Nearly 1 in 3 family members or friends of around 300 health care workers interviewed by KHN or The Guardian expressed concerns about a fallen workers’ PPE.

Health care workers’ labor unions asked for the more-protective N95 respirators when the pandemic began. But Centers for Disease Control and Prevention guidelines said the unfitted surgical masks worn by workers who feed, bathe and lift COVID patients were adequate amid supply shortages.

Mary Turner, an ICU nurse and president of the Minnesota Nurses Association, said she protested alongside nurses all summer demanding better protective gear, which she said was often kept from workers because of supply-chain shortages and the lack of political will to address them.

“It shouldn’t have to be that way,” Turner said. “We shouldn’t have to beg on the streets for protection during a pandemic.”

At Garfield, it was even hard to get tested. Critical care technician Tony Ramirez said he started feeling ill on July 12. He had an idea of how he might have been exposed: He’d cleaned up urine and feces of a patient suspected of having COVID-19 and worked alongside two staffers who also turned out to be COVID-positive. At the time, he’d been wearing a surgical mask and was worried it didn’t protect him.

Yet he was denied a free test at the hospital, and went on his own time to Dodger Stadium to get one. His positive result came back a few days later.

As Ramirez rested at home, he texted Alex Palomo, 44, a Garfield medical secretary who was also at home with COVID-19, to see how he was doing. Palomo was the kind of man who came to many family parties but would often slip away unseen. A cousin finally asked him about it: Palomo said he just hated to say goodbye.

Palomo would wear only a surgical mask when he would go into the rooms of patients with flashing call lights, chat with them and maybe bring them a refill of water, Ramirez said.

Ramirez said Palomo had no access to patient charts, so he would not have known which patients had COVID-19: “In essence, he was helping blindly.”

Palomo never answered the text. He died of COVID-19 on Aug. 14.

And Thong Nguyen had fared no better. His daughter, a hospital pharmacist in Fresno, had pressed him to go on a ventilator after seeing other patients survive with the treatment. It might mean he could retire and watch his grandkids grow up. But it made no difference.

“He definitely should not have passed [away],” Kozuki said.

Nursing Homes Devastated

During the summer, as nursing homes recovered from their spring surge, Heather Pagano got a new assignment. The Doctors Without Borders adviser on humanitarianism had been working in cholera clinics in Nigeria. In May, she arrived in southeastern Michigan to train nursing home staffers on optimal infection-control techniques.

Federal officials required worker death reports from nursing homes, which by December tallied more than 1,100 fatalities. Researchers in Minnesota found particular hazards for these health workers, concluding they were the ones most at risk of getting COVID-19.

Pagano learned that staffers were repurposing trash bin liners and going to the local Sherwin-Williams store for painting coveralls to backfill shortages of medical gowns. The least-trained clinical workers — nursing assistants — were doing the most hazardous jobs, turning and cleaning patients, and brushing their teeth.

She said nursing home leaders were shuffling reams of federal, state and local guidelines yet had little understanding of how to stop the virus from spreading.

“No one sent trainers to show people what to do, practically speaking,” she said.

As the pandemic wore on, nursing homes reported staff shortages getting worse by the week: Few wanted to put their lives on the line for $13 an hour, the wage for nursing assistants in many parts of the U.S.

The organization GetusPPE, formed by doctors to address shortages, saw almost all requests for help were coming from nursing homes, doctors’ offices and other non-hospital facilities. Only 12% of the requests could be fulfilled, its October report said.

And a pandemic-weary and science-wary public has fueled the virus’s spread. In fact, whether or not a nursing home was properly staffed played only a small role in determining its susceptibility to a lethal outbreak, University of Chicago public health professor Tamara Konetzka found. The crucial factor was whether there was widespread viral transmission in the surrounding community.

“In the end, the story has pretty much stayed the same,” Konetzka said. “Nursing homes in virus hot spots are at high risk and there’s very little they can do to keep the virus out.”

The Vaccine Arrives

From March through November, 40 complaints were filed about the Garfield Medical Center with the California Department of Public Health, nearly three times the statewide average for the time. State officials substantiated 11 complaints and said they are part of an ongoing inspection.

For Thanksgiving, AHMC Healthcare Chairman Jonathan Wu sent hospital staffers a letter thanking “frontline healthcare workers who continue to serve, selflessly exposing themselves to the virus so that others may cope, recover and survive.”

The letter made no mention of the workers who had died. “A lot of people were upset by that,” said critical care technician Melissa Ennis. “I was upset.”

By December, all workers were required to wear an N95 respirator in every corner of the hospital, she said. Ennis said she felt unnerved taking it off. She took breaks to eat and drink in her car.

Garfield said on its website that it is screening patients for the virus and will “implement infection prevention and control practices to protect our patients, visitors, and staff.”

On Dec. 9, Ennis received notice that the vaccine was on its way to Garfield. Nationwide, the vaccine brought health workers relief from months of tension. Nurses and doctors posted photos of themselves weeping and holding their small children.

At the same time, it proved too late for some. A new surge of deaths drove the toll among health workers to more than 2,900.

And before Ennis could get the shot, she learned she would have to wait at least a few more days, until she could get a COVID test.

She found out she’d been exposed to the virus by a colleague.

Shoshana Dubnow and Anna Sirianni contributed to this report.Video by Hannah NormanWeb production by Lydia Zuraw

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Catching up on care post Covid-19 requires ‘digital compassion’

In addition to human empathy, we are also seeing a new “digital compassion” emerging as healthcare providers work to support patients in need during this uncertain time. Showing this kind of compassion has become easier as technology becomes more advanced and patient-centric in response to the pandemic.

Inside the First Chaotic Days of the Effort to Vaccinate America

One tray of COVID-19 vaccine from pharmaceutical giant Pfizer contains 975 doses — way too many for a rural hospital in Arkansas.

But with the logistical gymnastics required to safely get the Pfizer vaccine to rural health care workers, splitting the trays into smaller shipments has its own dangers. Once out of the freezer that keeps it at 94 degrees below zero, the vaccine lasts only five days and must be refrigerated in transit.

In Arkansas — where over 40% of its counties are rural and COVID infections are climbing — solving this distribution puzzle is urgently critical, said Dr. Jennifer Dillaha, the state’s epidemiologist.

“If their providers come down with COVID-19,” Dillaha said, “there’s no one there to take care of the patients.”

Such quandaries resonate with officials in Georgia, Kentucky, Utah, Indiana, Wisconsin and Colorado. The first push of the nation’s mass COVID vaccination effort has been chaotic, marked by a lack of guidance and miscommunication from the federal level.

With Washington punting most vaccination decisions, each state and county is left to weigh where to send vaccines first and which of two vaccines authorized by the Food and Drug Administration for emergency use makes the most sense for each nursing home, hospital, local health department and even school. And after warning for months that they lacked the resources to distribute vaccines, state officials are only now set to receive a major bump in funding — $8.75 billion in Congress’ latest relief bill, which lawmakers are likely to pass this week.

The feat facing public health officials has “absolutely no comparison” in recent history, said Claire Hannan, executive director of the Association of Immunization Managers.

Officials who thought the H1N1 swine flu shot in 2009 was a logistical nightmare say it now looks simple in comparison. “It was a flu vaccine. It was one dose. It came at refrigerator-stable temperatures,” Hannan said. “It was nothing like this.”

Within just a few days, the logistical barriers of the vaccine made by Pfizer and BioNTech were laid bare. Many officials now hang their hopes on Moderna, whose vaccine comes in containers of 100 doses, doesn’t require deep freezing and is good for 30 days from the time it’s shipped.

The federal government had divvied up nearly 8 million doses of Pfizer and Moderna’s vaccines to distribute this week, on top of roughly 3 million Pfizer shots that were sent last week, said Army Gen. Gustave Perna, chief operating officer of the Trump administration’s Operation Warp Speed effort.

Perna said he took “personal responsibility” for overstating how many Pfizer doses states would receive.

Federal delays have led to confusion, Dillaha said: “Sometimes we don’t have information from CDC or Operation Warp Speed until right before a decision needs to be made.”

Officials in other states painted a mixed picture of the rollout.

Georgia’s Coastal Health District, which oversees public health for eight counties and has offices in Savannah and Brunswick, spent more than $27,000 on two ultra-cold freezers for the Pfizer vaccine, which it’s treating “like gold,” said Dr. Lawton Davis, its health director. Health care workers are being asked to travel, some up to 40 minutes, to get their vaccinations, because shipping them would risk wasting doses, he said. Vaccination uptake has been lower than Davis would like to see. “It’s sort of a jigsaw puzzle and balancing act,” he said. “We’re kind of learning as we go.”

In Utah, sites to vaccinate teachers and first responders starting in January had no capability to store the Pfizer vaccine, although officials are trying to secure some ultra-cold storage, a state department of health spokesperson said. Very few of Kentucky’s local health offices could store the Pfizer shots, because of refrigeration requirements and the size of shipments, said Sara Jo Best, public health director of the Lincoln Trail District. Indiana’s state health department had to identify alternative cold storage options for 17 hospitals following changes in guidance for the vaccine thermal shippers.

And in New Hampshire, where the National Guard will help administer vaccines, officials last week were still finalizing details for 13 community-based sites where first responders and health care workers are due to get vaccinated later this month. Jake Leon, a state Health and Human Services spokesperson, said that while the sites will be able to administer both companies’ vaccines, most likely they’ll get Moderna’s because of its easier transport. Even as the earliest vaccines are injected, much remains up in the air.

“It’s day to day and even then hour by hour or minute by minute — what we know and how we plan for it,” Leon said Friday. “We’re building the plane while flying it.”

In all, the Trump administration has bought 900 million COVID vaccine doses from six companies, but most of the vaccines are still in clinical studies. Even the front-runners whose shots have received FDA emergency authorization— Pfizer and BioNTech on Dec. 11, Moderna on Dec. 18 — will require months to manufacture at that scale. The Trump administration plans to distribute 20 million vaccine doses to states by early January, Perna said Saturday.

By spring, officials hope to stage broader vaccine deployment beyond top-priority populations of health care workers, nursing home residents and staff, as well as first responders.

During the effort to vaccinate Americans against H1N1, Dillaha said, health departments set up mass vaccination clinics in their counties and delivered doses to schools. But hospitals are taking charge of parts of the initial COVID immunization campaign, both because health care workers are at highest risk of illness or death from COVID-19, and to pick up the slack from health departments overwhelmed by case investigations and contact tracing from an unending stream of new infections.

Best said her workforce is struggling to keep up with COVID infections alone, much less flu season and upcoming COVID vaccinations. Public health department personnel in Kentucky shrank by 49% from 2009 to 2019, according to state data she supplied. Across the country, 38,000 state and local health positions have disappeared since the 2008 recession. Per capita spending for local health departments has dropped by 18% since 2010.

Nationally, Pfizer and Moderna have signed contracts with the federal government to each provide 100 million vaccine doses by the end of March; Moderna is set to deliver a second tranche of 100 million doses by June. States were playing it safe last week, directing Pfizer vials mainly to facilities with ultra-cold freezers, Hannan said.

“A lot of that vaccine is destined for institutional facilities,” Sean Dickson, director of health policy for West Health Policy Center, said of the Pfizer shots. The center, with the University of Pittsburgh School of Pharmacy, found that 35% of counties have two or fewer facilities to administer COVID vaccines.

The analysis found tremendous variation in how far people would need to drive for the vaccine. Residents of North Dakota, South Dakota, Montana, Wyoming, Nebraska and Kansas face the longest drives, with more than 10% living more than 10 miles from the closest facility that could administer a shot.

Counties with long driving distances between sites and a low number of sites overall “are going to be the hardest ones to reach,” said Inmaculada Hernandez, an assistant professor at the University of Pittsburgh School of Pharmacy and lead author of the analysis.

Certain vaccines could be better suited for such places, including Johnson & Johnson’s potential offering, which is a single shot, and health departments could distribute in rural areas through mobile units, she said. The company is expected to apply for FDA emergency authorization in February, Operation Warp Speed chief scientific adviser Moncef Slaoui said this month.

Until then, Pfizer and Moderna are the companies supplying doses for the country, and they’re not considered equal even though each is more than 90% effective at reducing disease.

In Wisconsin, the Moderna vaccine “gives us many more options” and “allows for us to get doses to those smaller clinics, more-rural clinics, in a way that reduces the number of logistics” needed for ultra-cold storage, Dr. Stephanie Schauer, the state’s immunization program manager, told reporters Wednesday.

Alan Morgan, head of the National Rural Health Association, echoed that the Moderna vaccine is being looked to as a “rural solution.” But he said states including Kansas have shown that a Pfizer rural rollout can be done.

“It’s where these states put a priority — either they prioritize rural or they don’t,” he said. “It’s a cautionary tale of what we may see this spring, of rural populations perhaps being second-tier when it comes to vaccination.”

Virginia, too, has a plan for getting the Pfizer vaccine to far-flung places. It’s shipping the vaccines to 18 health facilities with ultra-cold freezers across the state. The hubs are distributed widely enough so vaccinators can bring shots from there to health workers even in thinly populated areas before they spoil, said Brookie Crawford, spokesperson for the Virginia Department of Health’s central region.

Washington, on the other hand, allows hospitals without ultra-cold freezers to temporarily store Pfizer vaccines in the thermal boxes they arrive in, said Franji Mayes, spokesperson for the state’s health department. That means a box needs to be used quickly, before doses expire. “We are also working on a policy that will allow hospitals who don’t expect to vaccinate 975 people to transfer extra vaccine to other enrolled facilities,” she said. “This will reduce wasted vaccine.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospital CEO pay

How much are hospital CEOs getting paid? A paper by Mulligan et al. (2020) provides the answer:

Between 2010 and 2015, mean hospital CEO compensation (in 2015 US$…) increased 7.8%, from approximately $639,000 to $689,000 (p = .05), and median compensation increased from $431,000 to $464,000.

Not surprisingly, CEOs of larger hospitals systems get paid more.

For all institutions, higher revenues are associated with higher CEO compensation, and for hospitals a 10% increase in revenues results in a 2.4% increase in CEO compensation

Additionally, compensation varies dramatically across states. Even after controlling for hospital revenue, the study found that:

predicted average state-level hospital CEO compensation is highly variable, ranging from 60% below the national median (Utah) to 79% above the national median (New Jersey).

However, hospital CEOs make far less then CEOs in the health care industry. While hospital CEOs made $689,000 in 2015, CEOs at non-health publicly traded companies made $6.7 million and those at publicly traded health care companies made $8.3 million.

These trends persist even after adjusting for differences in company revenues.

A CEO at a hospital with median revenues in 2015 would earn approximately $704,000. In contrast, a CEO at a publicly traded health care (other) institution with the same revenues is predicted to earn $3.2 ($1.7) million, or 4.5 times as much as a CEO at a hospital. Predicted
compensation is lowest ($406,000) for CEOs at institutions of higher education;

In short, hospital CEOs are not going to the poor house anytime soon, but they are paid far less than CEOs of both health and non-health publicly-traded companies.

Source:

‘Nine Months Into It, the Adrenaline Is Gone and It’s Just Exhausting’

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In March, during the first week of the San Francisco Bay Area’s first-in-the-nation stay-at-home order, KHN spoke with emergency department physicians working on the front lines of the burgeoning COVID-19 pandemic. At the time, these doctors reported dire shortages of personal protective equipment and testing supplies. Health officials had no idea how widespread the virus was, and some experts warned hospitals would be overwhelmed by critically ill patients.

In the end, due to both the early sweeping shutdown order and a state-sponsored effort to bolster the supply chain, Bay Area hospitals were able to avert that catastrophe. The region so far has fared much better than most other U.S. metro regions when it comes to rates of COVID infection and death. Even so, with intensive care unit capacity dwindling to critical levels statewide, San Francisco on Thursday issued another drastic order, announcing a mandatory 10-day quarantine for anyone returning to the city who has spent time outside the region.

Amid this fierce second surge, we circled back last week to check in with Dr. Jeanne Noble, director of the COVID response at the University of California-San Francisco medical center emergency department, to get her reflections on the Bay Area’s experience. She explained how even as her hospital has made so many improvements, including recently launching universal testing so that everyone who comes to the emergency room is tested for COVID-19, the lockdown and burnout are wearing on her and her colleagues. The conversation has been edited for length.

Q: How are you doing at UCSF right now? 

We’re OK in terms of our numbers. We have our ICU capacity; today’s numbers are 74% occupied. Acute care is a little bit tighter; the emergency department is seeing an increase in patients. [Editor’s note: As of Sunday, ICU capacity had dropped to 13%.]

We did have a period of time before this last surge where we often had a few days with no COVID patients. That was great. That ended in late September. This morning we have 11 patients on ventilators in the ICU.

I think we’re the first hospital in the state for universal testing. Everyone who comes to the ER gets tested. I’ve been working on this for months, but it’s new this week. Now we have testing, so we don’t have to do so much guesswork.

Q: When we spoke during the week of the first stay-at-home order, back in March, you were very worried. How do things compare now?

The supply [of masks] is just much better than it was back in March. In March, we had furloughed engineers from our local museum, the Exploratorium, making us face shields, and we started a makers lab in the library across the street to make supplies. It doesn’t feel like that this time around. We have a longer horizon.

I think in terms of our COVID care and our hospital capacity, we are fine. But my own sort of perspective on all of this is: When are we going to be done with this? Because even though things are smoother — we have PPE, we have testing — it’s a tremendous amount of work and stress. Frankly, the fact that my children have not been in school since March is one of my major sources of stress.

We’re all working way more than we ever have before. And nine months into it, the adrenaline is gone and it’s just purely exhausting.

Q: Can you tell me more about that, the physical and emotional toll on the hospital staff?

We don’t allow eating in the ED anymore, so we don’t have break rooms. Especially if you’re the supervising doctor, you need to do this elaborate handoff to another doctor if you need to eat. You know, it’s 10 hours into your shift and you want a cup of coffee.

The hassles and the discomforts. Wearing an N95 day after day is really uncomfortable. A lot of us have ulcers on our noses. They become painful.

And the lack of being able to socialize with colleagues is hard. The ED has always been a pretty intense environment. That’s offset by this closeness and being a team. All of this emotional intensity, treating people day after day at these incredible junctures in their lives — a lot of the camaraderie and morale comes from being able to debrief together. When you’re not supposed to be closer than a few feet from one another and you don’t take off your masks, it’s a lot of strain.

People are much less worried about coming home to their families. It hasn’t been the fomite disease we were all worried about initially, worried we’d give our kids COVID from our shoes. But there’s still the concern. Every time you get a runny nose or a sore throat you need to get tested, and you worry about what if you infected your family.

Q: So will you and your colleagues be able to take a break over the holidays?

We’ll see what happens. We’re just now starting to feel like we’re seeing the post-Thanksgiving numbers. But I think that even without having to do extra shifts in the ED, certainly for someone like me doing COVID response, there’s always a huge number of issues to work through. We just got the monoclonal antibodies, which is great, but that’s a whole new workflow.

I think what is going to bother people the most is that we are in lockdown. Kind of longing for that relaxation and time with family that we’re all kind of craving.

Q: It sounds like things are hard, but the hospital is in a relatively good place.

I was deployed to the Navajo Nation and helped with their surge in May in Gallup, New Mexico, and that is much, much harder than what we’ve faced in the Bay Area. In Gallup, at Indian Health Service, they were incredible in just the can-do attitude with way fewer resources than we have here. As of this summer, they had had the worst per capita surge in the country. They redesigned their ED essentially by cutting every room in half, hanging plastic on hooks you would use to hang your bicycle wheel. They hung thick plastic and right there doubled their capacity of patients they could see.

Our tents at UCSF are these blue medical tents with HVAC systems, heaters, negative pressure. They are really nice. There they had what looked like beach cabanas — open walls with just a tent overhead. In March and April they were taking care of patients in the snow. In the summer, it was hot and windy. When I was there, almost every single one of my patients had COVID.

That level of intensity was not something we had to go through in the Bay Area. Not to say that it’s easy [here]; I just told you all the ways it’s hard. But everything is relative. In terms of the COVID landscape, we have been very lucky.

Q: The Bay Area was early to close and has had stricter regulations than many parts of the country. As someone directly affected, what do you think of the response?

I think that we have benefited from early closures, unquestionably, when we did our shelter-in-place in March and probably saved 80,000 lives. It was really a tremendous and a bold move.

We’ve done some things well and other things not so well. We were very late to implement closures in a targeted fashion. Restaurants and dining reopened this summer, and a lot of us couldn’t figure out why indoor dining was open. Why is indoor dining something we need to even be considering when we’ve just barely flattened our curve? It was very predictable that cases would go up when dining happened. And they did.

We need to evaluate what is more important for our society and well-being, and to say what is the risk associated with that activity. Schools are of high social value. And [the closures are] really hard for kids. We’re seeing a lot of adolescents with suicidal ideation brought to the emergency department, which is related to school closure. I would put dining and restaurants as being of minimal social importance and very high risk.

We could have done this better. Closing [down society] when numbers go up is reasonable and that saves lives. But I think we know enough that it should not be an across-the-board closing. I mean, with this latest order, they temporarily closed parks. And we’ve been telling people to go outside. It’s like, what? Are you kidding?

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Financial strain, new modes of care delivery to drive provider consolidation through 2030

Office workstation top view of business people working around M&A, keyboard, calculator, phablet and money on wooden table - merger and acquisition concept

As a result of rapid consolidation, the 10 biggest health systems controlled 24% of market share based on patient revenue by 2018. The trend is expected to continue through the next decade, with health systems facing growing financial pressures and an increase in demand for new types of care delivery.

Oregon Health & Science University, GE set up state’s first virtual ICU program

The academic medical center collaborated with GE Healthcare to set up the first virtual intensive care unit program in the state, which will help the organization extend its critical care expertise across rural areas and manage bed capacity amid climbing Covid-19 cases.

No More ICU Beds at the Main Public Hospital in the Nation’s Largest County as COVID Surges

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She lay behind a glass barrier, heavily sedated, kept alive by a machine that blew oxygen into her lungs through a tube taped to her mouth and lodged at the back of her throat. She had deteriorated rapidly since arriving a short time earlier.

“Her respiratory system is failing, and her cardiovascular system is failing,” said Dr. Luis Huerta, a critical care expert in the intensive care unit. The odds of survival for the patient, who could not be identified for privacy reasons, were poor, Huerta said.

The woman, in her 60s, was among 50 patients so ill with COVID-19 that they required constant medical attention this week in ICUs at Los Angeles County+USC Medical Center, a 600-bed public hospital on L.A.’s Eastside. A large majority of them had diabetes, obesity or hypertension.

An additional 100 COVID patients, less ill at least for the moment, were in other parts of the hospital, and the numbers were growing. In the five days that ended Wednesday, eight COVID patients at the hospital died — double the number from the preceding five days.

As COVID patients have flooded into LAC+USC in recent weeks, they’ve put an immense strain on its ICU capacity and staff — especially since non-COVID patients, with gunshot wounds, drug overdoses, heart attacks and strokes, also need intensive care.

No more ICU beds were available, said Dr. Brad Spellberg, the hospital’s chief medical officer.

Similar scenes — packed wards, overworked medical staffers, harried administrators and grieving families — are playing out in hospitals across the state and the nation.

In California, only 4.1% of ICU beds were available as of Wednesday. In the 11-county Southern California region, just 0.5 % of ICU beds were open, and in the San Joaquin Valley, none were.

The county of Los Angeles, the nation’s largest, was perilously close to zero capacity.

County health officials reported Wednesday that the number of daily new COVID cases, deaths and hospitalizations had all soared beyond their previous highs for the entire pandemic.

LAC+USC has had a heavy COVID burden since the beginning of the pandemic, largely because the low-income, predominantly Latino community it serves has been hit so hard. Latinos represent about 39% of California’s population but have accounted for nearly 57% of the state’s COVID cases and 48% of its COVID deaths, according to data updated this week.

Many people who live near the hospital have essential jobs and “are not able to work from home. They are going out there and exposing themselves because they have to make a living,” Spellberg said. And, he said, “they don’t live in giant houses where they can isolate themselves in a room.”

The worst cases end up lying amid a tangle of tubes and bags, in ICU rooms designed to prevent air and viral particles from flowing out into the hall. The sickest among them, like the woman described above, need machines to breathe for them. They are fed through nose tubes, their bladders draining into catheter bags, while intravenous lines deliver fluids and medications to relieve pain, keep them sedated and raise their blood pressure to a level necessary for life.

To take some pressure off the ICUs, the hospital this week opened a new “step-down” unit, for patients who are still very sick but can be managed with a slightly lower level of care. Spellberg said he hopes the unit will accommodate up to 10 patients.

Hospital staff members have also been scouring the insurance plans of patients to see if they can be transferred to other hospitals. “But at this point, it’s become almost impossible, because they’re all filling up,” Spellberg said.

Two weeks ago, a smaller percentage of COVID patients in the ER were showing signs of severe disease, which meant fewer needed to be admitted to the hospital or the ICU than during the July surge. That was helping, as Spellberg put it, to keep the water below the top of the levee.

But not anymore.

“Over the last 10 days, it is my distinct impression that the severity has worsened again, and that’s why our ICU has filled up quickly,” Spellberg said Monday.

The total number of COVID patients in the hospital, and the number in its ICUs, are now well above the peak of July — and both are nearly six times as high as in late October. “This is the worst it’s been,” Spellberg said. And it will only get worse over the coming weeks, he added, if people travel and gather with their extended families over Christmas and New Year’s as they did for Thanksgiving.

“Think New York in April. Think Italy in March,” Spellberg said. “That’s how bad things could get.”

They are already bad enough. Nurses and other medical staffers are exhausted from long months of extremely laborious patient care that is only getting more intense, said Lea Salinas, a nurse manager in one of the hospital’s ICU units. To avoid being short-staffed, she’s been asking her nurses to work overtime.

Normally, ICU nurses are assigned to two patients each shift. But one really sick COVID patient can take up virtually the entire shift — even with help from other nurses. Jonathan Magdaleno, a registered nurse in the ICU, said he might have to spend 10 hours during a 12-hour shift at the bedside of an extremely ill patient.

Even in the best case, he said, he typically has to enter a patient’s room every 30 minutes, because the bags delivering medications and fluids empty at different rates. Every time nurses or other care providers enter a patient’s room, they must put on cumbersome protective gear — then take it off when they leave.

One of the most delicate and difficult tasks is a maneuver known as “proning,” in which a patient in acute respiratory distress is flipped onto his or her stomach to improve lung function. Salinas said it can take a half-hour and require up to six nurses and a respiratory therapist, because tubes and wires have to be disconnected, then reconnected — not to mention the risks involved in moving an extremely fragile person. And they must do it twice, because every proned patient needs to be flipped back later in the day.

For some nurses, working on the COVID ward at LAC+USC feels very personal. That’s the case for Magdaleno, a native Spanish speaker who was born in Mexico City. “I grew up in this community,” he said. “Even if you don’t want to, you see your parents, you see your grandparents, you see your mom in these patients, because they speak the language.”

He planned to spend Christmas only with members of his own household and urged everyone else to do the same. “If you lose any member of your family, then what’s the purpose of Christmas?” he asked. “Is it worth it going to the mall right now? Is it worth even getting a gift for somebody who’s probably going to die?”

That the darkest hour of the pandemic should come precisely at the moment when COVID vaccines are beginning to arrive is especially poignant, said Dr. Paul Holtom, chief epidemiologist at LAC+USC.

“The tragic irony of this is that the light is at the end of the tunnel,” he said. “The vaccine is rolling out as we speak, and people just need to keep themselves alive until they can get the vaccine.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Intermountain, UnitedHealthcare create ACO for Medicare Advantage members

The health system and payer will coordinate care for eligible Medicare Advantage patients through the ACO, with the aim of improving health outcomes and reducing costs. The ACO expands a long-standing relationship between the two entities.

Correcting the record: Biopharmaceutical companies remain committed to the 340B program and helping patients

The New York Times recently ran a story that paints an inaccurate picture of the 340B program, contract pharmacy participation in the program and the biopharmaceutical industry’s commitment to the program. Today, we’re correcting the record.

Fact: Manufacturers are still giving the 340B discounts, as required by law, to “covered entities” – more than 12,700 hospitals and clinics currently participating in the 340B program. Some companies have recently implemented changes to shipment of 340B drugs in response to decades of program failures, which is being mischaracterized by some. These companies are still providing discounts to 340B covered entities, but in some cases not to offsite pharmacies that were never included in the program to begin with when Congress created 340B.

Why healthcare orgs are joining an effort to create 1M jobs for Black Americans

jobs, job seeking, job, job finding

The newly created organization, dubbed OneTen, aims to create 1 million jobs for Black people over the next decade. Its founders include some big names in healthcare, such as Cleveland Clinic, Intermountain Healthcare and Humana.

Hospitals sue drug companies over discount program

The lawsuit follows action by at least a half-dozen drug companies to rein in what they see as waste and abuse in the program, overseen by the Department of Health and Human Services. Meanwhile, the Hospital plaintiffs have a potentially powerful ally in the person picked to head the department under the incoming Biden administration.

Readers and Tweeters Defend Front-Line Nurses and Blind Us With Science

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 demand for skilled nurses during the pandemic is through the roof! Travel nurses command a hefty salary and they are worth every penny… #COVID19 #pandemic #RN https://t.co/gYQpkHqaoX

— Talmage Egan, MD (@UofU_Anes_Chair) November 26, 2020

— Dr. Talmage Egan, Salt Lake City

Nurses Deserve to Be Paid Handsomely

I read your article “Need a COVID-19 Nurse? That’ll Be $8,000 a Week” (Nov. 24) in the Springfield Journal-Register. It was an interesting article as I have a daughter who is a nurse. Nurses have been underpaid and unappreciated for years. It made me angry that the article characterized the wages some hospitals are willing to pay for nurses as exorbitant. Hogwash if you think someone should risk their life every hour of the day to care for COVID patients without proper compensation. How many doctors make over a million a year? You don’t cite that as unusual. I feel that nurses should go for the gold as they have been taken advantage of for years and, too bad, but good for them. Choose your words more carefully in the future. Nurses ROCK!!!!

— Mike Booher, Lincoln, Illinois

Hospitals go out of their way to avoid competing for nursing labor by raising wages. Now hospital executives and public health advocates act like it’s a travesty that COVID nurses are finally getting paid market rates to take on risky jobs. https://t.co/6z0idToVn6

— Devon M. Herrick (@DevonHerrick) November 24, 2020

— Devon M. Herrick, Dallas

Missing in the Mix of Vaccine Coverage

I must note two important omissions in the article “Time to Discuss Potentially Unpleasant Side Effects of COVID Shots? Scientists Say Yes” (Nov. 12). First, although these were interim trial results, the placebo arm should also have been reported out. What was the placebo infection rate? Reporting 90% effectiveness is irrelevant without reporting the placebo rate simultaneously. And one needs to align the infection rate in trial subjects with the incidence of disease in the U.S. population. They should be similar, but if not, any discrepancy must be explained (such as, no elderly people or children participating in the trial). Secondly, and perhaps more important: What other mitigating measures were volunteers in this trial required/advised to take? For example, physical distancing, masks, etc. I could find no mention of this, positively or negatively, when reading the protocol on clinicaltrials.gov. Any vaccine alone could not provide 94.5% efficacy. To determine the relative contributions of other measures, you’d need, say, a four-arm study — placebo with mask, placebo without mask, vaccine with mask, vaccine without mask. Statistically and clinically, one must account for other variables that may confound an apparent result.

This is a crucial point as the lay public is thinking that, by getting the vaccine, masks might no longer be necessary and they’ll have a 95% chance of not being infected. This is rubbish. The media and the public “experts” need to address this as they are setting themselves up for an immense PR failure and still greater skepticism. People may need to wear masks for many more months, maybe years, even with an effective vaccine.

— Stephen Zaruby, Truckee, California

I’m already confused 😕 https://t.co/UlJPh2EEvK

— hameen tariq (@hameentariq) November 23, 2020

— Hameen Tariq, Wilmington, Delaware

Exploring Cancer Drug’s Effects on COVID

Your story “Clots, Strokes and Rashes: Is COVID a Disease of the Blood Vessels?” (Nov. 13) was reprinted in my local newspaper. My brother, James L. Kinsella Ph.D., led the original work at the National Institutes of Health researching how the chemotherapy drug Taxol could reduce inflammation in coronary articles following the placement of coronary stents. This led to the very effective use of drug-eluting coronary stents. My unprofessional musing causes me to wonder if this anti-inflammatory response to Taxol might have some application as an early therapeutic intervention to reduce the inflammatory response of COVID-19 being studied by Dr. William Li. I can’t ask my brother; he passed away.

— Rick Kinsella, Oneida, New York

He wouldn’t be dead without covid. We’ve learned that things that aren’t life threatening are made life threatening by this disease. It attacks your blood vessels so it can exacerbate anything anywhere in your body that uses blood vessels. Stay safe indeed https://t.co/BFsqrKSFmH

— James McPicnic (@WhiteRatbit) December 3, 2020

— James “J.P.” McPicnic, Los Angeles

Women’s Health Should Not Be Up for Debate

Birth control medication is so much more than a pawn in politics (“Coming Abortion Fight Could Threaten Birth Control, Too,” Nov. 5). It changes the lives of so many women for the better. Birth control access has been proven to lead to higher rates of education for women, lower levels of child poverty, lower Medicaid costs for women’s health and higher productivity of society as a whole. It also treats a large number of medical conditions associated with women’s health. It effectively treats severe menstrual migraines, hormonal acne, endometriosis, severe menstrual pain, uterine abnormalities, anemia and heavy menstrual bleeding, among other health conditions. This medication is involved in treating so many women’s health concerns, improves infant and child health outcomes, and reduces child poverty, and yet almost 20 million women in the U.S. currently have no access to birth control medication. American politicians need to consider, if nothing else, the spillover costs to society when birth control access is reduced.

Women’s reproductive health should not be up for debate and yet it is at the center of so many political agendas. As a 24-year-old woman pursuing dual master’s degrees in public health and physician assistant studies, my focus should be on learning to become an exceptional health care provider, not whether my health will be up for debate in court. If politicians truly have the best interests of Americans at heart, they should be looking to expand birth control access, not restrict it.  Evidence needs to be incorporated into political agendas, and the evidence shows that when women succeed, society succeeds. Women’s education, health and reproductive rights should be at the forefront of every discussion on what constitutes a thriving population — the evidence has proven that women’s autonomy holds the answer and access to birth control is a vital piece of that.

— Gabby Henshue, Madison, Wisconsin

Scary times for women’s bodies.

“States could effectively ban contraception by arguing that some contraceptives act as abortifacients.” Threat is real. I’ve worked in states where this argument has been made.https://t.co/LmdWFRUNOZ

— Elizabeth M. Baskett (@EMBaskett) November 11, 2020

— Elizabeth M. Baskett, Denver

Injustice in High Gear

I was appalled at the charges on the medical bill from the Carson City emergency department for that child who fell off his bike (“Bill of the Month: After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion,” Nov. 25) — $18,000 for an exam and stitches? What would it take to sort out such problems in our health system? Lower prices from providers could only result in lower insurance premiums.

— Karen Johnson, San Rafael, California

Attempted subrogation, man, I tell yah https://t.co/spxcMlSiCk

— Annie M. Davidson (@attyannie) November 25, 2020

— Annie M. Davidson, St. Paul, Minnesota

KHN Morning Briefing: A Wealth of Information in One Spot!

I just wanted to say it is awesome to have portions of articles from many major news outlets because never does one tell the whole story. Case in point: I was trying to research what exactly President Donald Trump had done that “allowed doctors to discriminate against LGBT people,” and it was very helpful having a wide array of media sources on a single page to help get the bigger picture and try and weed through the bias of all of them (“Trump Administration’s Expanded Conscience Rule Will Allow Medical Professionals To Refuse To Provide Health Care Services,” May 3). Just sending my compliments. Keep up the great work.

— Nolan Steeley, Greensburg, Pennsylvania

💥Racism in #healthcare undermines #quality of care and patient safety. There’s hard work to be done to weed it out of all parts of society, especially clinical care. https://t.co/TbK0yIuraB

— Natalie S. Burke (@natalie4health) November 28, 2020

— Natalie S. Burke, Washington, D.C.

Education and Coverage Gaps Lead to Avoidable Amputations 

Coming to terms with systemic racism in health care is long overdue (“What Doctors Aren’t Always Taught: How to Spot Racism in Health Care,” Nov. 17). The way medicine is taught and the payment policies that shape the system have created persistent disparities in patient outcomes across racial and ethnic groups.

As a result, Black Americans are 80% more likely than whites to be diagnosed with diabetes and are twice as likely to die from the disease. Furthermore, Black American patients are up to four times more likely to experience an amputation than their white counterparts due to advanced peripheral artery disease (PAD), a common complication for people with diabetes and other chronic conditions. Similarly, Latinos are up to 75% more likely to experience an amputation than whites, while Native Americans are twice as likely to lose a limb.

As many as 85% of the nation’s 200,000 non-traumatic amputations could be prevented with access to screening and early detection. By screening for PAD through non-invasive arterial testing, the likelihood of an individual needing a PAD-related amputation can be reduced by up to 90%. Unfortunately, too few Americans — particularly racial and ethnic minorities — are even offered routine screening for PAD due to a widespread lack of understanding about the disease, as well as structural coverage barriers to simple, painless tests. As a result, many do not even know they have the disease until it is too late to save their limbs.

Communities of color deserve better. Members of the Congressional PAD Caucus — led by Rep. Donald Payne Jr. (D-N.J.) — recently introduced the Amputation Reduction and Compassion (ARC) Act to establish an education program about the disease — particularly for high-risk populations — and update reimbursement policy to disallow payment for non-emergent amputations unless arterial testing has been done in the three months before amputation. These simple solutions have the power to prevent thousands of avoidable amputations, and begin to correct health disparities in minority communities.

While we still have a long way to go as our country continues to grapple with systemic racism in health care, the ARC Act represents an important step toward ending disparities in PAD care.

— Dr. Foluso Fakorede, CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi

Racism in Health Care? Another example of injecting Politics. Inarguably, racism exists everywhere, but to make this a big issue is a disservice. Diff DX requires inclusion of Race/Ethnicity, to wit: Sickle Cell in Blacks,Alpha & Beta Thalassemia in Asians https://t.co/xyP54dPjH8

— Alexander R. Lim, MD (@AlexanderLim13) November 25, 2020

— Dr. Alexander R. Lim, Corpus Christi, Texas

‘Obamacare’ Unfairly Politicizes Health Law

I found this article interesting (“Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” Nov. 11) but was surprised that the Affordable Care Act was referred to as “Obamacare.” Please don’t politicize the ACA — we really need it to continue allowing people to access health care. Many people do not have health care through their workplace and are unable to afford private insurance premiums. I was once one of those people before I was hired at our local library. It was really tough. Thank you for your reporting.

— Pamela Elicker, Port Townsend, Washington

Putting People First on the Podcast

When you were talking about drug policy and the ballot in a recent podcast (“KHN’s ‘What the Health?’: Change Is in the Air,” Nov. 6), you used terms that are considered incorrect or stigmatizing. For example, saying “opioid epidemic” when it’s really a crisis and referring to substance use as “abuse.” The Associated Press and NPR, among others, have pledged to use people-first language, as also supported by the American Psychological Association.

— Deirdre Dingman, Philadelphia

The Backbone of the Insurance Industry

It’s disingenuous to assert that people “can’t always rely on insurance brokers to give them accurate information or steer them to comprehensive coverage” based on the unfortunate experience of one consumer with a short-term health plan, as Michelle Andrews did in the article “Think Your Health Care Is Covered? Beware of the ‘Junk’ Insurance Plan” (Dec. 4).

Agents and brokers are crucial to our nation’s efforts to get people covered. This year, they assisted almost half of all healthcare.gov enrollees — and brought 1.12 million new enrollees into the marketplace. It’s no wonder that a new report from the Centers for Medicare & Medicaid Services has called agents and brokers “instrumental in driving greater participation in the individual health insurance market.”

Further, agents and brokers have long maintained that short-term plans are not appropriate substitutes for comprehensive exchange coverage. We at the National Association of Health Underwriters stated as much in official comments filed with the Trump administration before it finalized a rule extending the duration of short-term plans to 12 months.

— Janet Trautwein, CEO of the National Association of Health Underwriters, Washington, D.C.

 


Not Tickling My Funny Bone

You ought to find some cartoonists who are not so flagrantly left-leaning — continuing to provide left-sided commentary is not right. It’s like all of the news stations pushing for socialism.

— Harry Gousha, Upland, California

Editor’s note: It is the tradition and mission among editorial cartoonists to satirize those in power. As with the nation’s leadership, the targets of political cartoons toggle from right to left. Balance is not these artists’ goal, but over time their commentary balances out. Stick with us, and we hope to amuse you in the future.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Cerner to snap up Kantar’s health division for $375M

The EHR giant is planning to buy Kantar Health, which provides data, analytics and research to the life sciences industry. Through the acquisition, Cerner aims to provide its clients with more access to data analytics and research expertise and engagement with life sciences companies.

LeanTaaS to use $130M to expand predictive analytics product suite, scale teams  

The health technology company raised a whopping $130 million in a Series D funding round. Its solutions aim to improve operational efficiency and better manage patient volume through predictive analytics, a growing need for providers as Covid-19 cases rise.

Fine-tuning telehealth, addressing mental health take precedence for providers in 2021

Telemedicine

As 2020 draws to a close, healthcare providers are strategizing for the new year and the new normal. Providers will need to retool their telehealth efforts and prepare to meet a burgeoning mental crisis, among other issues.

Desafío en hospitales: a qué trabajadores de salud vacunar primero contra COVID

Si existe una cita con el destino, está escrita en el calendario del doctor Taison Bell.

Al mediodía del martes 15 de diciembre, Bell, especialista en cuidados intensivos del Sistema de Salud de la Universidad de Virginia será uno de los primeros en arremangarse para recibir la vacuna que lo protegerá del coronavirus.

Bell, de 37 años, se inscribió la semana pasada a través del correo electrónico del hospital para recibir la vacuna. “La historia de esta crisis es que cada semana se siente como un año. Esta es realmente la primera vez que hay una esperanza genuina de que podemos revertir esta situación”.

Por ahora, esa esperanza se limita a unos pocos elegidos. Bell atiende a algunos de los pacientes con COVID-19 más enfermos en el hospital UVA Health en Charlottesville, Virginia.

Bell es uno de los 12,000 trabajadores del hospital “que trabajan directo con estos pacientes”, que podrían ser elegibles para unas 3,000 primeras dosis de vacunas, dijo el doctor Costi Sifri, director de epidemiología del hospital.

“Estamos tratando de encontrar las categorías de mayor riesgo, aquellas que realmente pasan una cantidad significativa de tiempo cuidando a los pacientes”, dijo Sifri. “No se tiene en cuenta a todo el mundo”.

Incluso cuando la Administración de Alimentos y Medicamentos (FDA) participaba en intensas deliberaciones antes de la autorización del viernes de la vacuna contra COVID de Pfizer y BioNTech, y días antes de que se liberaran las 6.4 millones de dosis iniciales, los hospitales de todo el país ya estaban planeando cómo distribuir la primeras, y escasas, dosis.

Un comité asesor de los Centros para el Control y Prevención de Enfermedades (CDC) recomendó que la máxima prioridad sea para los hogares de adultos mayores de atención a largo plazo y para los trabajadores de atención médica de primera línea.

Pero se sabía que la primera tanda de vacunas no iba a cubrir toda la necesidad y que se iba a tener que hacer un proceso más selectivo, incluso entre los trabajadores críticos del hospital.

En general, se aconseja a los hospitales que cubran a los miembros de su fuerza laboral con mayor riesgo, pero las instituciones deben decidir exactamente quiénes serán, dijo Colin Milligan, vocero de la Asociación Estadounidense de Hospitales, en un correo electrónico.

“Está claro que los hospitales no recibirán lo suficiente en las primeras semanas para vacunar a todos los miembros de su personal, por lo que hubo que tomar decisiones”, escribió Milligan.

En Intermountain Healthcare, en Salt Lake City, Utah, las primeras inyecciones serán para los miembros del personal “con el mayor riesgo de contacto con pacientes COVID positivos o sus desechos”, dijo la doctora Kristin Dascomb, directora médica de prevención de infecciones y salud del personal. Dentro de ese grupo, los gerentes determinarán qué cuidadores son los primeros en la fila.

En la UW Medicine, en Seattle, Washington, que incluye el Harborview Medical Center, un plan temprano requería que el personal de alto riesgo fuera seleccionado al azar para recibir las primeras dosis, dijo la doctora Shireesha Dhanireddy, directora médica de la clínica de enfermedades infecciosas.

Pero el sistema hospitalario de la Universidad de Washington espera recibir dosis suficientes para vacunar a todas las personas en ese nivel de alto riesgo dentro de dos semanas, por lo que la selección aleatoria no ha sido necesaria por ahora.

“Permitimos que las mismas personas programen la cita”, dijo Dhanireddy, y alentamos al personal a vacunarse cerca del final de sus semanas laborales en caso de que tengan reacciones a la nueva vacuna.

Los resultados de los ensayos han demostrado que las inyecciones con frecuencia producen efectos secundarios que, aunque no debilitantes, podrían causar síntomas como fiebre, dolores musculares o fatiga que podrían mantener a alguien en casa por uno o dos días.

“Queremos asegurarnos de que no todo el mundo reciba la vacuna el mismo día para que, si hay algunos efectos secundarios, no acabemos quedando cortos de personal”, dijo Sifri, de UVA Health, y señaló que las directrices exigen que no más del 25% de cualquier unidad se vacune a la vez.

En UVA Health, una vez que se distribuyan las 3,000 dosis iniciales, el hospital planea confiar en lo que Sifri describió como “un código de honor muy estricto” para permitir que los miembros del personal decidan qué lugar ocupar en la fila. Se les ha pedido que consideren factores profesionales, como el tipo de trabajo que realizan, así como riesgos personales: la edad o afecciones subyacentes como la diabetes.

“Vamos a pedirles a los miembros del equipo, utilizando el código de honor, que determinen cuál es su riesgo de COVID y si necesitan tener una cita temprana para la vacuna o una fecha posterior”, explicó.

Se elaboró este plan después que el personal de atención médica rechazara rotundamente otras opciones. Por ejemplo, pocos favorecieron una propuesta para asignar dosis a través de una lotería, como el caótico sistema basado en la fecha de cumpleaños de la película “Contagion”, sobre una horrible pandemia.

Funcionarios del hospital también enfatizaron que están tratando de diseñar planes de distribución que garanticen que las vacunas se asignen de manera equitativa entre los trabajadores de salud, incluidos los grupos sociales, raciales y étnicos que han sido perjudicados de manera desproporcionada por COVID-19. Eso requiere pensar más allá de los médicos y enfermeras de primera línea.

Por ejemplo, en UVA Health, uno de los primeros grupos invitados a vacunarse será el de 17 trabajadores cuya tarea es limpiar cuartos en la unidad de patógenos especiales donde se tratan los casos graves de COVID.

“Reconocemos que todo el mundo está en riesgo de contraer COVID, todo el mundo merece una vacuna”, dijo Sifri.

En muchos casos, quedará claro quién debe ir primero. Por ejemplo, aunque Dhanireddy es doctora especialista en enfermedades infecciosas que consulta sobre casos de COVID, está feliz de esperar. “No me pondría en el primer grupo en absoluto”, dijo. “Creo que tenemos que proteger a nuestro personal que realmente está ahí con ellos la mayor parte del día, y esa no soy yo”.

Para algunos trabajadores de salud, no ser el primero en la fila para la vacunación está bien. Debido a que la vacuna inicialmente fue autorizada solo para uso de emergencia, los hospitales no requerirán que los empleados sean vacunados como parte de esta primera ronda. Entre el 70% y el 75% del personal de atención médica de UVA Health e Intermountain Health aceptaría una vacuna COVID, mostraron encuestas internas. El resto no está seguro o no está dispuesto.

“Hay algunos que aceptarán de inmediato y otros querrán observar y esperar”, dijo Dascomb.

Aún así, autoridades del hospital dicen que confían en que aquellos que quieran la vacuna no tengan que esperar mucho. Dosis suficientes para aproximadamente 21 millones del personal de atención médica deberían estar disponibles a principios de enero, según funcionarios de los CDC.

Bell, el médico de cuidados intensivos, dijo que está agradecido de estar entre los primeros en recibir la vacuna, especialmente después que sus padres, que viven en Boston, contrajeran COVID-19. Publicó sobre su próxima cita en Twitter y dijo que otros trabajadores de salud que se encuentran entre los primeros en la fila deberían hacer público el proceso.

“Serviremos como ejemplo de que esta es una vacuna segura y eficaz”, dijo. “La estamos dejando entrar en nuestros cuerpos. Deberías dejar que entre en el tuyo también”.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospitals Scramble to Prioritize Which Workers Are First for COVID Shots


This story also ran on NBC News. It can be republished for free.

If there’s such a thing as a date with destiny, it’s marked on Dr. Taison Bell’s calendar.

At noon Tuesday, Bell, a critical care physician, is scheduled to be one of the first health care workers at the University of Virginia Health System to roll up his sleeve for a shot to ward off the coronavirus.

“This is a long time coming,” said Bell, 37, who signed up via hospital email last week. “The story of this crisis is that each week feels like a year. This is really the first time that there’s genuine hope that we can turn the corner on this.”

For now, that hope is limited to a chosen few. Bell provides direct care to some of the sickest COVID-19 patients at the UVA Health hospital in Charlottesville, Virginia. But he is among some 12,000 “patient-facing” workers at his hospital who could be eligible for about 3,000 early doses of vaccine, said Dr. Costi Sifri, director of hospital epidemiology.

“We’re trying to come up with the highest-risk categories, those who really spend a significant amount of time taking care of patients,” Sifri said. “It doesn’t account for everybody.”

Even as the federal Food and Drug Administration engaged in intense deliberations ahead of Friday’s authorization of the Pfizer and BioNTech COVID vaccine, and days before the initial 6.4 million doses were to be released, hospitals across the country have been grappling with how to distribute the first scarce shots.

An advisory committee of the Centers for Disease Control and Prevention has recommended that top priority go to long-term care facilities and front-line health care workers, but the early allocation was always expected to fall far short of the need and require selective screening even among critical hospital workers.

Hospitals in general are advised to target the members of their workforce at highest risk, but the institutions are left on their own to decide exactly who that will be, Colin Milligan, a spokesperson for the American Hospital Association, said in an email.

“It is clear that the hospitals will not receive enough in the first weeks to vaccinate everyone on their staff, so decisions had to be made,” Milligan wrote.

At Intermountain Healthcare in Salt Lake City, the first shots will go to staff members “with the highest risk of contact with COVID-positive patients or their waste,” said Dr. Kristin Dascomb, medical director of infection prevention and employee health. Within that group, managers will determine which caregivers are first in line.

At UW Medicine in Seattle, which includes Harborview Medical Center, one early plan called for high-risk staff to be selected randomly to receive first doses, said Dr. Shireesha Dhanireddy, medical director of the infectious disease clinic. But the University of Washington hospital system expects to receive enough doses to vaccinate everyone in that high-risk tier within two weeks, so randomization isn’t necessary — for now.

“We are allowing people to schedule themselves,” Dhanireddy said, and encouraging staffers to be vaccinated near the end of their workweeks in case they have reactions to the new vaccine.

Trial results have shown the shots frequently produce side effects that, while not debilitating, could cause symptoms such as fever, muscle aches or fatigue that might keep someone home for a day or two.

“We want to make sure that not everybody has the vaccine on the same day so that if there are some side effects, we don’t end up being short-staffed,” said Sifri, of UVA Health, noting that guidelines call for no more than 25% of any unit to be vaccinated at once.

At UVA Health, once the initial 3,000 doses are distributed, the hospital plans to rely on what Sifri described as “a very strong honor code” to allow staff members to decide where they should be in line. They’ve been asked to consider professional factors, like the type of work they do, as well as personal risks, such as age or underlying conditions like diabetes.

“We’re going to ask team members, using the honor code, to determine what their risk is for COVID and to determine whether they need to have an early vaccine sign-up time or a later vaccine sign-up time,” he said.

That plan was chosen after health care staff members soundly rejected other options. For instance, few favored a proposal to allocate dosages via a lottery, like the chaotic birthday-based system depicted in the 2011 pandemic horror film “Contagion.” “That was the biggest loser,” he said.

Hospital officials also stressed they are trying to devise distribution plans that ensure vaccines are allocated equitably among health care workers, including the social, racial and ethnic groups that have been disproportionately harmed by COVID-19 infections. That requires thinking beyond front-line doctors and nurses.

At UVA Health, for example, one of the first groups invited to get shots will be 17 workers whose job is to clean rooms in the special pathogens unit where severe COVID cases are treated.

“We acknowledge that everybody is at risk for COVID, everybody is deserving of a vaccine,” Sifri said.

In many cases, it will be clear who should go first. For instance, although Dhanireddy is an infectious disease doctor who consults on COVID cases, she is happy to wait to be vaccinated. “I wouldn’t put myself in the first group at all,” she said. “I think that we need to protect our staff that are really right there with them most of the day — and that’s not me.”

But hospitals must remain vigilant about relying on workers to prioritize their own access, Dhanireddy cautioned. “Sometimes, self-selection works more for self-advocacy,” she said. “It’s great that some individuals say they would defer to others, but sometimes that’s not actually the case.”

For some health care workers, not being first in line for vaccination is fine. Because the vaccine initially has been authorized only for emergency use, hospitals won’t require employees to be inoculated as part of this first round. Between 70% and 75% of health care staff at UVA Health and Intermountain Health would accept a COVID vaccine, internal surveys showed. The rest are unsure — or unwilling.

“There are some that will be immediate acceptors and some who will want to watch and wait,” Dascomb said.

Still, hospital officials say they’re confident that those who want the vaccine won’t have to wait long. Enough doses for roughly 21 million health care personnel should be available by early January, according to CDC officials.

Bell, the critical care doctor, said he’s grateful to be among the first to receive the vaccine, especially after his parents, who live in Boston, both contracted COVID-19. He has posted about his upcoming appointment on Twitter and said he and other health care workers who are among the first in line should be public about the process.

“We’ll serve as an example that this is a safe and effective vaccine,” he said. “We’re letting it go into our bodies. You should let it go into yours, too.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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The perils of health systems

Last week I reviewed an article on some of the potential positives and negatives of large, integrated health systems. A recent 60 Minutes episode talks about some of the perils by examining how Sutter health system has become a near monopoly provider in Northern California. Consider the following interaction between Leslie Stahl of 60 minutes and Glenn Melnick, a health economist at USC.

Glenn Melnick: …[Sutter Health] have monopoly powers in a number of these counties, right? And their prices went up. The next year, they went up even faster. And they figured out, “Wow, this really works!”
Lesley Stahl: You might look at that and say, “That’s monopolistic.” Someone else might look at it and say, “Wow, that’s smart business. That’s- that’s really clever. Good for them!”
Glenn Melnick: If Sutter is able to raise their prices by improving quality, value, and service, that’s fine. What they came up with is a model that allowed them to acquire market power, and get higher prices without doing any of those good things for consumers. 
In the lawsuit, evidence showed that Sutter’s quality of care, while well-regarded, was generally comparable to other hospitals in California, and that its higher prices have been contagious. 
Glenn Melnick: So we called it the “Sutter effect,” where if you have a large, dominant system like this, they raise their prices high, all their competitors can raise their prices higher. So there’s kind of this second-order effect: that this type of behavior leads to much higher prices across the board. 

One key issue is a lack of price transparency, an issue that has been well-known in health care for many years. Hillary Ronen–a City Councilwomen in San Francisco (and my wife’s cousin!) laments this lack of transparency

A reason their health costs were so high, she says, is because Sutter was able to block the city and its insurer, Blue Shield of California, from steering employees to hospitals with lower prices. And it was able to prevent Blue Shield from telling the city what Sutter’s hospitals would charge for individual procedures.
Hillary Ronen: Sutter won’t allow us to see how much they charge for their services. It– it’s unbelievable. And so we can’t comparison shop. And they keep naming their price, and I feel like I’m handcuffed to do anything about it. 
Lesley Stahl: The insurance company, Blue Shield?
Hillary Ronen: Yes.

https://www.cbsnews.com/news/california-sutter-health-hospital-chain-high-prices-lawsuit-60-minutes-2020-12-13/

While the Sutter case makes a good story, the increased provider consolidation is happening across the country. Elizabeth Mitchell, the CEO of Pacific Business Group on Health, notes this trend is nationwide. Further, hospital prices are the key driver of health care spending.

Elizabeth Mitchell: This is happening in Maine. It’s happening in Texas. It’s happening across the country, the largest health systems are buying up everything. 
Lesley Stahl: Do you think that this is the main reason that health costs are going up?
Elizabeth Mitchell: We have seen the data. It is the largest driver of health care cost increases. It’s hospital prices. And they’re not providing more services. And the quality isn’t increasing. They are just charging more for the same thing. It is just the prices. And they do it because they can. 

Watch the full episode here.

Covid Meds Are Scarce, but Not for Trump Cronies

Rudy Giuliani got monoclonal antibodies. You probably can’t.

Covid Meds Are Scarce, but Not for Trump Cronies

Rudy Giuliani got monoclonal antibodies. You probably can’t.

QliqSOFT, CPSI to offer Covid-19 vaccine chatbot to community hospitals

The COVID-19 Vaccination Assistant will provide information about the new vaccines to help allay fears among the U.S. public. It will also help people schedule their vaccinations and connect them with rideshare services to make it to their appointment.

On the promise and peril of health systems

Integrated delivery networks. IDNs. Accountable Care Organizations. ACOs. Systems of care. Health systems.

Whatever you call them, many health policy experts claim that they are the best way for the U.S. health care system to deliver high quality care in a cost-effective manner. But is that really the case? A commentary by UCSD professor and former AHRQ Director, Richard Kronick in Health Services Research provides a balanced perspective.

First, some of the promise:

  • Potential for productive and allocative efficiency. Health care systems could be helpful for determining which configuration of inputs is able to most efficiently produce a given quantity of high-quality output. In some countries–such as those with a single payer system–the government does this. In the US, with a very disjointed payer system, health systems may be able to coordinate inputs and leverage economies of scale to improve quality and reduce costs.
  • Leverage technology. Electronic health records system implementation have high fixed cost but much lower cost per physician added to the system or per patient treated. Large health systems have the potential to leverage these economies of scale to better incorporate technology into care pathways.
  • Institute best practices. Given their size, they may be able to roll out and train physicians on recent best practices compared to what is the case with smaller practices.
  • Patient-centered outcomes. Health system size may also facilitate the use of patient-centered outcomes for two reasons. The first is that their scale makes investments in data collection of patient-reported outcomes more economical. The second is that a health system will have more patient touchpoints than a single practice and thus patient-centered outcomes are more relevant. If you want to know about patient-centered quality of care, but you are a small specialty practice, your impact on the patient’s experience with the health care system may be marginal, compared to a health system which–in many cases–will be the main organization with whom the patient interacts.

Health systems do bring up a number of concerns however. These include:

  • Added bureaucracy. While the increased size may make investments in quality improvements and EHR more economical, they also risk increasing bureaucracy and increasing administrative cost. Government agencies may like health systems better ability to collect data, but these data collection costs are often non-trivial.
  • Reduced competition may lead to higher prices. Providers may like health systems, because the increase negotiating power with payers. More consolidation and less competition may lead to increased prices. Health systems could also lobby policymakers to make laws more favorable to health systems.
  • Erode professional autonomy. While policymakers may like integrated health systems, physicians themselves may or may not. They may like being salaried and outsourcing administrative tasks to others; on the other hand, they may not like that administrators are telling them how to practice medicine, ostensibly based on best practices.

Another question is: what are health systems? AHRQ’s Compendium of Health Systems is one attempt to classify and identify them. This 2016 snapshot shows that health systems made up 88.2% of beds and employed 44.6% of physicians. By 2018, however, more than half of physicians were employed at health systems.

Yet there is much left to learn. According to Dr. Kronick, there are at least 3 key questions that are still un-answered:

We do not yet have a report card on health system performance that would allow comparison of performance across systems; we do not yet have much empirical evidence about the characteristics of health systems that are associated with high performance, nor of the payment and other accountability mechanisms that lead to performance improvement; and we do not yet know much about what tools and resources systems would need to facilitate improvement.

The commentary, while brief, is an interesting and balanced take on US health systems and well worth a read.

CMS’ new Geo care delivery model: 5 things to know

The new Geographic Direct Contracting Model aims to improve quality of care and slash costs for Medicare beneficiaries across an entire region. It involves setting up risk-sharing arrangements where participants will be responsible for the total cost of care for beneficiaries in the region.

Northwell, Conversa Health join forces to provide employers with Covid-19 screening tool

A subsidiary of Northwell Health has collaborated with the virtual care company to offer businesses a Covid-19 screening tool for their workers. The tool helps identify employees who may have been exposed to the new coronavirus or those showing symptoms of the disease and suggests next steps.

Sanford Health halts merger talks with Intermountain ‘indefinitely’

handshake, break, deal

The South Dakota-based health system has suspended talks related to its planned merger with Utah-based Intermountain Healthcare after the sudden departure of its CEO, Kelby Krabbenhoft. Sanford and its new CEO will instead focus on organizational needs, the system said.

Cleveland Clinic to help bring affordable broadband to city neighborhood

The Ohio-based health system is working with three organizations to provide residents of Cleveland’s Fairfax neighborhood with access to high-speed internet at affordable prices. The collaboration aims to alleviate health disparities that arise from a lack of reliable access to the internet.

What Happened When the Only ER Doctor in a Rural Town Got COVID

Kurt Papenfus, a doctor in Cheyenne Wells, Colorado, started to feel sick around Halloween. He developed a scary cough, intestinal symptoms and a headache. In the midst of a pandemic, the news that he had COVID-19 wasn’t surprising, but Papenfus’ illness would have repercussions far beyond his own health.

Papenfus is the lone full-time emergency room doctor in the town of 900, not far from the Kansas line.

“I’m chief of staff and medical director of everything at Keefe Memorial Hospital currently in Cheyenne County, Colorado,” he said.

With Papenfus sick, the hospital scrambled to find a replacement. As coronavirus cases in rural Colorado, and the state’s Eastern Plains especially, surge to unprecedented levels, Papenfus’ illness is a test case for how the pandemic affects the fragile rural health care system.

“He is the main guy. And it is a very large challenge,” said Stella Worley, CEO of the hospital.

If she couldn’t find someone to fill in while he was sick, Worley might have to divert trauma and emergency patients nearly 40 miles north to Burlington.

“Time is life sometimes,” she said. “And that is not something you ever want to do.”

‘The ‘Rona Beast Is a Very Nasty Beast’

As deaths from the coronavirus have surpassed 250,000 in the U.S., new data show the pandemic has been particularly lethal in rural areas — it’s taking lives in those areas at a rate reportedly nearly 3.5 times higher than in metropolitan communities.

About 63 people in Cheyenne County have been diagnosed with COVID-19, most of them in the past three weeks.

Papenfus, a lively 63-year-old, was discharged after a nine-day stay at St. Joseph’s Hospital in Denver, and he was eager to sound the alarm about the disease he calls the ‘rona.

“The ‘rona beast is a very nasty beast, and it is not fun. It has a very mean temper. It loves a fight, and it loves to keep coming after you,” Papenfus said.

He isn’t sure where he picked it up but thinks it might have been on a trip east in October. He said he was meticulous on the plane, sitting in the front, last on, first off. But on landing at Denver International Airport, Papenfus boarded the crowded train to the terminal, and soon alarm bells went off in his head.

“There are people literally like inches from me, and we’re all crammed like sardines in this train,” Papenfus said. “And I’m going, ‘Oh, my God, I am in a superspreader event right now.’”

An airport spokeswoman declined to comment about Papenfus’ experience.

A week later, the symptoms hit. He tested positive and decided to drive himself the three hours to the hospital in Denver. “I’m not going to let anybody get in this car with me and get COVID, because I don’t want to give anybody the ‘rona,” he said. County sheriff’s deputies followed his car to ensure he made it.

Once in the hospital, chest X-rays revealed he’d developed pneumonia.

“Dude, I didn’t get a tap on the shoulder by ‘rona, I got a big viral load,” he texted a reporter, sending images of his chest scans that show large, opaque, white areas of his lung. Just a week earlier, his chest X-ray was normal, he said.

Back in Cheyenne Wells, Dr. Christine Connolly picked up some of Papenfus’ shifts, although she had to drive 10 hours each way from Fort Worth, Texas, to do it. She said the hospital staff is spread thin already.

“It’s not just the doctors; it’s the nurses, you know. It’s hard to get spare nurses,” she said. “There’s not a lot of spares of anything out that far.”

Besides himself, six other employees — out of a staff of 62 at Keefe Memorial — also recently got a positive test, Papenfus said.

Hospitals on the Plains often send their sickest patients to bigger hospitals in Denver and Colorado Springs. But with so many people around the region getting sick, Connolly is getting worried hospitals could be overwhelmed. Health care leaders created a new command system to transfer patients around the state to make more room, but Connolly said there is a limit.

“It’s dangerous when the hospitals in the cities fill up, and when it becomes a problem for us to send out,” she said.

‘Bank Robbers Wear Masks Out There’

The impact of Papenfus’ absence stretches across Colorado’s Eastern Plains. He usually worked shifts an hour to the northwest, at Lincoln Community Hospital in Hugo. Its CEO, Kevin Stansbury, said the town mostly dodged the spring surge and his facility could take in recovering COVID patients from Colorado’s cities. Now, Stansbury said, the virus is reaching places such as Lincoln County, population 5,700. It has had 144 cases, according to state data, and neighboring Kit Carson has had 301. Crowley County to the south, home to a privately managed state prison, has had 1,239 cases. It is far and away the No. 1 most affected county per capita in the state.

“So those numbers are huge,” Stansbury said. He said that as of mid-November about a half-dozen hospital staffers had tested positive for the virus; they think that outbreak is unrelated to Papenfus’ case.

Lincoln Community Hospital is ready once again to take recovering patients. Finances in rural health care are always tight, and accepting new patients would help.

“We have the staff to do that, so long as my staff doesn’t get ravaged with the disease,” Stansbury said.

Rural communities are particularly vulnerable. Residents tend to suffer from underlying health conditions that can make COVID-19 more severe, including high rates of cigarette smoking, high blood pressure and obesity. And Brock Slabach of the National Rural Health Association said 61% of rural hospitals do not have an intensive care unit.

“This is an unprecedented situation that we find ourselves in right now,” Slabach said. “I don’t think that in our lifetimes we’ve seen anything like what is developing in terms of surge capacity.”

A couple of hours east of Cheyenne Wells, COVID-19 recently hit Gove County, Kansas, hard.

The county’s emergency management director, the local hospital CEO and more than 50 medical staff members tested positive. In a nursing home, most of the more than 30 residents caught the virus; six have died since late September, according to The Associated Press. A county sheriff ended up in a hospital more than an hour from home, fighting to breathe, because of the lack of space at the local medical center.

Papenfus fretted about his home county and its odds of fighting off the virus.

“The western prairie isn’t mask country,” he said. “People don’t wear masks out there; bank robbers wear masks out there.” He is urging Coloradans to stay vigilant, calling the virus an existential threat. “It’s a huge wake-up call.”

Since being released from the hospital, Papenfus has had a rocky recovery. His wife, Joanne, drove him back to Cheyenne Wells, wearing an N95 mask and gloves, while he rode in the back on oxygen, coughing through the three-hour drive.

Once back at home after that initial nine-day stay, Papenfus hunkered down, with the occasional trip outside to hang out with his pet falcon.

But a week after going home, he started having nightly fevers. He had a CT scan done at Keefe Memorial, the hospital where he works. It revealed pneumonia in his lungs, so he went back to Denver, getting readmitted at St. Joseph’s Hospital. This time, Papenfus arrived via ambulance.

Finding a replacement for Papenfus at Keefe has been hard. The hospital is working with services that provide substitute physicians, but these days, with the coronavirus roaring across the country, the competition is fierce.

“They’re really scrambling to get coverage,” Papenfus texted from his hospital bed. “Whole county can’t wait for my return but this illness has really taken me down.”

He said he was now at Day 35 from his first symptoms, lying in his hospital bed in Denver, “wondering when I’ll ever get back.” Papenfus noted that COVID-19 has affected his critical thinking and that he will need to be cleared cognitively to return to work. He said he knows he won’t have the physical stamina to get back to full duty “for a while, if ever.”

This story is from a reporting partnership that includes Colorado Public RadioNPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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How Jefferson Health is caring for chronic disease patients amid a pandemic

Providing care for chronic disease patients during a one-in-a-century pandemic is full of challenges, but health systems like Jefferson Health are finding ways — with help from technology — to make sure their patients are getting the care they need.

Con récord de internaciones por COVID, la crisis ahora es la falta de personal médico

Los hospitales en gran parte del país están tratando de hacer frente a un número sin precedentes de pacientes con COVID-19.

El lunes 30 de noviembre hubo 96,039 internaciones a lo largo del país, un récord alarmante que supera con creces los dos picos anteriores en abril y julio de poco menos de 60,000 pacientes hospitalizados.

Pero las camas y el espacio no son la principal preocupación. Es la fuerza laboral. A los hospitales les preocupa que los niveles de personal no puedan satisfacer la demanda, ya que los médicos, enfermeras y especialistas, como los terapeutas respiratorios, se agotan o, peor aún, se infectan y enferman.

La solución típica para la escasez de personal (contratar médicos de afuera) ya no es la solución, a pesar de que ayudó a aliviar la tensión al principio de la pandemia, cuando el primer aumento de casos se concentró en un puñado de “puntos calientes” como Nueva York, Detroit, Seattle y Nueva Orleans.

Reclutar esos refuerzos temporales también fue más fácil en la primavera porque los hospitales fuera de esas primeras ciudades afectadas estaban atendiendo a menos pacientes de lo normal, lo que llevó a despidos masivos.

Eso hizo que muchas enfermeras cesantes no dudaran en viajar a otra ciudad y ayudar en otro frente de batalla.

En muchos casos, los hospitales compitieron por las enfermeras itinerantes y las tasas de pago de las enfermeras temporales se dispararon. En abril, el Centro Médico de la Universidad de Vanderbilt en Nashville, Tennessee, tuvo que aumentar el salario de algunas enfermeras del personal, que ganaban menos que las temporales recién llegadas.

En la primavera, estas enfermeras que viajaron a las “zonas calientes” no solo recibieron mejores salarios. Muchas contaron lo gratificante que fue salvar vidas en una pandemia histórica, estar cerca de pacientes que morían lejos de su familia.

“Era realmente una zona caliente, no nos sacábamos el equipo de protección y todos los que ingresaban eran COVID positivos”, contó Laura Williams, de Knoxville, Tennessee, quien ayudó a inaugurar el Ryan Larkin Field Hospital en la ciudad de Nueva York.

“Trabajaba seis o siete días a la semana, pero me sentí muy realizada”.

Después de dos meses agotadores, Williams regresó en junio a su trabajo de enfermería en el Centro Médico de la Universidad de Tennessee. Durante un tiempo, el frente de COVID se mantuvo relativamente tranquilo en Knoxville.

Pero luego golpeó la segunda ola. Y ha habido hospitalizaciones récord en Tennessee casi todos los días: aumentaron un 60% en el último mes.

Los funcionarios de salud informan que es mucho más difícil encontrar médicos suplentes.

Tennessee ha construido sus propios hospitales de campaña para manejar el desborde de pacientes: uno se encuentra dentro de las antiguas oficinas del periódico Commercial Appeal en Memphis y otro ocupa dos pisos sin usar en el Nashville General Hospital.

Pero si fueran necesarios en este momento, el estado tendría problemas para encontrar médicos y enfermeras para administrarlos porque los hospitales ya están luchando para cubrir las camas que tienen.

“La capacidad hospitalaria depende casi exclusivamente de la dotación de personal”, explicó la doctora Lisa Piercey, quien dirige el Departamento de Salud de Tennessee. “Las camas no son el problema”.

Cuando se trata de dotación de personal, el coronavirus crea un desafío extremo.

A medida que el número de casos alcanza nuevos picos, un número récord de empleados del hospital tienen COVID-19 o se ven obligados a dejar de trabajar porque tienen que ponerse en cuarentena después de una posible exposición.

“Pero aquí está la trampa”, dijo el doctor Alex Jahangir, que preside el grupo de trabajo sobre el coronavirus de Nashville. “No se infectan en los hospitales. De hecho, los hospitales en su mayor parte son bastante seguros. Se están infectando en la comunidad”.

Algunos estados, como Dakota del Norte, ya han decidido permitir que las enfermeras con COVID positivo sigan trabajando mientras se sientan bien, una medida que ha generado una reacción violenta.

La escasez de enfermeras es tan aguda que algunos puestos de enfermeras itinerantes pagan un salario de $8,000 a la semana. A algunas enfermeras y médicos jubilados se les pidió que consideraran regresar a la fuerza laboral al comienzo de la pandemia, y al menos 338 de 65 años o más murieron de COVID-19.

En Tennessee, el gobernador Bill Lee emitió una orden de emergencia que flexibiliza algunas restricciones regulatorias sobre quién puede hacer qué dentro de un hospital, dándoles más flexibilidad al personal.

La doctora Jessica Rosen es médica de emergencias en St. Thomas Health en Nashville, donde tener que derivar pacientes a otros hospitales era algo raro. Dijo que ahora es algo común.

“Tratamos de enviar ambulancias a otros hospitales porque no tenemos camas disponibles”, expresó.

Incluso los hospitales más grandes de la región se están llenando. La primera semana de diciembre, el Centro Médico de la Universidad de Vanderbilt abrió espacio en su hospital infantil para pacientes que no tenían COVID. Su hospital de adultos tiene más de 700 camas. Y como muchos otros hospitales, ha enfrentado el desafío de dotar de personal a dos unidades de cuidados intensivos, una exclusivamente para pacientes con COVID y otra para todos los demás.

Y los pacientes vienen de lugares tan lejanos como Arkansas y el suroeste de Virginia.

“La gran mayoría de nuestros pacientes que ahora están en la unidad de cuidados intensivos no ingresan a través de nuestro departamento de emergencias”, dijo el doctor Matthew Semler, neumonólogo en VUMC que trabaja con pacientes con COVID.

“Los transfieren a este centro, que está a horas de distancia, porque no hay capacidad en ningún otro”.

Semler dijo que su hospital normalmente traía enfermeras de fuera de la ciudad para ayudar. Pero ya no hay.

Los grupos de proveedores nacionales todavía están enviando personal, aunque cada vez más significa dejar a otro lugar con menos trabajadores. El doctor James Johnson, de la empresa de servicios médicos Envision, con sede en Nashville, ha desplegado refuerzos en Lubbock y El Paso, Texas.

Con esta crisis, la limitación no serán los ventiladores o el equipo de protección, dijo. En la mayoría de los casos, será la fuerza laboral médica. El poder de la gente.

Johnson, veterano de la Fuerza Aérea que trató a soldados heridos en Afganistán, dijo que está más concentrado que nunca en tratar de levantar la moral de los médicos y evitar el agotamiento. En general, es optimista, especialmente después de servir cuatro semanas en la ciudad de Nueva York al comienzo de la pandemia.

“Lo que experimentamos en Nueva York, y desde entonces, muestra que la humanidad está a la altura de las circunstancias”, dijo.

Pero Johnson agregó que los sacrificios no deberían provenir solo de los trabajadores de salud. Todos son responsables de tratar de evitar que los demás, y ellos mismos, se enfermen en primer lugar, dijo.

Esta historia es parte de una colaboración que incluye Nashville Public Radio, NPR y Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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As Hospitals Fill With COVID Patients, Medical Reinforcements Are Hard to Find

Hospitals in much of the country are trying to cope with unprecedented numbers of COVID-19 patients. As of Monday, 96,039 were hospitalized, an alarming record that far exceeds the two previous peaks in April and July of just under 60,000 inpatients.

But beds and space aren’t the main concern. It’s the workforce. Hospitals are worried staffing levels won’t be able to keep up with demand as doctors, nurses and specialists such as respiratory therapists become exhausted or, worse, infected and sick themselves.

The typical workaround for staffing shortages — hiring clinicians from out of town — isn’t the solution anymore, even though it helped ease the strain early in the pandemic, when the first surge of cases was concentrated in a handful of “hot spot” cities such as New York, Detroit, Seattle and New Orleans.

Recruiting those temporary reinforcements was also easier in the spring because hospitals outside of the initial hot spots were seeing fewer patients than normal, which led to mass layoffs. That meant many nurses were able — and excited — to catch a flight to another city and help with treatment on the front lines.

In many cases, hospitals competed for traveling nurses, and the payment rates for temporary nurses spiked. In April, Vanderbilt University Medical Center in Nashville, Tennessee, had to increase the pay of some staff nurses, who were making less than newly arrived temporary nurses.

In the spring, nurses who answered the call from beleaguered “hot spot” hospitals weren’t merely able to command higher pay. Some also spoke about how meaningful and gratifying the work felt, trying to save lives in a historic pandemic, or the importance of being present for family members who could not visit loved ones who were sick or dying.

“It was really a hot zone, and we were always in full PPE and everyone who was admitted was COVID-positive,” said Laura Williams of Knoxville, Tennessee, who helped launch the Ryan Larkin Field Hospital in New York City.

“I was working six or seven days a week, but I felt very invigorated.”

After two taxing months, Williams returned in June to her nursing job at the University of Tennessee Medical Center. For a while, the COVID front remained relatively quiet in Knoxville. Then the fall surge hit. There have been record hospitalizations in Tennessee nearly every day, increasing by 60% in the past month.

Health officials report that backup clinicians are becoming much harder to find.

Tennessee has built its own field hospitals to handle patient overflows — one is inside the old Commercial Appeal newspaper offices in Memphis, and another occupies two unused floors in Nashville General Hospital. But if they were needed right now, the state would have trouble finding the doctors and nurses to run them because hospitals are already struggling to staff the beds they have.

“Hospital capacity is almost exclusively about staffing,” said Dr. Lisa Piercey, who heads the Tennessee Department of Health. “Physical space, physical beds, not the issue.”

When it comes to staffing, the coronavirus creates a compounding challenge.

As patient caseloads reach new highs, record numbers of hospital employees are themselves out sick with COVID-19 or temporarily forced to stop working because they have to quarantine after a possible exposure.

“But here’s the kicker,” said Dr. Alex Jahangir, who chairs Nashville’s coronavirus task force. “They’re not getting infected in the hospitals. In fact, hospitals for the most part are fairly safe. They’re getting infected in the community.”

Some states, like North Dakota, have already decided to allow COVID-positive nurses to keep working as long as they feel OK, a move that has generated backlash. The nursing shortage is so acute there that some traveling nurse positions posted pay of $8,000 a week. Some retired nurses and doctors were asked to consider returning to the workforce early in the pandemic, and at least 338 who were 65 or older have died of COVID-19.

In Tennessee, Gov. Bill Lee issued an emergency order loosening some regulatory restrictions on who can do what within a hospital, giving them more staffing flexibility.

For months, staffing in much of the country had been a concern behind the scenes. But it’s becoming palpable to any patient.

Dr. Jessica Rosen is an emergency physician at St. Thomas Health in Nashville, where having to divert patients to other hospitals has been rare over the past decade. She said it’s a common occurrence now.

“We have been frequently on diversion, meaning we don’t take transfers from other hospitals,” she said. “We try to send ambulances to other hospitals because we have no beds available.”

Even the region’s largest hospitals are filling up. This week, Vanderbilt University Medical Center made space in its children’s hospital for non-COVID patients. Its adult hospital has more than 700 beds. And like many other hospitals, it has had the challenge of staffing two intensive care units — one exclusively for COVID patients and another for everyone else.

And patients are coming from as far away as Arkansas and southwestern Virginia.

“The vast majority of our patients now in the intensive care unit are not coming in through our emergency department,” said Dr. Matthew Semler, a pulmonary specialist at VUMC who works with COVID patients.

“They’re being sent hours away to be at our hospital because all of the hospitals between here and where they present to the emergency department are on diversion.”

Semler said his hospital would typically bring in nurses from out of town to help. But there is nowhere to pull them from right now.

National provider groups are still moving personnel around, though increasingly it means leaving somewhere else short-staffed. Dr. James Johnson with the Nashville-based physician services company Envision has deployed reinforcements to Lubbock and El Paso, Texas, this month.

He said the country hasn’t hit it yet, but there’s a limit to hospital capacity.

“I honestly don’t know where that limit is,” he said.

At this point, the limitation won’t be ventilators or protective gear, he said. In most cases, it will be the medical workforce. People power.

Johnson, an Air Force veteran who treated wounded soldiers in Afghanistan, said he’s more focused than ever on trying to boost doctors’ morale and stave off burnout. He’s generally optimistic, especially after serving four weeks in New York City early in the pandemic.

“What we experienced in New York and happened in every episode since is that humanity rises to the occasion,” he said.

But Johnson said the sacrifices shouldn’t come just from the country’s health care workers. Everyone bears a responsibility, he said, to try to keep themselves and others from getting sick in the first place.

This story is from a reporting partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Brigham and Women’s, Biofourmis launch hospital-at-home solution nationwide

The Boston-based hospital and digital therapeutics company are rolling out their co-developed remote monitoring solution across the country, which can help hospitals rapidly implement hospital-at-home programs. The announcement comes soon after CMS launched a program enabling health systems to provide hospital-level care at home for more than 60 conditions.

OSHA Let Employers Decide Whether to Report Health Care Worker Deaths. Many Didn’t.

As Walter Veal cared for residents at the Ludeman Developmental Center in suburban Chicago, he saw the potential future of his grandson, who has autism.


This story also ran on The Guardian. It can be republished for free.

So he took it on himself not just to bathe and feed the residents, which was part of the job, but also to cut their hair, run to the store to buy their favorite body wash and barbecue for them on holidays.

“They were his second family,” said his wife, Carlene Veal.

Even after COVID-19 struck in mid-March and cases began spreading through the government-run facility, which serves nearly 350 adults with developmental disabilities, Walter was determined to go to work, Carlene said.

Staff members were struggling to acquire masks and other personal protective equipment at the time, many asking family members for donations and wearing rain ponchos sent by professional baseball teams.

All Walter had was a pair of gloves, Carlene said.

By mid-May, rumors of some sick residents and staffers had turned into 274 confirmed positive COVID tests, according to the Illinois Department of Human Services COVID tracking site. On May 16, Walter, 53, died of the virus. Three of his colleagues had already passed, according to interviews with Ludeman workers, the deceased employees’ families and union officials.

State and federal laws say facilities like Ludeman are required to alert Occupational Safety and Health Administration officials about work-related employee deaths within eight hours. But facility officials did not deem the first staff death on April 13 work-related, so they did not report it. They made the same decision about the second and third deaths. And Walter’s.

It’s a pattern that’s emerged across the nation, according to a KHN review of hundreds of worker deaths detailed by family members, colleagues and local, state and federal records.

Workplace safety regulators have taken a lenient stance toward employers during the pandemic, giving them broad discretion to decide internally whether to report worker deaths. As a result, scores of deaths were not reported to occupational safety officials from the earliest days of the pandemic through late October.

KHN examined more than 240 deaths of health care workers profiled for the Lost on the Frontline project and found that employers did not report more than one-third of them to a state or federal OSHA office, many based on internal decisions that the deaths were not work-related — conclusions that were not independently reviewed.

Work-safety advocates say OSHA investigations into staff deaths can help officials pinpoint problems before they endanger other employees as well as patients or residents. Yet, throughout the pandemic, health care staff deaths have steadily climbed. Thorough reviews could have also prompted the Department of Labor, which oversees OSHA, to urge the White House to address chronic protective gear shortages or sharpen guidance to help keep workers safe.

Since no public agency releases the names of health care workers who die of COVID-19, a team of reporters building the Lost on the Frontline database has scoured local news stories, GoFundMe campaigns, and obituary and social media sites to identify nearly 1,400 possible cases. More than 260 fatalities have been vetted with families, employers and public records.

For this investigation, journalists examined worker deaths at more than 100 health care facilities where OSHA records showed no fatality investigation was underway.

At Ludeman, the circumstances surrounding the April 13 worker death might have shed light on the hazards facing Veal. But no state work safety officials showed up to inspect — because the Department of Human Services, which operates Ludeman and employs the staff, said it did not report any of the four deaths there to Illinois OSHA.

The department said “it could not determine the employees contracted COVID-19 at the workplace” — despite its being the site of one of the largest U.S. outbreaks. Since Veal’s death in May, dozens more workers have tested positive for COVID-19, according to DHS’ COVID tracking site.

OSHA inspectors monitor local news media and sometimes will open investigations even without an employer’s fatality report. Through Nov. 5, federal OSHA offices issued 63 citations to facilities for failing to report a death. And when inspectors do show up, they often force improvements — requiring more protective equipment for workers and better training on how to use it, files reviewed by KHN show.

Still, many deaths receive little or no scrutiny from work-safety authorities. In California, public health officials have documented about 200 health care worker deaths. Yet the state’s OSHA office received only 75 fatality reports at health care facilities through Oct. 26, Cal/OSHA records show.

Nursing homes, which are under strict Medicare requirements, reported more than 1,000 staff deaths through mid-October, but only about 350 deaths of long-term care facility workers appear to have been reported to OSHA, agency records show.

Workers whose deaths went unreported include some who took painstaking precautions to avoid getting sick and passing the virus to family members: One California lab technician stayed in a hotel during the workweek. An Arizona nursing home worker wore a mask for family movie nights. A Nevada nurse told his brother he didn’t have adequate PPE. Nevada OSHA confirmed to KHN that his death was not reported to the agency and that officials would investigate.

KHN asked health care employers why they chose not to report fatalities. Some cited the lack of proof that a worker was exposed on-site, even in workplaces that reported a COVID outbreak. Others cited privacy concerns and gave no explanation. Still others ignored requests for comment or simply said they had followed government policies.

“It is so disrespectful of the agencies and the employers to shunt these cases aside and not do everything possible to investigate the exposures,” said Peg Seminario, a retired union health and safety director who co-authored a study on OSHA oversight with scholars from Harvard’s T.H. Chan School of Public Health.

A Department of Labor spokesperson said in a statement that an employer must report a fatality within eight hours of knowing the employee died and after determining the cause of death was a work-related case of COVID-19.

The department said employers also are bound to report a COVID death if it comes within 30 days of a workplace incident — meaning exposure to COVID-19.

Yet pinpointing exposure to an invisible virus can be difficult, with high rates of pre-symptomatic and asymptomatic transmission and spread of the virus just as prevalent inside a hospital COVID unit as out.

Those challenges, plus May guidance from OSHA, gave employers latitude to decide behind closed doors whether to report a case. So it’s no surprise that cases are going unreported, said Eric Frumin, who has testified to Congress on worker safety and is health and safety director for Change to Win, a partnership of seven unions.

“Why would an employer report unless they feel for some reason they’re socially responsible?” Frumin said. “Nobody’s holding them to account.”

Downside of Discretion

OSHA’s guidance to employers offered pointers on how to decide whether a COVID death is work-related. It would be if a cluster of infections arose at one site where employees work closely together “and there is no alternative explanation.” If a worker had close contact with someone outside of work infected with the virus, it might not have been work-related, the guidance says.

Ultimately, the memo says, if an employer can’t determine that a worker “more likely than not” got sick on the job, “the employer does not need to record that.”

In mid-March, the union that represented Paul Odighizuwa, a food service worker at Oregon Health & Science University, raised concerns with university management about the virus possibly spreading through the Food and Nutrition Services Department.

Workers there — those taking meal orders, preparing food, picking up trays for patient rooms and washing dishes — were unable to keep their distance from one another, said Michael Stewart, vice president of the American Federation of State, County and Municipal Employees Local 328, which represents about 7,000 workers at OHSU. Stewart said the union warned administrators they were endangering people’s lives.

Soon the virus tore through the department, Stewart said. At least 11 workers in food service got the virus, the union said. Odighizuwa, 61, a pillar of the local Nigerian community, died on May 12.

OHSU did not report the death to the state’s OSHA and defended the decision, saying it “was determined not to be work-related,” according to a statement from Tamara Hargens-Bradley, OHSU’s interim senior director of strategic communications.

She said the determination was made “[b]ased on the information gathered by OHSU’s Occupational Health team,” but she declined to provide details, citing privacy issues.

Stewart blasted OHSU’s response. When there’s an outbreak in a department, he said, it should be presumed that’s where a worker caught the virus.

“We have to do better going forward,” Stewart said. “We have to learn from this.” Without an investigation from an outside regulator like OSHA, he doubts that will happen.

Stacy Daugherty heard that Oasis Pavilion Nursing and Rehabilitation Center in Casa Grande, Arizona, was taking strict precautions as COVID-19 surged in the facility and in Pinal County, almost halfway between Phoenix and Tucson.

Her father, a certified nursing assistant there, was also extra cautious: He believed that if he got the virus, “he wouldn’t make it,” Daugherty said.

Mark Daugherty, a father of five, confided in his youngest son when he fell ill in May that he believed he contracted the coronavirus at work, his daughter said in a message to KHN.

Early in June, the facility filed its first public report on COVID cases to Medicare authorities: Twenty-three residents and eight staff members had fallen ill. It was one of the largest outbreaks in the state. (Medicare requires nursing homes to report staff deaths each week in a process unrelated to OSHA.)

By then, Daugherty, 60, was fighting for his life, his absence felt by the residents who enjoyed his banjo, accordion and piano performances. But the country’s occupational safety watchdog wasn’t called in to figure out whether Daugherty, who died June 19, was exposed to the virus at work. His employer did not report his death to OSHA.

“We don’t know where Mark might have contracted COVID 19 from, since the virus was widespread throughout the community at that time. Therefore there was no need to report to OSHA or any other regulatory agencies,” Oasis Pavilion’s administrator, Kenneth Opara, wrote in an email to KHN.

Since then, 15 additional staffers have tested positive and the facility suspects a dozen more have had the virus, according to Medicare records.

Gaps in the Law

If Oasis Pavilion needed another reason not to report Daugherty’s death, it might have had one. OSHA requires notice of a death only within 30 days of a work-related incident. Daugherty, like many others, clung to life for weeks before he died.

That is one loophole — among others — in work-safety laws that experts say could use a second look in the time of COVID-19.

In addition, federal OSHA rules don’t apply to about 8 million public employees. Only government workers in states with their own state OSHA agency are covered. In other words, in about half the country if a government employee dies on the job — such as a nurse at a public hospital in Florida, or a paramedic at a fire department in Texas — there’s no requirement to report it and no one to look into it.

So there was little chance anyone from OSHA would investigate the deaths of two health workers early this year at Central State Hospital in Georgia — a state-run psychiatric facility in a state without its own worker-safety agency.

On March 24, a manager at the facility had warned staff they “must not wear articles of clothing, including Personal Protective Equipment” that violate the dress code, according to an email KHN obtained through a public records request.

Three days later, what had started as a low-grade illness for Mark DeLong, a licensed practical nurse at the facility, got serious. His cough was so severe late on March 27 that he called 911 — and handed the phone to his wife, Jan, because he could barely speak, she said.

She went to visit him in the hospital the next day, fully expecting a pleasant visit with her karaoke partner. “By the time I got there it was too late,” she said. DeLong, 53 “had passed.”

She learned after his death that he’d had COVID-19.

Back at the hospital, workers had been frustrated with the early directive that employees should not wear their own PPE.

Bruce Davis had asked his supervisors if he could wear his own mask but was told no because it wasn’t part of the approved uniform, according to his wife, Gwendolyn Davis. “He told me ‘They don’t care,’” she said.

Two days after DeLong’s death, the directive was walked back and employees and contractors were informed they could “continue and are authorized to wear Personal Protective Gear,” according to a March 30 email from administrators. But Davis, a Pentecostal pastor and nursing assistant supervisor, was already sick. Davis worked at the hospital for 27 years and saw little distinction between the love he preached at the altar and his service to the patients he bathed, fed and cared for, his wife said.

Sick with the virus, Davis died April 11.

At the time, 24 of Central State’s staffers had tested positive, according to the Georgia Department of Behavioral Health and Developmental Disabilities, which runs the facility. To date, nearly 100 staffers and 33 patients at Central State have gotten the virus, according to figures from the state agency.

“I don’t think they knew what was going on either,” Jan DeLong said. “Somebody needs to check into it.”

In response to questions from KHN, a spokesperson for the department provided a prepared statement: “There was never a ban on commercially available personal protective equipment, even if the situation did not call for its use according to guidelines issued by the Centers for Disease Control and Prevention and the Georgia Department of Public Health at the time.”

KHN reviewed more than a dozen other health worker deaths at state or local government workplaces in states like Texas, Florida and Missouri that went unreported to OSHA for the same reason — the facilities were run by government agencies in a state without its own worker safety agency.

Inside Ludeman

In mid-March, staff members at the Ludeman Developmental Center were desperate for PPE. The facility was running low on everything from gloves and gowns to hand sanitizer, according to interviews with current and former workers, families of deceased workers, and union officials.

Due to a national shortage at the time, surgical masks went only to staffers working with known positive cases, said Anne Irving, regional director for AFSCME Council 31, the union that represents Ludeman employees.

Residents in the Village of Park Forest, Illinois, where the facility is located, tried to help by sewing masks or pivoting their businesses to produce face shields and hand sanitizer, said Mayor Jonathan Vanderbilt. But providing enough supplies for more than 900 Ludeman employees proved difficult.

Michelle Abernathy, 52, a newly appointed unit director, bought her own gloves at Costco. In late March, a resident on Abernathy’s unit showed symptoms, said Torrence Jones, her fiancé who also works at the facility. Then Abernathy developed a fever.

When she died on April 13 — the first known Ludeman staff member lost to the pandemic — the Illinois Department of Human Services, which runs Ludeman, made no report to safety regulators. After seeing media reports, Illinois OSHA sent the agency questions about Abernathy’s daily duties and working conditions. Based on DHS’ responses and subsequent phone calls, state OSHA officials determined Abernathy’s death was “not work-related.”

Barbara Abernathy, Michelle’s mom, doesn’t buy it. “Michelle was basically a hermit,” she said, going only from work to home. She couldn’t have gotten the virus anywhere else, she said. In response to OSHA’s inquiry for evidence that the exposure was not related to her workplace, her employer wrote “N/A,” according to documents reviewed by KHN.

Two weeks after Abernathy’s passing, two more employees died: Cephus Lee, 59, and Jose Veloz III, 52. Both worked in support services, boxing food and delivering it to the 40 buildings on campus. Their deaths were not reported to Illinois OSHA.

Veloz was meticulous at home, having groceries delivered and wiping down each item before bringing it inside, said his son, Joseph Ricketts.

But work was another story. Maintaining social distance in the food prep area was difficult, and there was little information on who had been infected or exposed to the virus, according to his son.

“No matter what my dad did, he was screwed,” Ricketts said. Adding, he thought Ludeman did not do what it should have done to protect his dad on the job.

A March 27 complaint to Illinois OSHA said it took a week for staff to be notified about multiple employees who tested positive, according to documents obtained by the Documenting COVID-19 project at the Brown Institute for Media Innovation and shared with KHN. An early April complaint was more frank: “Lives are endangered,” it said.

That’s how Rose Banks felt when managers insisted she go to work, even though she was sick and awaiting a test result, she said. Her husband, also a Ludeman employee, had already tested positive a week earlier.

Banks said she was angry about coming in sick, worried she might infect co-workers and residents. After spending a full day at the facility, she said, she came home to a phone call saying her test was positive. She’s currently on medical leave.

With some Ludeman staff assigned to different homes each shift, the virus quickly traveled across campus. By mid-May, 76 staff and 198 residents had tested positive, according to DHS’ COVID tracking site.

Carlene Veal said her husband, Walter, was tested at the facility in late April. But by the time he got the results weeks later, she said, he was already dying.

Carlene can still picture the last time she saw Walter, her high school sweetheart and a man she called her “superhero” for 35 years of marriage and raising four kids together. He was lying on a gurney in their driveway with an oxygen mask on his face, she said. He pulled the mask down to say “I love you” one last time before the ambulance pulled away.

The Illinois Department of Human Services said that, since the beginning of the pandemic, it has implemented many new protocols to mitigate the outbreak at Ludeman, working as quickly as possible based on what was known about the virus at the time. It has created an emergency staffing plan, identified negative-airflow spaces to isolate sick individuals and made “extensive efforts” to procure more PPE, and it is testing all staffers and residents regularly.

“We were deeply saddened to lose four colleagues who worked at Ludeman Developmental Center and succumbed to the virus,” the agency said in a statement. “We are committed to complying with and following all health and safety guidelines for COVID-19.”

The number of new cases at Ludeman has remained low for several months now, according to DHS’ COVID tracking site.

But that does little to console the families of those who have died.

When a Ludeman supervisor called Barbara Abernathy in June to express condolences and ask if there was anything they could do, Abernathy didn’t know how to respond.

“There was nothing they could do for me now,” she said. “They hadn’t done what they needed to do before.”

Shoshana Dubnow, Anna Sirianni, Melissa Bailey and Hannah Foote contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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AI-powered surveillance systems are helping health systems and public health agencies with their response to the Covid-19 pandemic. The current health crisis offers a glimpse of how it may be possible to predict and prevent a range of chronic health concerns, including healthcare-associated infections.

Rural Areas Send Their Sickest Patients to Cities, Straining Hospitals

Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.

But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees, like on a recent stop for carryout food.

“No one in the entire restaurant was wearing a mask,” Muhindura said. “And there’s no social distancing. I had to get out, because I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?’”

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.

Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.

Kansas City has a mask mandate, but in many smaller communities nearby, masks aren’t required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.

At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouri don’t have a single intensive care unit bed, so when people from these places get critically ill, they’re sent to city hospitals.

A recent patient count at St. Luke’s Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.

Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke’s.

“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients,” said Larsen. “We get the sickest of the sick.”

Dr. Rex Archer, head of Kansas City’s health department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.

“We’ve had this huge swing that’s occurred because they’re not wearing masks, and yes, that’s putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed,” Archer said.

study newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while counties without mask mandates recorded increases.

Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas’ conservative legislature, to implement stringent, statewide mask requirements but without success.

Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of “making the mask a political issue.” He said county leaders should decide whether to close businesses or mandate masks.

“We’re going to encourage them to take some sort of action,” Parson said Thursday. “The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door.”

In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.

The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to health care experts.

Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.

Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.

Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.

“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat said.

Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.

Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states’ hospital systems.

The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.

“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.

Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region’s hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.

Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system’s chief medical officer, Dr. Steven Stites.

But bed space isn’t the only hospital resource that’s running out. Half of the hospitals in the Kansas City area are now reporting “critical” staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.

“The hospitals are not fine, because people taking care of patients are on the brink,” Muhindura said. “We are tired.”

This story is from a reporting partnership that includes KCUR, NPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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For Nurses Feeling the Strain of the Pandemic, Virus Resurgence Is ‘Paralyzing’

For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies and other surgeries.

That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. “It’s paralyzing, I’m not going to lie,” said Nester, who’s worked at the Worcester hospital for nearly two decades. “My little clan of nurses that I work with, we panicked when it started to uptick here.”

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus’s surge is not contained this winter, advocates and researchers warn.

Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.

“They have become, in some ways, a kind of emotional surrogate for family members who can’t be there, to support and advise and offer a human touch,” Rushton said. “They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses.”

A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.

Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called “moral injury.” That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.

Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, “Probably the biggest driver of burnout is unrecognized unattended moral injury.”

In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.

“Not enough to really process it all,” she said. “I think that’s a process that will take several years. And it’s probably going to be extended because the pandemic itself is extended.”

Sense of Powerlessness

Before the pandemic hit her Massachusetts hospital “like a forest fire” in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.

Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn’t breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn’t even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester’s unit.

“Then both parents died, and the daughter died,” Nester said. “There’s not really words for it.”

During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has written a book about preventing moral injury among health care providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.

At St. Vincent Hospital, the nurses on Nester’s unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.

“You’re trying to yell through all of these barriers and try to show them with your eyes that you’re here and you’re not going to leave them and will take care of them,” she said. “But yet you’re panicking inside completely that you’re going to get this disease and you’re going to be the one in the bed or a family member that you love, take it home to them.”

When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic “we have prioritized the safety and well-being of our staff, and we remain focused on that.”

Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, 6% of adults hospitalized were health care workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.

As cases mount in the winter months, moral injury researcher Dean said, “nurses are going to do the calculation and say, ‘This risk isn’t worth it.’”

Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he’s been seeing a therapist “to navigate my powerlessness in all of this.”

Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.

Innocenti said he was concerned about “the lack of planning and just blatant disregard for the basic safety of patients and staff.” Profit motives too often drive decisions, he suggested. “That’s what I’m taking a break from.”

Building Resiliency

As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.

The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have compiled online resources with links to mental health programs as well as tips for getting through each pandemic workday.

Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.

“It doesn’t mean that you’re not taking it home with you,” Henry said, “but you’re actually verbally processing it to your peers.”

When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn’t want to return.

“But you know that your friends are there,” she said. “And the only ones that really truly understand what’s going on are your co-workers. How can you leave them?”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Need a COVID-19 Nurse? That’ll Be $8,000 a Week

DENVER — In March, Claire Tripeny was watching her dream job fall apart. She’d been working as an intensive care nurse at St. Anthony Hospital in Lakewood, Colorado, and loved it, despite the mediocre pay typical for the region. But when COVID-19 hit, that calculation changed.

She remembers her employers telling her and her colleagues to “suck it up” as they struggled to care for six patients each and patched their protective gear with tape until it fully fell apart. The $800 or so a week she took home no longer felt worth it.

“I was not sleeping and having the most anxiety in my life,” said Tripeny. “I’m like, ‘I’m gonna go where my skills are needed and I can be guaranteed that I have the protection I need.’”

In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a “mass exodus” of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.

Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.

Early in the pandemic, hospitals were competing for ventilators, COVID tests and personal protective equipment. Now, sites across the country are competing for nurses. The fall surge in COVID cases has turned hospital staffing into a sort of national bidding war, with hospitals willing to pay exorbitant wages to secure the nurses they need. That threatens to shift the supply of nurses toward more affluent areas, leaving rural and urban public hospitals short-staffed as the pandemic worsens, and some hospitals unable to care for critically ill patients.

“That is a huge threat,” said Angelina Salazar, CEO of the Western Healthcare Alliance, a consortium of 29 small hospitals in rural Colorado and Utah. “There’s no way rural hospitals can afford to pay that kind of salary.”

Surge Capacity

Hospitals have long relied on traveling nurses to fill gaps in staffing without committing to long-term hiring. Early in the pandemic, doctors and nurses traveled from unaffected areas to hot spots like California, Washington state and New York to help with regional surges. But now, with virtually every part of the country experiencing a surge — infecting medical professionals in the process — the competition for the finite number of available nurses is becoming more intense.

“We all thought, ‘Well, when it’s Colorado’s turn, we’ll draw on the same resources; we’ll call our surrounding states and they’ll send help,’” said Julie Lonborg, a spokesperson for the Colorado Hospital Association. “Now it’s a national outbreak. It’s not just one or two spots, as it was in the spring. It’s really significant across the country, which means everybody is looking for those resources.”

In North Dakota, Tessa Johnson said she’s getting multiple messages a day on LinkedIn from headhunters. Johnson, president of the North Dakota Nurses Association, said the pandemic appears to be hastening a brain drain of nurses there. She suspects more nurses may choose to leave or retire early after North Dakota Gov. Doug Burgum told health care workers to stay on the job even if they’ve tested positive for COVID-19.

All four of Utah’s major health care systems have seen nurses leave for traveling nurse positions, said Jordan Sorenson, a project manager for the Utah Hospital Association.

“Nurses quit, join traveling nursing companies and go work for a different hospital down the street, making two to three times the rate,” he said. “So, it’s really a kind of a rob-Peter-to-pay-Paul staffing situation.”

Hospitals not only pay the higher salaries offered to traveling nurses but also pay a commission to the traveling nurse agency, Sorenson said. Utah hospitals are trying to avoid hiring away nurses from other hospitals within the state. Hiring from a neighboring state like Colorado, though, could mean Colorado hospitals would poach from Utah.

“In the wake of the current spike in COVID hospitalizations, calling the labor market for registered nurses ‘cutthroat’ is an understatement,” said Adam Seth Litwin, an associate professor of industrial and labor relations at Cornell University. “Even if the health care sector can somehow find more beds, it cannot just go out and buy more front-line caregivers.”

Litwin said he’s glad to see the labor market rewarding essential workers — disproportionately women and people of color — with higher wages. Under normal circumstances, allowing markets to determine where people will work and for what pay is ideal.

“On the other hand, we are not operating under normal circumstances,” he said. “In the midst of a severe public health crisis, I worry that the individual incentives facing hospitals on the one side and individual RNs on the other conflict sharply with the needs of society as whole.”

Some hospitals are exploring ways to overcome staffing challenges without blowing the budget. That could include changing nurse-to-patient ratios, although that would likely affect patient care. In Utah, the hospital association has talked with the state nursing board about allowing nursing students in their final year of training to be certified early.

Growth Industry

Meanwhile business is booming for companies centered on health care staffing such as Wanderly and Krucial Staffing.

“When COVID first started and New York was an epicenter, we at Wanderly kind of looked at it and said, ‘OK, this is our time to shine,’” said David Deane, senior vice president of Wanderly, a website that allows health care professionals to compare offers from various agencies. “‘This is our time to help nurses get to these destinations as fast as possible. And help recruiters get those nurses.’”

Deane said the company has doubled its staff since the pandemic started. Demand is surging — with Rocky Mountain states appearing in up to 20 times as many job postings on the site as in January. And more people are meeting that demand.

In 2018, according to data from a national survey, about 31,000 traveling nurses worked nationwide. Now, Deane estimated, there are at least 50,000 travel nurses. Deane, who calls travel nurses “superheroes,” suspects a lot of them are postoperative nurses who were laid off when their hospitals stopped doing elective surgeries during the first lockdowns.

Competition for nurses, especially those with ICU experience, is stiff. After all, a hospital in South Dakota isn’t competing just with facilities in other states.

“We’ve sent nurses to Aruba, the Bahamas and Curacao because they’ve needed help with COVID,” said Deane. “You’re going down there, you’re making $5,000 a week and all your expenses are paid, right? Who’s not gonna say yes?”

Krucial Staffing specializes in sending health care workers to disaster locations, using military-style logistics. It filled hotels and rented dozens of buses to get nurses to hot spots in New York and Texas. CEO Brian Cleary said that, since the pandemic started, the company has grown its administrative staff from 12 to more than 200.

“Right now we’re at our highest volume we’ve been,” said Cleary, who added that over Halloween weekend alone about 1,000 nurses joined the roster of “reservists.”

With a base rate of $95 an hour, he said, some nurses working overtime end up coming away with $10,000 a week, though there are downsides, like the fact that the gig doesn’t come with health insurance and it’s an unstable, boom-and-bust market.

Hidden Costs

Amber Hazard, who lives in Texas, started as a traveling ICU nurse before the pandemic and said eye-catching sums like that come with a hidden fee, paid in sanity.

“How your soul is affected by this is nothing you can put a price on,” she said.

At a high-paying job caring for COVID patients during New York’s first wave, she remembers walking into the break room in a hospital in the Bronx and seeing a sign on the wall about how the usual staff nurses were on strike.

“It said, you know, ‘We’re not doing this. This is not safe,’” said Hazard. “And it wasn’t safe. But somebody had to do it.”

The highlight of her stint there was placing a wedding ring back on the finger of a recovered patient. But Hazard said she secured far more body bags than rings on patients.

Tripeny, the traveling nurse who left Colorado, is now working in Kentucky with heart surgery patients. When that contract wraps up, she said, she might dive back into COVID care.

Earlier, in New Jersey, she was scarred by the times she couldn’t give people the care they needed, not to mention the times she would take a deceased patient off a ventilator, staring down the damage the virus can do as she removed tubes filled with blackened blood from the lungs.

She has to pay for mental health therapy out-of-pocket now, unlike when she was on staff at a hospital. But as a so-called traveler, she knows each gig will be over in a matter of weeks.

At the end of each week in New Jersey, she said, “I would just look at my paycheck and be like, ‘OK. This is OK. I can do this.’”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Parents Complain That Pediatricians, Wary of COVID, Shift Sick Kids to Urgent Care

A mom of eight boys, Kim Gudgeon was at her wits’ end when she called her family doctor in suburban Chicago to schedule a sick visit for increasingly fussy, 1-year-old Bryce.

He had been up at night and was disrupting his brothers’ e-learning during the day. “He was just miserable,” Gudgeon said. “And the older kids were like, ‘Mom, I can’t hear my teacher.’ There’s only so much room in the house when you have a crying baby.”

She hoped the doctor might just phone in a prescription since Bryce had been seen a few days earlier for a well visit. The doctor had noted redness in one ear but opted to hold off on treatment.

To Gudgeon’s surprise, that’s not what happened. Instead, when she called, her son was referred to urgent care, a practice that has become common for the Edward Medical Group, which included her family doctor and more than 100 other doctors affiliated with local urgent care and hospital facilities. Because of concerns about the transmission of the coronavirus, the group is now generally relying on virtual visits for the sick, but often refers infants and young children to urgent care to be seen in person.

“We have to take into consideration the risk of exposing chronically ill and well patients, staff and visitors in offices, waiting areas or public spaces,” said Adam Schriedel, chief medical officer and a practicing internist with the group.

Gudgeon’s experience is not unusual. As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.

That policy is troubling to Dr. Arthur “Tim” Garson Jr., a clinical professor in the College of Medicine at the University of Houston who studies community health and medical management issues. “It’s a practice’s responsibility to take care of patients,” Garson said. He worries about patients who can’t do video visits if they don’t have a smartphone or access to the internet or simply aren’t comfortable using that technology.

Garson supports protocols to protect staff and patients, including in some instances referrals to urgent care. In those cases, practices should be making sure their patients are referred to good providers, he said. For instance, children should be seen by urgent care facilities with pediatric specialists.

Referrals for children have become so prevalent that the American Academy of Pediatrics came out with interim guidance on how practices can safely see patients, in an effort to promote patient-centered care and to ease the strain on other medical facilities as the peak of flu season approaches. The academy recommended that pediatricians strive “to provide care for the same variety of visits that they provided prior to the public health emergency.”

The academy raises concerns about unintended consequences of referrals, such as the fragmentation of care and increased exposure to other illnesses, both caused by patients seeing multiple providers; higher out-of-pocket costs for families; and an unfair burden shifting to the urgent care system as illnesses surge.

“I think this is all being driven by fear, not really knowing how to do this safely, and not really thinking about all of the sorts of consequences that are going to come as flu and other respiratory illnesses surge this fall and winter,” said Dr. Susan Kressly, who recently retired from her practice in Warrington, Pennsylvania, and authored the AAP guidance.

Fear is not unfounded. More than 900 health care workers, 20 of them pediatricians and pediatric nurses, have died of COVID-19, according to a KHN-Guardian database of front-line health care workers lost to the coronavirus.

For the Edward Medical Group, referrals are a safe way to treat patients by using all the resources of its medical system, Schriedel said.

“We can assure patients, regardless of COVID-19, we have multiple options to provide the care and services they need,” he said.

Besides urgent care referrals and virtual visits, doctors have been given guidelines on how to safely see sick patients. That might mean requesting a negative COVID test before a doctor visit or having staff escort a sick patient from the car directly to an exam room. Also, a pilot program is underway with designated offices taking patients with a respiratory illness that could be flu or COVID-19.

It is a balancing act with some risks. In August, friends sent Kressly screenshots of parents’ online message boards from states such as Texas, Indiana and Florida that were seeing a summer spike in COVID-19 cases. Mothers felt abandoned by their pediatricians because they were being sent to urgent care and emergency departments. Kressly fears some patients will fall through the cracks if they are seen by several different providers and don’t have a continuity of care.

Also, there’s the expense. Bryce’s case is a good example. Gudgeon reluctantly took him to an urgent care facility, worried about exposure and frustrated because she felt her doctor knew Bryce best. His exam included a COVID test. “They barely looked in his ears, and we went home to wait for the results,” she said, and got no medicine to treat Bryce. The next day, she had a negative test and still a fussy, sick baby.

Urgent care facilities across the country are reporting higher numbers of patients, said Dr. Franz Ritucci, president of the American Board of Urgent Care Medicine. His clinic in Orlando, Florida, is seeing twice as many patients, both children and adults, as it did at this time last year.

“In urgent care, we’re seeing all comers, whether they are sick with COVID or not,” he said.

Meanwhile, ERs are seeing far fewer pediatric patients than usual, said Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians and the director of clinical services at Virtua Our Lady of Lourdes Emergency Department in Camden, New Jersey. Although adult emergency room visits have largely returned to pre-COVID levels, pediatric visits are 30% to 40% lower, he said. Sacchetti suspects several factors are at play, including fewer kids in daycare and school with less opportunity to spread illness and people avoiding emergency rooms for fear of the coronavirus.

“You see parents looking around the department and if someone clears their throat, you can look in their eyes and see the concern,” Sacchetti said. “We reassure them” that the precautions taken in hospitals will help keep them safe, he added.

Gudgeon considered taking Bryce to an emergency room, but she felt increasingly uncomfortable both with the thought of exposing him to another health care facility and the cost. In the end, she called an out-of-state doctor she had seen often years before moving to Illinois. That doctor phoned in an antibiotic prescription, and Bryce quickly improved, she said.

“I just wish he didn’t have to suffer for so long,” Gudgeon said.

Kressly hopes doctors become more creative in finding ways to provide direct care. She likes the “Swiss cheese” approach of layering several imperfect solutions to see patients and offer protection from COVID-19: screening for symptoms before the patient comes in, requiring everyone to wear masks, allowing only one caregiver to accompany a sick child and offering parking lot visits for sick kids in their cars.

Most important is good communication, Kressly said. Not only does that help the patient, it can also help protect the doctor from patients who may not want to admit they have COVID symptoms.

“We can’t create this barrier to care for uncomplicated, acute illnesses,” Kressly said. “This is not temporary. We all have to creatively figure out how to get patients and families connected to the right care at the right place at the right time.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Florida’s New Hospital Industry Head Ran Medicaid in State and Fought Expansion

With its choice of a new leader, the Florida Hospital Association has signaled that seeking legislative approval to expand Medicaid to nearly 850,000 uninsured adults won’t be among its top priorities.

In October, Mary Mayhew became the association’s CEO. Mayhew, who led the state’s Medicaid agency since 2019, has been a vocal critic of the Affordable Care Act’s Medicaid expansion adopted by 38 other states. She has argued that expansion puts states in a difficult position because the federal government is unlikely to keep its financial commitment to pay its share of the costs.

Had Medicaid been expanded in Florida, hospitals there would have gained thousands of paying patients. But the institutions have done little in recent years to persuade the Republican-led legislature and Gov. Ron DeSantis, also Republican, who oppose such a move.

Mayhew acknowledged in an interview with KHN that expanding Medicaid to cover more uninsured patients could help hospitals financially, especially at a time when facilities have seen demand for services decline as people avoid care for fear of contracting COVID-19.

With that in mind, she said, she is now open to the idea of expanding Medicaid. “We need to look at all options on the table,” she said. “Is it doable? Yes.”

Still, she was quick to point out concerns about whether Florida can afford to expand.

Under the ACA, the federal government pays 90% of the costs for newly enrolled Medicaid recipients. In the traditional Medicaid program — which covers children, people who are disabled and pregnant women — the federal government pays nearly two-thirds of Florida’s Medicaid costs.

“It will be financially challenging in our state budget as revenues have dropped,” Mayhew said, echoing comments of state officials. “That 10% cost has to come from somewhere.”

Mayhew’s hire worries advocates who have spent more than seven years lobbying lawmakers to expand Medicaid. Without strong support from the hospital industry, they fear they’re unlikely to change many votes.

“It may make it harder,” said Karen Woodall, executive director of Florida People’s Advocacy Center, a group that lobbies for policies to help low-income citizens. Marshaling hospital support is important, she said, because of the industry’s money and political clout.

In many state capitals, hospitals have led the fight for Medicaid expansion either by lobbying lawmakers or bankrolling ballot initiatives. The latest example was in Missouri, which this summer expanded Medicaid via a voter initiative. The campaign for the measure was partly funded by hospitals.

But in Florida, hospitals appear to have made a calculated decision to avoid pushing an initiative that Republican leaders have said they don’t want. Among the dozen states that have not expanded Medicaid, Florida is second only to Texas in the number of residents who could gain coverage.

Aurelio Fernandez, CEO of Memorial Healthcare System in Hollywood, Florida, who was chair of the hospital association board when it hired Mayhew, said her opposition to Medicaid expansion never came up in the process. The association hired Mayhew because of the “phenomenal job” she did guiding hospitals amid the COVID pandemic, he said.

“There is no appetite at this juncture [for the legislature] to expand the Medicaid program with Obamacare,” said Fernandez, despite his belief that expansion would help hospitals and patients.

Mayhew, sounding more like a state official than a hospital industry spokesperson, said the ultimate decision on expansion will be up to lawmakers, who must review spending priorities. When states face a financial crunch, lawmakers look to reduce spending in education and Medicaid, which are the biggest parts of the budget, she said.

“The last thing we want to see is the state budget balanced on the backs of hospitals with deep Medicaid reimbursement cuts,” Mayhew said.

Mayhew said her previous opposition to expanding Medicaid occurred when she was responsible for balancing the state budget and managing the programs in Florida and, before that, in Maine. When she ran Maine’s program, she said she opposed expanding Medicaid to allow nondisabled adults into the program while there were disabled enrollees already on waiting lists to get care.

The Florida Hospital Association, which represents more than 200 hospitals, spent years lobbying state lawmakers to expand Medicaid. But since DeSantis was elected in 2018, the group has focused on other issues because the governor and Republican lawmakers made clear they would not expand the program.

Asked what the association’s current position is on Medicaid expansion, Mayhew noted she has been in her job less than a month and “we have not had that policy decision by the board for me to answer that.”

Miriam Harmatz, executive director of the Florida Health Justice Project, an advocacy group, said Mayhew’s hire suggests that hospitals are unlikely to get behind a fledgling effort to put the expansion question to voters in 2022.

Others advocating for Medicaid expansion agree.

“It does not look like they [Florida’s hospitals] are on board with helping us expand Medicaid at the moment,” said Louisa McQueeney, program director of Florida Voices for Health, a consumer group helping with the ballot initiative.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Simpler bills, more payment options can improve hospital billing experience

A new survey from healthcare revenue cycle firm Waystar shows that most patients find their medical bills confusing and delay payment because of financial constraints. But there are steps hospitals can take to improve the billing experience for patients.

Reimaging population health at INVEST Pop Health Virtual: Register today

MedCity News is partnering with the New Orleans Business Alliance to host the executive summit November 16-18. It focuses on population health and highlights where innovation and investment are occurring in the field.

Listen: COVID Stresses Rural Hospitals Already ‘Teetering on the Brink’

When KHN Editor-in-Chief Elisabeth Rosenthal heard a sample of the voices that correspondent Sarah Jane Tribble brought back from her reporting trip to rural Kansas, Rosenthal said she knew the story needed to be told through audio.

That’s the genesis for “No Mercy,” season one of the podcast “Where It Hurts.” The series documents the fallout after Mery Hospital closed in Fort Scott, Kansas.

Rosenthal and Tribble were featured on the latest episode of Crooked Media’s “America Dissected: Coronavirus.”

“When a rural hospital shuts down, it’s much more than health care that’s lost. It was really pulling the fabric of this town apart economically and socially,” Rosenthal said.

Fort Scott is a town of about 8,000, and more than 200 people — from janitorial staff to physicians — lost their jobs when the hospital closed.

“The trickle-down effect of a major anchor institution in a rural community closing is not just from the hospital jobs but from all the jobs supporting the hospital,” said Tribble, who grew up in southeastern Kansas and is the host of “No Mercy.”

The coronavirus pandemic is an added stress for rural hospitals, she said.

“COVID, despite what Donald Trump has said, is not a good moneymaker. It is a money loser for hospitals,” Rosenthal said. “If you’re teetering on the edge, as these hospitals were, a massive pandemic that requires a lot of high-intensity care, that will not get reimbursed that well, is going to push you over the edge.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘No Mercy’ Chapter 7: After a Rural Town Loses Hospital, Is a Health Clinic Enough?

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Family physician Maxwell Self is doing his same old job for a new employer. For two decades he was a doctor with Mercy Hospital. But when Mercy packed up and left, a federally qualified health center moved to town — into the hospital building itself — and hired Dr. Self.

The Community Health Center of Southeast Kansas does things differently.

“What CHC says really has teeth and they’re solid,” Self said. “There’s real follow-through. And I have a lot more, I feel like, freedom to take care of people the way I want to and to get them what they need.”

With nutrition counseling and mental health and addiction services, and even things like arranging rides for patients, the center offers people what they need to be healthy, clinic executives said — not only health care for when they’re sick.

In the final chapter of the podcast, we also meet Sherise Beckham, 31, who lost work as a dietitian at Mercy when the hospital closed — just as she was expecting her second child.

“Initially, I cried a lot because I would be losing my job as well as losing a place to have my baby,” Beckham said.

Beckham helps explain how much more difficult it can be to have a baby when a town loses full-service maternity care. Then, later when she gets a job at — where else? — the new CHC clinic, Beckham gives us a front-row seat to the new vision for health care in Fort Scott.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A risk prediction model for Covid-19, developed by researchers at Cleveland Clinic, is now available to all health systems worldwide that use the Epic MyChart patient portal. The model will help clinicians estimate the likelihood of a patient testing positive for the disease.

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‘Is This Worth My Life?’: Traveling Health Workers Decry COVID Care Conditions


This story also ran on The Guardian. It can be republished for free.

David Joel Perea called from Maine, Vermont, Minnesota and, ultimately, Nevada, always with the same request: “Mom, can you send tamales?” Dominga Perea would ship them overnight.

That’s how she knew where her 35-year-old son was.

The traveling nurse had “a tremendous work ethic,” routinely putting in 80 hours a week, said his brother, Daniel.

But when Perea took a job at Lakeside Health & Wellness Suites — a Reno nursing home that has received dozens of safety citations since 2017 from the Centers for Medicare & Medicaid Services — Dominga was “scared silly.”

During Perea’s stint, nearly one-fifth of Lakeside’s residents were infected with COVID-19, according to state health records. Lakeside’s “top priority is the safety of those who live and work in our facility,” a spokesperson said.

When her son didn’t respond to her text on April 6, Dominga knew something was wrong. Perea had COVID-19. He died days later.

As COVID-19 surges across the country, health care systems continue to suffer critical shortages, especially among non-physician staff such as nurses, X-ray technicians and respiratory therapists.

To replenish their ranks, facilities have relied on “travelers” like Perea. Staff agencies have deployed tens of thousands nationally since March outbreaks in the Northeast.

Now the virus is tearing through rural areas — particularly in the Great Plains and Rocky Mountain states — stressing the limited medical infrastructure.

Rural hospitals have relied largely on traveling nurses to fill staffing shortages that existed even before the pandemic, said Tim Blasl, president of the North Dakota Hospital Association. “They find staff for you, but it’s really expensive labor,” he said. “Our hospitals are willing to invest so the people of North Dakota get care.”

The arrangement presents risks for travelers and their patients. Personnel ping-ponging between overwhelmed cities and underserved towns could introduce infections. As contractors, travelers sometimes feel tensions their full-time colleagues do not. Frequently employed by staffing agencies based thousands of miles away, they can find themselves working in crisis without advocates or adequate safety equipment.

In 2020, the upsides of their jobs — freedom and flexibility — have been dwarfed by treacherous conditions. Now the ranks of travelers are thinning: The work is exhausting, bruising and dangerous. Thousands of front-line health workers have gotten the virus and hundreds have died, according to reporting by KHN and The Guardian.

On April 17, Lois Twum, a 23-year-old traveling nurse from New Orleans, was one of four passengers on a flight to New York’s John F. Kennedy Airport.

When the self-described “adventure-seeking adrenaline junkie” arrived for her first shift at Columbia University’s Irving Medical Center, she said, she was assigned four patients on a COVID-19 unit. (Intensive care nurses typically care for two or three patients.) As these “constantly crashing” patients required resuscitations and intubations, “there was practically no one to help,” Twum said, because “everyone’s patient was critical.” The hospital did not respond to requests for comment on the workplace conditions and treatment of travelers.

Meanwhile, as hospital employees got sick, quit or were furloughed amid budget cuts, travelers picked up the slack. They were redeployed, Twum said, assigned more patients as well as the sickest ones.

“It was like we were airdropped into Iraq,” Twum said. “Travelers, we got the worst of it.”

On social media and in email groups, recruiters for travelers circulate photos of sun-splashed skylines or coastlines emblazoned with dollar signs, boasting salaries two or three times those of staff nurses. They promise signing bonuses, relocation bonuses and referral bonuses. They make small talk, ask about travelers’ families and suggest restaurants in new cities.

But when it comes to navigating workplace issues, “these people can just disappear on you,” said Anna Skinner, a respiratory therapist who has traveled for over a decade. “They are not your friends.”

Caught between the hospitals where they report for duty and remote staffing agencies, their worker protections are blurred.

For instance, under the Occupational Safety and Health Act, providing protective equipment is the agency’s responsibility — but the travelers who spoke with KHN said agencies rarely distribute any.

Perea’s family said they believe David did not have adequate PPE. His employer said it was the nursing home’s responsibility to provide it. “It is up to each of our clients to provide PPE to our staff while they are working assignments through MAS,” said Sara Moore, a spokesperson for Perea’s agency, MAS Medical Staffing.

Sometimes travelers are assigned to emergency rooms or intensive care units with which they have little experience. Skinner, a pediatric specialist, said she landed in adult ICUs when deployed to the University of Miami Health System in April. She received an hour of orientation, she said, but “nothing could have prepared me for what I had to deal with.”

Over five weeks, she said, she intubated one patient after another; suctioned the blood pouring into patients’ lungs and out of their noses and mouths; and dealt with families who were aghast, angry and afraid. Under the stress, Skinner said, she couldn’t sleep and lost weight. The hospital did not respond to requests for comment on workplace conditions for travelers.

Travelers often face “incredibly onerous” hurdles to the overtime, sick leave or workers’ compensation they are entitled to under the Fair Labor Standards Act, said Nathan Piller, a lawyer at Schneider Wallace Cottrell Konecky, an employment and business litigation firm.

Even the number of hours they can count on working is out of their control, Skinner said. Contracts reviewed by KHN authorize travelers to work a set number of hours, but only a fraction of those hours are guaranteed, and must be approved by on-site managers. The guaranteed hours may be compensated at rates hovering around minimum wage, and may require working holidays, which are not uniformly recognized.

The terms can be “modified from time to time during employment,” according to the contracts.

In 2018, AMN Healthcare, one of the country’s largest travel nursing agencies, agreed to a $20 million settlement for wage violations involving nearly 9,000 travelers. Violations “appear fairly commonplace across the industry,” said Piller, who worked on the settlement.

Travelers, Skinner said, are left to advocate for themselves to managers they might have just met — and “complaining just isn’t an option.”

KHN reviewed travel nursing contracts issued by Aya Healthcare, a large staffing agency, and found that any disputes — wrongful termination claims; claims of discrimination, harassment or retaliation; wage claims; and claims for violation of federal, state or other laws or regulations — must be settled out of court, in arbitration.

Officials at the Service Employees International Union, the American Nurses Association and National Nurses United said their constituents have been suspended or fired from traveling worker agencies for speaking to the news media, posting on social media or otherwise voicing concerns about unfair practices.

Matthew Wall, a longtime traveling nurse, knows this all too well. In July, two days into his assignment at Piedmont Henry Hospital in Stockbridge, Georgia, Wall said, he reported to hospital administrators “undeniably unsafe” conditions for himself and patients, including inadequate PPE, long hours and high patient-to-staff ratios.

Instead of addressing his concerns, Wall said, the hospital — which is under investigation by the federal government for workplace safety issues after another traveling nurse died of COVID-19 in mid-March — canceled his contract. “Travelers are treated like dog chow,” Wall said. “The second you become a liability, they dispose of you.”

“We continue to closely follow Centers for Disease Control and Prevention guidelines paired with our best practices in patient care and safety for all,” said John Manasso, a hospital spokesperson, who declined to comment on Wall’s case.

Some see an impossible choice. “We all know, if not for us, these patients would have no one,” Twum said, “but watching each other get sick left and right, it makes you wonder, is this worth my life?”

Skinner, for her part, took a job as a staff nurse in Aspen, Colorado. After his current contract in New Orleans ends, Wall is planning a break from nursing.

It was like we were airdropped into Iraq.

Lois Twum

Dominga Perea finally received a text back the night of April 6: “Don’t panic, Mama, I have the COVID.

“Pray for me.”

She saw David over FaceTime on Easter. “He struggled even eating mashed potatoes” she said, “because he couldn’t breathe.” The next morning he went on a ventilator and never woke up.

Months later, Lakeside hadn’t filled Perea’s position. “Ideal candidate must be a caring individual dedicated to providing high quality care,” the job listing read, and “able to react to emergency situations appropriately when required.”

KHN Mountain States editor Matt Volz contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘No Mercy’ Chapter 6: Trickle-Down Heartache Reaches the Next Generation in a Rural Town With No Hospital

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Josh is 17. He said he smokes marijuana. He struggles with anger.

He’s also juggling some extraordinary responsibilities for a teenager. Josh’s mother died of a drug overdose when he was 3 years old and he has lived with his grandparents ever since. When his grandfather’s heart started failing, Josh and his grandmother followed as his grandfather was shuttled from one regional hospital to another. The family couldn’t pay their light bill and struggled to find the money to pay for gas for the car. They wanted to stay nearby as Josh’s grandfather recovered in the hospital, but paying for a hotel was another financial burden.

Josh said he had to be there to help even though it meant missing school.

“I’m just taking care of my family. I’m doing what I was raised and taught to do,” he said. “Gotta survive. Family sticks together.”

To protect his privacy and because Josh was a minor when he shared his story, we are not including his last name.

In Chapter 6 of “No Mercy,” he talks about the health care challenges his family faces — and his own struggles growing up in a town where drugs are readily available but jobs aren’t.

The podcast also spotlights new health services now available in Fort Scott. Mercy Hospital, which closed at the end of 2018, did not provide addiction or behavioral health services, but the new community health center in town does.

“I get the privilege of working with hardworking, blue-collared folks and they oftentimes view, you know, depression, anxiety or bipolar disorder or battles with addiction as a weakness,” said Eric Thomason, director of addiction treatment and behavioral health services.

“And there’s no hardworking person that wants to just sit here and admit that they have a problem. And so a lot of times we avoid it. And what happens when we avoid chronic illness, regardless of if it’s diabetes, hypertension or depression, is it gets worse.”

Thomason said part of the health center’s work is convincing people to feel comfortable enough to come in and get help.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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¿Estás internado? Todavía puedes votar en gran parte del país

Johnathon Talamantes se rompió la cadera en un accidente de auto el 22 de octubre y se sometió a una cirugía cinco días después en un hospital público cerca del centro de Los Angeles.

Talamantes tendrá que estar en el hospital del condado de LA USC Medical Center hasta pasadas las elecciones, algo que le preocupaba antes de la cirugía.

“Una de las primeras cosas que le pregunté a mi enfermera esa mañana fue: ‘Oh, ¿cómo voy a votar?’”, contó Talamantes, de 30 años, el día antes de la operación.

Primero le pidió a su mamá que buscara la boleta electoral que había recibido tiempo antes, como todos los votantes registrados de California para esta elección.

Pero el personal de LAC + USC le dio otra opción: podían ayudarlo a obtener una boleta de emergencia y emitir su voto sin tener que levantarse de la cama. Entonces Talamantes le dijo a su mamá que no se molestara.

“No quiero que ella venga aquí, por las restricciones de COVID”, dijo.

La ley de California protege los derechos de los votantes que se encuentran en el hospital u otras instalaciones de atención, o confinados en sus hogares. Les permite obtener ayuda de cualquier persona que elijan, que no sea un empleador o un representante sindical, y emitir un voto de emergencia.

Al menos otros 37 estados permiten la votación de emergencia por razones médicas, según la Conferencia Nacional de Legislaturas Estatales. Pero las prácticas varían.

En algunos, solo los miembros de la familia pueden ayudar a los pacientes hospitalizados a votar desde el hospital.

En California, Nueva York y varios otros estados, los empleados y voluntarios del hospital pueden ayudar a un paciente a completar una solicitud de boleta de emergencia. Pueden recoger la boleta del paciente y enviarla a la oficina electoral o depositarla en un buzón oficial.

Por el contrario, en Carolina del Norte, que un trabajador de salud ayude a un paciente a votar es un delito.

En 18 estados, la ley permite que las juntas electorales locales envíen representantes directamente a las cabeceras de los pacientes, aunque seis de esos estados cancelaron ese servicio este otoño debido a la pandemia de COVID-19, dijo el doctor Kelly Wong, fundadora de Patient Voting, un organización no partidista dedicada a aumentar la participación entre los votantes registrados hospitalizados inesperadamente durante la época de las elecciones.

El sitio web del grupo tiene un mapa interactivo de los Estados Unidos con información estado por estado sobre la votación en el hospital. También permite a los pacientes verificar si están registrados para votar.

Wong, residente de la sala de emergencias del Hospital de Rhode Island en Providence, recordó que cuando era estudiante de medicina y trabajaba en una sala de emergencias, los pacientes que estaban a punto de ser ingresados ​​en el hospital le decían: “No puedo estar internado, tengo que cuidar a mi perro o atender a mi abuela”. Luego, durante las elecciones de 2016, escuchó: “No puedo quedarme. Tengo que ir a votar”.

“Eso realmente me llamó la atención”, dijo Wong. Investigó y descubrió que los pacientes podían votar en el hospital mediante una boleta de emergencia, algo que ninguno de sus compañeros de trabajo sabía. “Nuestros pacientes no saben esto. Debería ser nuestro trabajo decírselo”, dijo.

Algunos hospitales han estado ayudando a los pacientes a votar en las elecciones principales durante dos décadas o más, como parte de una tendencia en la industria de la atención médica hacia el compromiso cívico.

Las clínicas comunitarias registran a los votantes en sus salas de espera o en campañas de registro público. En un número cada vez mayor de salas de emergencia, los pacientes y sus familias tienen la oportunidad de registrarse. Muchos hospitales, incluido LAC + USC, tendrán unidades de votación móviles este año, abiertas a los miembros del personal, a los pacientes que están lo suficientemente bien para caminar y a sus familias.

Estos esfuerzos tienen como telón de fondo el papel protagónico de la atención médica en el acalorado drama político de la nación: COVID-19 se ha convertido en un tema principal de la campaña presidencial, mientras que la Corte Suprema de los Estados Unidos, más conservadora desde esta semana, se prepara para escuchar un caso, una semana después de las elecciones, que podría ser la sentencia de muerte para la Ley del Cuidado de Salud a Bajo Precio (ACA).

La pandemia ha hecho que la votación para los pacientes internados sea un desafío debido a las estrictas restricciones en los hospitales y a los muchos empleados que han sido despedidos, cesanteados o que trabajan desde la casa. Y un aumento significativo en la votación adelatanda y el uso de boletas por correo en muchos estados puede reducir la cantidad de pacientes que necesitan ayuda.

“La mayoría de nuestros pacientes, espero, ya habrán votado, porque eso aliviará el estrés; para ellos, es una cosa menos de qué preocuparse”, dijo Camille Camello, directora asociada de servicios de voluntariado en las casi 900 camas del Cedars-Sinai Medical Center en Los Angeles, que tiene un programa para ayudar a los pacientes hospitalizados a votar. Dijo que, en elecciones pasadas, más de 200 pacientes solicitaron boletas.

En LAC + USC, los administradores han intentado asegurarse de que los pacientes sepan que pueden obtener ayuda para votar. Hay carteles en los espacios comunes y el personal está repartiendo volantes con información sobre las votaciones a cada paciente que ingresa, dijo Gabriela Hernández, directora de servicios voluntarios del hospital.

Hernández dijo que ella y unos 25 voluntarios han estado visitando las distintas unidades durante el último mes, preguntando a los pacientes si quieren ayuda para votar.

Los pacientes que dicen que sí reciben solicitudes de boleta de emergencia, que el hospital ha estado enviando al área de registro de votos condado del condado de Los Ángeles para verificación. Las solicitudes de boleta seguirán estando disponibles para los pacientes hasta la mañana del día de las elecciones.

Hernández y su equipo recogerán las boletas y las distribuirán a los pacientes, luego las devolverán al registro antes de las 8 pm, fecha límite el día de las elecciones.

Otros hospitales tienen una agenda más apretada.

En St. Jude Medical Center en Fullerton, California, el personal del hospital está preguntando a los pacientes el lunes 2 de noviembre si quieren asistencia para votar y les traerán boletas el día de las elecciones, dijo Gian Santos, gerente de servicios voluntarios en el hospital. En las elecciones de 2016, solo unos siete u ocho pacientes votaron de esa manera, agregó Santos.

El Hospital St. Joseph en Orange, California, planea hacer todo -solicitudes y boletas- el mismo día de las elecciones.

Para los grandes hospitales, la votación de pacientes hospitalizados puede ser una tarea enorme. Las personas a menudo necesitan asistencia en varios idiomas y los hospitales suelen contratar servicios de traducción.

Muchos hospitales reciben pacientes de numerosos condados y de otros estados.

El Hospital Lenox Hill en Manhattan planea ayudar hasta a 200 pacientes de nueve condados en el estado de Nueva York y tres en Nueva Jersey, dijo Erin Smith, enfermera especializada en obstetricia que, junto con su colega Lisa Schavrien, está liderando el esfuerzo.

El hospital asignará uno o dos “corredores” a cada una de las 12 juntas electorales del condado, dijo Smith. Para ella, hacer que los pacientes vulnerables puedan ejercer su derecho al voto merece el esfuerzo.

“Si no los ayudamos, ¿cuántas miles de personas no van a votar en las elecciones porque sufrieron un accidente automovilístico, tuvieron apendicitis, o una cirugía cerebral inesperada?”, se preguntó Smith.

“Si no lo hacemos en el hospital, es como negarles el voto a los votantes”.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: David vs. Goliath: How to Beat a Big Hospital in Small Claims Court

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When Jeffrey Fox and his wife got an outrageous medical bill for a simple test, he said to his wife, “No way am I paying this.” In a classic — and hilarious — David vs. Goliath story, Fox takes on a huge hospital, and wins.

He’s a bit of an expert in using small claims court to get satisfaction and shared detailed instructions with the rest of us.

Fox doesn’t only take on big opponents. He said even his small wins are a way to get better at standing up for himself.

It’s pretty good practice for us all.

Want more? Here are some extras:

Our episode Can They Freaking DO That?!? describes how some folks have used just the threat of small claims court to get outrageous bills lowered.

Law professor Christopher Robertson describes some of the legal theory behind this method in this post from a Harvard Law School blog.

Fox posted documents from his case and a brief narrative.

Finally, here’s this episode transcript.

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

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Medicare Fines Half of Hospitals for Readmitting Too Many Patients

Nearly half the nation’s hospitals, many of which are still wrestling with the financial fallout of the unexpected coronavirus, will get lower payments for all Medicare patients because of their history of readmitting patients, federal records show.

The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between July 2016 and June 2019, so the flood of coronavirus patients that have swamped hospitals this year were not included.

The Centers for Medicare & Medicaid Services announced in September it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.

For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.

Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.

The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.

“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”

The penalties are based on readmissions of Medicare patients who initially came to the hospital with diagnoses of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.

A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.

The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.

Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.

“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospitalized? You Can Still Vote in Most Parts of the Country

Johnathon Talamantes, of South-Central Los Angeles, broke his hip in a car accident on Oct. 22 and underwent surgery five days later at a public hospital near downtown.

His post-op recovery will keep him in the hospital, L.A. County+USC Medical Center, beyond Election Day, and as he prepared himself for the surgery, he wondered what that would mean.

“One of the first things I asked my nurse this morning was, ‘Oh, how am I going to vote?’” Talamantes, 30, said from his hospital bed the day before the operation.

He initially thought of asking his mom to rummage through a pile of papers at the home he shares with her and bring him the mail-in ballot that he, like all registered California voters, received for this election.

But then staffers at LAC+USC told him about another option: They could help him get an emergency ballot and cast his vote without having to get out of bed. So Talamantes told his mom not to bother.

“I don’t want her coming down here, because of the COVID restrictions,” he said.

California law protects the rights of voters who are in the hospital or other care facilities, or confined at home. It allows them to get help from anyone they choose — other than an employer or a union representative — and to cast an emergency ballot.

At least 37 other states allow emergency voting for medical reasons, according to the National Conference of State Legislatures. But practices vary.

In some states, only family members can assist hospitalized patients with voting from the hospital.

In California, New York and several other states, hospital employees and volunteers can help a patient complete an emergency ballot application. They can pick up the ballot for the patient and deliver the finished ballot back to the election office or deposit it in an official drop box.

In North Carolina, by contrast, it is a felony for a health care worker to assist a patient with voting.

In 18 states, the law allows local election boards to send representatives directly to patients’ bedsides, though six of those states have canceled that service this fall because of the COVID-19 pandemic, said Dr. Kelly Wong, founder of Patient Voting, a nonpartisan organization dedicated to increasing turnout among registered voters unexpectedly hospitalized around election time.

The group’s website features an interactive map of the United States with state-by-state information on voting while in the hospital. It also allows patients to check whether they are registered to vote.

Wong, an emergency room resident at Rhode Island Hospital in Providence, recalled that when she was a medical student working in an ER, patients who were about to be admitted to the hospital would tell her, “‘I can’t be admitted; I have let the dogs out, or I’m the sole caretaker of my grandmother.’” Then during the election of 2016, she heard, “‘I can’t stay. I have to go vote.’”

“That really caught my attention,” Wong said. She did research and learned patients could vote in the hospital using an emergency ballot — something none of her co-workers knew. “Our patients don’t know this, she said. “It should be our job to tell them.”

Some U.S. hospitals have been assisting patients with voting in major elections for two decades or more, part of a broader tendency in the health care industry toward civic engagement.

Community clinics register voters in their waiting rooms or at public registration drives. In an increasing number of ERs, patients and their families are offered the chance to register. Many hospitals, including LAC+USC, this year will have mobile voting units on-site, open to staff members, patients who are well enough to walk, and their families.

These efforts come against the backdrop of health care’s starring role in the nation’s heated political drama: COVID-19 has become a top presidential campaign issue, while the U.S. Supreme Court, its conservative majority fortified this week, prepares to hear a case — one week after the election — that could be the death knell for the Affordable Care Act.

The pandemic has made inpatient voting a challenge because of tight restrictions at hospitals and the many employees furloughed, laid off or working at home. And a significant increase in early voting and the use of mail-in ballots in many states may reduce the number of patients who need help.

“The majority of our patients, I am hoping, will have voted already, because that will alleviate the stress — for them, it’s one less thing to worry about,” said Camille Camello, associate director of volunteer services at the nearly 900-bed Cedars-Sinai Medical Center in Los Angeles, which has a program to help inpatients vote. In past elections, she said, over 200 patients have requested ballots.

At LAC+USC, administrators have been trying to ensure patients know they can get help voting. Posters line the walls of common spaces and staffers are handing out flyers with voting information to every patient who is admitted, said Gabriela Hernandez, the hospital’s director of volunteer services.

Hernandez said she and about 25 volunteers have been walking the halls in the inpatient units of the hospital for the past month, asking patients if they want help voting.

Patients who say yes get emergency ballot applications, which the hospital has been sending to the L.A. County Registrar-Recorder for verification. The ballot applications will continue to be made available to patients up to the morning of Election Day.

Hernandez and her team will collect the ballots and distribute them to patients, then return them to the registrar before the 8 p.m. deadline on Election Day.

Other hospitals have a more collapsed timeline.

At St. Jude Medical Center in Fullerton, California, hospital staffers will start asking patients Monday if they want voting assistance and bring them ballots on Election Day, said Gian Santos, manager of volunteer services at the hospital. In the 2016 election, only about seven or eight patients voted that way, Santos said.

St. Joseph Hospital in Orange, California, plans to do everything — applications and ballots — on Election Day.

For big hospitals, inpatient voting can be a massive undertaking. People often require assistance in multiple languages, and the hospitals frequently contract with translation services to accommodate them.

Many hospitals receive patients from numerous counties — and across state lines.

Lenox Hill Hospital in Manhattan plans to assist as many as 200 patients from nine counties in New York state and three in New Jersey, said Erin Smith, an obstetrical nurse navigator who, along with fellow OB nurse navigator Lisa Schavrien, is leading the effort.

The hospital will assign one or two “runners” to each of the 12 county election boards, Smith said. For her, enabling vulnerable patients to exercise their right to vote is worth the effort.

“If we’re not helping them do it, how many thousands of people are not voting in elections because they were in a car accident, because they had appendicitis, because they had unexpected brain surgery?” Smith asked.

“If we’re not making it happen in the hospital, it kind of feels to me like voter suppression.”



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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RWJBarnabas Health’s new program aims to identify social barriers to care without stigmatizing patients

social determinants of health,

The New Jersey-based health system’s culturally nuanced social determinants of health program will screen all patients for social and behavioral factors that impact their health, in the hopes of improving outcomes and encouraging appropriate use of healthcare services.

‘No Mercy’ Chapter 5: In Rural America, Cancer Care Is Often Far From Home

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Sixty-five-year-old Karen Endicott-Coyan is living with a blood cancer.  Her chemotherapy takes less than 30 minutes. Before the hospital closed, it was just a short drive into the small town of Fort Scott, Kansas, for her to get treatment.

But these days getting to chemo means a trek on rural roads and narrow highways, driving help from her sister-in-law and some Ritz crackers tucked into her purse to steady her stomach on the way home. The whole trip should take less than three hours. Endicott-Coyan puts on her makeup, her diamond earrings and powers through.

“If I can help it, I’m not going to go over there looking like a sick person,” Endicott-Coyan said. “I don’t like looking like a sick person. That’s just me.”

Endicott-Coyan had a long career in hospital administration, and she uses that expertise to try to smooth out her newly fractured health care. But during every minute of the trip, a nagging worry at home steals her energy and attention. In this chapter of the podcast, host-reporter Sarah Jane Tribble goes along for the ride and is witness to the stress and frustration.

The journey illuminates one reason people in rural America are more likely to die from cancer than patients in metro areas.

Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Healthcare CIO survey reveals how Covid-19 is impacting startup collaboration

light bulb, innovation, idea

A new survey finds that health system leaders are actively seeking new commercial relationships with startups regardless of when “normal” returns but startup success hinges on not only addressing solutions that are on health systems’ shortlist but also data supporting a clear ROI.

How is population health innovation unfolding in Louisiana? [Sponsored]

With the annual INVEST Population Health virtual conference coming up November 16-18, here’s a look at our collaboration partner New Orleans Business Alliance. It plays a vital role in helping to stimulate the local economy by supporting the development and advancement of the healthcare and biotech infrastructure.

North Carolina Treasurer Took On the Hospitals. Now He’s Paying Political Price.

Cartel is a term frequently associated with illegal narcotics syndicates. In North Carolina, it has become the favored word of State Treasurer Dale Folwell to describe the state’s hospital industry, the antagonist in his quest to lower health care prices for state employees.

The treasurer manages the state employees’ health plan, which insures about 727,000 teachers, police officers, current and retired state workers and dependents. Folwell, a Republican, has tried to persuade hospitals to accept lower payments, but he has struggled to discover the existing rates the plan pays each hospital.

“These organizations’ business model is secrecy,” Folwell said, “from the billing all the way up to the way these hospitals’ organizations receive their tax-exempt status.”

Now, as Folwell, 62, seeks a second four-year term, the state’s hospitals are coming after him.

The North Carolina Healthcare Association, the hospital trade group, has endorsed Folwell’s Democratic challenger. It is a rare instance of a health care lobby seeking to topple an incumbent. Over 26 years, North Carolina’s hospital association donated $2.1 million to sitting officeholders but bestowed just $29,700 to challengers, according to a tally from the National Institute on Money in Politics, a Montana-based nonprofit. All donations made this year will not be fully disclosed until after the election.

In many states, hospital associations are political powerhouses, with stables of lobbyists and the influence that comes with often being the largest employer in many legislative districts. In the previous election cycle of 2018, the hospital industry across the country donated $71 million to local and state candidates, political parties and ballot initiatives, according to the Money in Politics data. That amounted to a fifth of all spending by the health care industry and nearly three times that spent by pharmaceuticals and health products companies.

“The hospitals have very strong political clout in North Carolina, and increasingly so as they get bigger,” said Aaron McKethan, a resident scholar at the Margolis Center for Health Policy at Duke University’s Fuqua School of Business. “They are huge sources of employment. If anything, COVID has reinforced and strengthened them — the job of wagging your finger at hospitals over their prices has gotten harder.”

Nationally, hospitals account for a third of health care spending. The prices hospitals charge private insurers including the state health plan are driving much of the increase in health care premiums. In North Carolina, hospital inpatient prices for private insurers rose by 10% from 2014 to 2018, according to the Health Care Cost Institute.

Folwell’s critics complain that, despite his verbal provocations about hospital power, his efforts to transform health care pricing have mostly fizzled. They also lament that he has made no effort to try to persuade the legislature to expand Medicaid, which would help shore up hospital finances.

“The treasurer has, for some reason, insisted on taking a ‘my way or the highway’ approach, rather than engage in honest conversations and negotiations,” Cynthia Charles, the hospital association’s spokesperson, said in an email. “As we have repeatedly said, we are willing to work together to redesign the plan in a manner to advance goals for cost reductions, price transparency and provider inclusion.”

Folwell’s Democratic challenger, Ronnie Chatterji, and the hospital industry insist a better way to bring health costs under control would be to tie payments to the quality of care, an approach Blue Cross and Blue Shield of North Carolina has begun experimenting with. With blunt cuts, “you’re just going to put people’s health care access in jeopardy,” said Chatterji, an economist at the Fuqua School who served on former President Barack Obama’s Council of Economic Advisers.

The bad blood between Folwell and North Carolina hospitals primarily traces back to 2018, when the treasurer told hospitals, doctors and other medical providers that to avoid having to ask the legislature for more money or raise employee contributions, he wanted to reduce by $300 million the amount the $3.3 billion health plan paid medical providers each year.

Folwell proposed to base prices on Medicare rates, an approach known as reference pricing. His plan offered to pay most hospitals 175% of what Medicare reimbursed them for inpatient services and 225% for outpatient services, on average. Rural hospitals, which tend to be in worse financial shape, would have received more, but their rates would also have been pegged to Medicare.

The plan would have amounted to a pay cut for most hospitals. A recent Rand Corp. study of hospital prices found that North Carolina hospitals in 2018 were paid on average 221% of Medicare rates for inpatient services and 334% of Medicare rates for outpatient services — well above what the treasurer was proposing.

The state’s two big nonprofit systems, Atrium Health and Novant Health, earned substantially more, according to the Rand data. For example, Atrium Health Mercy hospital in Charlotte collected 423% of Medicare outpatient prices. Forsyth Medical Center in Winston-Salem, owned by Novant, collected 377% of what Medicare paid for outpatient services.

In its newsletter, the hospital association told its members that it tried to negotiate with the treasurer but that “Folwell has responded with disinterest and hostility towards these overtures and is instead engaging in a public campaign to malign hospitals.”

The hospitals warned customers that if no agreement could be reached with the state plan, the hospitals would be classified as out-of-network providers and state employees would end up having to pay far more for their services.

Those arguments about financial penury obscured the fact that North Carolina’s major hospital systems run huge surpluses in most years. Financial disclosure documents show that Atrium, which owns 36 hospitals in the state, ended 2019 with a $370 million surplus, a 6% margin. Novant, which owns 12 hospitals in North Carolina, that year earned $155 million, a 3% margin.

UNC Health, which amassed $271 million — a 6.4% margin — in its 2019 fiscal year, said in a statement that the treasurer’s plan would have cost it $47 million in its 2020 fiscal year and “jeopardized the financial viability of some of our rural hospitals.”

“We’re overpaying for no reason but to build multimillion reserves for these hospital corporations,” said Ardis Watkins, executive director of the State Employees Association of North Carolina.

Ultimately, the hospitals maintained a solid wall of opposition. Only three of North Carolina’s 108 hospitals signed on to the treasurer’s plan.

Duke’s McKethan said it was “predictable” that the hospitals would refuse to give up the negotiating advantages they held. “On the diagnosis of the problem — we’ve got these opaque prices that vary — he’s on solid ground,” he said about Folwell. “But when a good idea runs into the disadvantageous structure of the health care market, it doesn’t go anywhere.”

Apart from hospitals, the treasurer had some success in persuading about 25,000 of the state’s 60,000 doctors, therapists and other medical providers to accept the new payment system, which he named the Clear Pricing Project. Dr. Dale Owen, CEO of Tryon Medical Partners, a large independent physicians’ group based in Charlotte, said his group’s reimbursements will come out about the same under the plan.

“Quite honestly, even if it had been a tiny loss, no big deal because it was the right thing to do for everybody,” said Owen, who formed his group with fellow physicians who seceded from Atrium. “What he’s doing is, he’s opening a sore and a problem that people have not been willing to deal with and pushed under the rug.”

The Clear Pricing Project has yet to demonstrate the ability to save the state money. In fact, the effort may be costing the state more because many of the providers that signed on — such as primary care doctors and behavioral health specialists — are getting higher reimbursements than they had been while those that would have lost money, like hospitals, have stayed away.

Asked why he thought the hospitals would volunteer to forgo higher payments, Folwell said he had hoped they would realize that their long-term survival is endangered by the unsustainable increase in health care costs.

“I thought they would want to be partnering with a solution instead of the same old way,” he said in an interview. “I don’t think they accept the notion that they’re going to be on the wrong side of history.”

The hospital industry has been taking steps to try to make Folwell and his proposal history. During his attempt to get hospitals to agree to the pricing plan, the industry’s allies in the legislature introduced a bill that would have blocked the state health plan from instituting any reference pricing plan through 2021. That effort ultimately died.

Folwell has continued to rankle the hospitals with his opposition to further concentration of hospital ownership. He has opposed the pending sale of a county-owned hospital based in Wilmington, which Novant is purchasing. That followed his 2018 attempt to challenge an ultimately unsuccessful merger of Atrium and UNC Health by requesting a $1 billion performance bond if the deal ultimately raised prices for the state health plan.

Last month, the hospital association gave Chatterji its endorsement with a clear swipe at Folwell. The association’s president, Steve Lawler, said in the statement that “it is apparent that Mr. Chatterji genuinely wants to collaborate.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Technology can ease pandemic challenges faced by hospitals, ambulatory surgery centers

To keep critical revenue flowing, hospitals and ambulatory surgery centers need to resume elective surgeries and procedures as quickly as possible and mobile apps can help by giving patients and staff vital information, provide advance symptom screening and help providers reduce elective procedure no-shows through better patient compliance.

340B hospitals and for-profit pharmacies generating significant revenue from program meant to help needy patients

The 340B program – a safety-net federal drug program meant to help vulnerable Americans – has become dominated by many large hospitals and for-profit corporations with no clear evidence they are always helping needy patients. At a time when too many Americans struggle to access the medicines and care they need, it is alarming to see 340B being taken so far off course from what Congress intended as the program’s goal.

Survey found insurance premiums grew faster than inflation in 2020

According to Kaiser Family Foundation’s recent survey on employer health benefits, premiums for people with employer-sponsored health insurance increased by 4% last year, faster than both the rate of wage growth and inflation. During this same time, prices for brand medicines increased just 1.7% after accounting for rebates and discounts, less than the rate of inflation for the third year in a row.

‘No Mercy’ Chapter 4: So, 2 Nuns Step Off a Train in Kansas … A Hospital’s Origin Story

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Ever since Mercy Hospital went “corporate,” things just haven’t been the same — that’s what lots of locals in Fort Scott, Kansas, said when the Mercy health system shuttered the only hospital in town.

It’s been years since Catholic nuns led Mercy Hospital Fort Scott, but town historian Fred Campbell is wistful for his boyhood in the 1940s when sisters in habits walked the hallways.

“Well, I had never, ever been in a hospital. And here came these ladies in flowing robes and white bands around their faces. And I was scared to death. But it wasn’t long ’til I found that, first thing I know, they had some iced Coca-Cola. I still remember them putting their hand on my head to see if I had a fever.”

For more than 100 years, Mercy Hospital — and the nuns who started it all — cared for local people. But in recent years, Fort Scott’s economy and the hospital’s finances faltered. Campbell hoped both could survive.

“Mercy Corporation, can you stay with us longer?” he wondered.

In Chapter 4 of Season One: No Mercy, podcast host Sarah Jane Tribble carries that question to Sister Mary Roch Rocklage, the powerhouse who consolidated all the Mercy hospitals in the Midwest.

Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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UVA Health Still Squeezing Money From Patients — By Seizing Their Home Equity

Doris Hutchinson wanted to use money from the sale of her late mother’s house to help her grandchildren go to college.

Then she learned the University of Virginia Health System was taking $38,000 of the proceeds because a 13-year-old medical bill owed by her deceased brother had somehow turned into a lien on the property.

“It was a mess,” she said. “There are bills I could pay with that money. I could pay off my car, for one thing.”

Property liens are the hidden icebergs of patient medical debt, legal experts say, lying unseen, often for decades, before they surface to claim hard-won family savings or inheritance proceeds.

An ongoing examination by KHN into hospital billing and collections in Virginia shows just how widespread and destructive they can be. KHN reported a year ago that UVA Health had sued patients 36,000 times over six years for more than $100 million, often for amounts far higher than what an insurer would have paid for their care. In response to the articles, the system temporarily suspended patient lawsuits and wage garnishments, increased discounts for the uninsured and broadened financial assistance, including for cases dating to 2017.

Those changes were “a first step” in reforming billing and collection practices, university officials said at the time.

However, UVA Health continues to rely on thousands of property liens to collect old bills, in contrast to VCU Health, another huge, state-owned medical system examined by KHN. VCU Health pledged in March to stop seizing patients’ wages over unpaid bills and to remove all property liens, which are created after a creditor wins a court judgment.

Working courthouse-by-courthouse, VCU Health now says it has discovered and released 45,000 property liens filed against patients just in Richmond, its home city, some dating to the 1990s. There are an estimated 35,000 more in other parts of the state. Fifteen thousand of those have been canceled and they are working on the rest, officials said. These figures have not been previously reported. The system is part of Virginia Commonwealth University.

VCU Health’s total caseload is “a huge number” but perhaps not astonishing given the energy with which many hospital systems sue their patients, said Carolyn Carter, deputy director of the National Consumer Law Center.

Despite having suspended patient lawsuits, UVA Health has continued to create property liens based on older court cases, court records show. The number of new liens is “small,” said UVA Health spokesperson Eric Swensen.

An advisory council of UVA Health officials and community leaders is expected to deliver new recommendations by the end of October, Swensen said. The council, whose schedule has been slowed by the coronavirus crisis, has discussed property liens, Don Gathers, an activist and council member, said in an interview this summer.

Nobody knows how many old or new UVA Health liens are scattered through scores of Virginia courthouses. The health system, which has sued patients in almost every county and city in the state, has failed to respond to repeated requests over two years to disclose the number and value of its property liens.

But in Albemarle County alone, which surrounds the university’s Charlottesville home, “there are thousands” of UVA Health judgments filed in the land records, which creates a lien, said Circuit Court Clerk Jon Zug.

Not just Virginia homes are at risk. UVA Health lawyers search the nation for property or other assets owned by patients with outstanding bills and have filed liens in Maryland, West Virginia, Ohio and Florida, court records show.

The system put a lien on a Nevada vacation condo owned by Veronica Musie’s family a decade ago over a $30,600 hospital bill, said Musie, who lives in northern Virginia. The family has since paid the debt.

Virginia property liens expire after 20 years. But UVA Health often renews them. Since 2017, just in Albemarle County, it has renewed more than three dozen liens. That means the medical system could seize families’ home equity until 2039 for bills dating to the last century.

UVA Health and other medical systems rarely force the sale of a home to claim money. Instead, they wait for families to refinance or sell, taking their cut at the settlement table. But with 6% simple interest accumulating year after year after the court judgment, as allowed by Virginia law, the final amount owed can be much more than the original charges.

UVA Health treated Hutchinson’s brother for heart disease in the early 2000s. The unpaid bill was $24,868. The system laid claim to their mother’s home because he was one of her heirs. The claim is up to $38,000 now, she said, because of interest charges. Hutchinson has been disputing it for more than a year.

VCU Health and its MCV Physicians affiliate estimate that eliminating two decades of property liens in courthouses across the state, which they began to do last year after KHN published its reports, won’t be finished until spring.

Richmond was especially problematic. Because releasing 40,000 Richmond liens by hand would have been impractical, VCU Health got a judge’s permission to do it with computer code.

Creditors such as UVA and VCU don’t need addresses to create liens. All they have to do is file a judgment in county or city land records. If debtors own any property there, title companies won’t approve a sale until the debt is paid, often with home equity.

Often owners don’t know debts exist until paralegals unearth them when homes are sold, property pros say. Old debts can create liens on newly acquired real estate.

“It could be your grandmother’s house, and as soon as you’ve inherited it, and you’ve got judgments, those [liens] are now attached,” said Richmond Court Clerk Edward Jewett.

Frequently debtors own no property, so judgments in the land records expire without hospitals or other creditors getting anything.

VCU and MCV had no idea how many liens they had placed across the state until they began investigating last year after KHN’s inquiries, officials said.

“It’s an incredibly manual process” to cancel the claims, partly because computer systems at many courthouses prohibit an easy tech solution, said Melinda Hancock, VCU Health’s chief administrative and financial officer. But it’s worth it to remove a burden on patients, she said, adding, “This is an outdated collections practice whose time has come and gone.”

But many medical systems still do it, consumer debt experts say, noting that obtaining a complete picture of hospital property liens is impossible.

Land and judgment records are held by thousands of local court clerks, often using separate computer systems. Records are difficult or impossible to obtain in bulk.

“There is not a good nationwide study that I know of that looks at how widespread this is, how many consumers are affected, what’s the average size of a lien,” said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing.

Mike Miller and Kitt Klein are among those hoping UVA Health follows VCU Health in canceling thousands of property liens. They fear a $129,000 judgment won by UVA in 2017 against Miller will cost them the equity in their home in Quicksburg, Virginia.

They make about $25,000 a year. Miller, a house painter, was insured but received out-of-network radiation at UVA that doctors said was necessary to treat his lung cancer.

After KHN wrote about his case a year ago, benefits firm WellRithms analyzed his UVA bill and found that a commercial insurer would have paid a little more than $13,000, not $129,000, for the treatment.

“We know all [health care] providers bill a lot, but usually ‘a lot’ is three to six times what reasonable prices would be,” said Jordan Weintraub, vice president of claims for WellRithms. Trying to collect 10 times as much, she said, “is really out there.”

UVA Health does not comment on individual patient cases, Swensen said.

KHN found last year that UVA frequently sued patients for far more than what the system could have collected from insurance.

Early this year Miller and Klein emailed UVA President James Ryan, asking for help in reducing or eliminating the judgment. His office phoned in February, saying it would review the case.

“I became very emotional, filled with gratitude,” Klein said. “I couldn’t talk.”

Months went by with no contact. Recently a lawyer from the office of Virginia Attorney General Mark Herring offered to settle the case for $120,000, Klein said, reducing the bill by only $9,000. They don’t have the money. Miller’s cancer has returned. Interest is mounting at 6%.

University officials do not comment on legal matters or individual cases, a Ryan spokesperson said. Herring’s office did not respond to requests for comment.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Medicare Accelerated and Advance Payments for COVID-19 Revenue Loss: More Time to Repay

This brief provides an overview and status update of the Medicare accelerated and advance payment program, which provided $100 billion in loans to Medicare providers in the spring of 2020 to compensate for revenue shortfalls due to the coronavirus pandemic. The brief describes who got the funds, and how these loans are distinct from other funds that providers received, which do not have to be repaid.

Moved by Plight of Young Heart Patient, Stranger Pays His Hospital Bill

Even with insurance, Matthew Fentress faced a medical bill of more than $10,000 after a heart operation. A cook at a senior living community in Kentucky, he figured he could never pay what he owed — until a stranger who lives 2,000 miles away stepped in to help.

“The system still failed me,” said Fentress, 31. “It was humanity that stepped up.”

Karen Fritz, a retired college professor in Las Vegas, saw part of his story on “CBS This Morning,” which partners with KHN and NPR on the crowdsourced Bill of the Month investigation. Fritz found the story online, and then she called the hospital to donate $5,000 toward Fentress’ bill.

“I’ve been a young person in college with medical bills. I just really felt convicted to help him out, to help him get beyond his financial struggles. I had no hesitation; I felt led by the Holy Spirit to do that,” said Fritz, 64, who taught business and marketing at various schools. “When you help other people, it gives you joy.”

Fentress was just 25 when doctors diagnosed him with viral cardiomyopathy, a heart disease that developed after a bout of the flu. In his six years of grappling with that chronic condition, which could lead to heart failure, he had already been sued by his hospital after missing a payment and declared bankruptcy.

Financial fears reignited this year when his cardiologist suggested he undergo an ablation procedure to restore a normal heart rhythm. He said hospital officials at Baptist Health Louisville assured him he wouldn’t be on the hook for more than $7,000, a huge stretch on his $30,000 annual salary.

Though the procedure went well, the bill filled him with dread. His portion totaled more than $10,000 for the ablation and related visits in 2019 and 2020. After an adjustment, a spokesperson for his insurer, United Healthcare, said he owed nearly $7,900. That was the same as the annual out-of-pocket maximum for in-network care under his plan, which also included a $1,500 annual deductible. Like millions of other Americans, Fentress is considered underinsured.

Fentress said he learned about Fritz’s donation when he got a call from a hospital representative. He submitted a recent pay stub to the hospital, and its financial aid program covered the rest.

Hospital officials said Fentress at one point had been under the incorrect impression that he’d have to pay big monthly payments and couldn’t apply for financial assistance because he’d gotten it before.

“Baptist Health consistently has encouraged Mr. Fentress to apply for financial assistance to provide the information we need to determine a qualifying amount,” Charles Colvin, Baptist Health’s vice president for revenue strategy, said in a statement. “We are pleased to have received the additional information needed to provide that financial assistance.”

Fentress said he’s incredibly grateful to Fritz. He plans to stay in touch with her, and he’s sending her a T-shirt he designed with a picture of a heart and the words “Be nice.”

“This is the first time ever since I was 25 that I haven’t had medical debt. It’s a wonderful feeling. It gives me a lot of peace of mind,” Fentress said. “But I feel guilty that a lot of other people are still suffering.”

Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘No Mercy’ Chapter 2: Unimaginable, After a Century, That Their Hospital Would Close

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Closing a hospital hurts. In Fort Scott, Kansas, no one was a bigger symbol for that loss — or bigger target for the town’s anger — than hospital president Reta Baker. Baker was at the helm when the hospital doors closed.

“I don’t even like going out in the community anymore, because I get confronted all the time,” Baker said. “Someone confronted me at Walmart. You know — ‘How could you let this happen?’”

The closure put Baker at bitter odds with City Manager Dave Martin, who some in town call “the Little Trump” of Fort Scott. Martin said his town wasn’t given the chance to keep the hospital open.

Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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How Hospital Innovation is Changing Amidst a Pandemic: Video from MedCity Invest Digital Health

We’re making video segments from our INVEST Digital Health conference available for viewing. The first of these installments is a panel discussion on innovation in hospital settings during the public health crisis.

CMS to penalize hospitals, labs that don’t report Covid-19 data

New rules by the Center for Medicare and Medicaid Services would penalize hospitals and laboratories that report Covid-19 data. Hospitals would be required to report the number of confirmed or suspected Covid-19 patient, occupied beds, and availability of ventilators and other critical supplies.

Another COVID Mystery: Patients Survive Ventilator, But Linger in a Coma

Leslie Cutitta said yes, twice, when clinicians from Massachusetts General Hospital in Boston called asking whether she wanted them to take — and then continue — extreme measures to keep her husband, Frank Cutitta, alive.

The first conversation, in late March, was about whether to let Frank go or to try some experimental drugs and treatments for COVID-19. The second call was just a few days later. Hospital visits were banned, so Leslie couldn’t be with her husband or discuss his wishes with the medical team in person. So she used stories to try to describe Frank’s zest for life.

“Frank used to joke that he wanted to be frozen, like Ted Williams, until they could figure out what was wrong with him if he died,” said Leslie Cutitta. It wasn’t a serious end-of-life discussion, but Cutitta knew her husband would want every possible lifesaving measure deployed.

So the Cutittas hung on and a small army of ICU caregivers kept working. On April 21, after 27 days on a ventilator, Frank’s lungs had recovered enough to remove the breathing tube.

After the removal, it typically takes hours, maybe a day, for the patient to return to consciousness. The body needs that time to clear the drugs that keep the patient sedated and comfortable — able to tolerate intubation and mechanical ventilation.

But doctors across the U.S. and in other countries have noted a troubling phenomenon associated with some COVID cases: Even after extubation, some patients remain unconscious for days, weeks or longer. There’s no official term for the problem, but it’s being called a “prolonged” or “persistent” coma or unresponsiveness.

Frank Cutitta, 68, was one of those patients. He just didn’t wake up.

“It was a long, difficult period of not — just not knowing whether he was going to come back to the Frank we knew and loved,” said Leslie Cutitta. “It was very, very tough.”

Doctors studying the phenomenon of prolonged unresponsiveness are concerned that medical teams are not waiting long enough for these COVID-19 patients to wake up, especially when ICU beds are in high demand during the pandemic.

As Frank’s unresponsive condition continued, it prompted a new conversation between the medical team and his wife about whether to continue life support. Although he no longer needed the ventilator, he still required a feeding tube, intravenous fluids, catheters for bodily waste and some oxygen support.

Leslie Cutitta recalled a doctor asking her: “If it looks like Frank’s not going to return mentally, and he’s going to be hooked up to a dialysis machine for the rest of his life in a long-term care facility, is that something that you and he could live with?”

She struggled to imagine the restricted life Frank might face. Every day, sometimes several times a day, she would ask Frank’s doctors for more information: What’s going on inside his brain? Why is this happening? When might something change?

Their candid and consistent answer was: We don’t know.

“Because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it will take any individual patient to recover consciousness,” said Dr. Brian Edlow, a critical care neurologist at Mass General.

Given all the unknowns, doctors at the hospital have had a hard time advising families of a patient who has remained unresponsive for weeks, post-ventilator. Some families in that situation have decided to remove other life supports so the patient can die. Edlow can’t say how many.

“It is very difficult for us to determine whether any given patient’s future will bring a quality of life that would be acceptable to them,” Edlow said, “based on what they’ve told their families or written in a prior directive.”

Theories abound about why COVID-19 patients may take longer to regain consciousness than other ventilated patients, if they wake up at all. COVID-19 patients appear to need larger doses of sedatives while on a ventilator, and they’re often intubated for longer periods than is typical for other diseases that cause pneumonia. Low oxygen levels, due to the virus’s effect on the lungs, may damage the brain. Some of these patients have inflammation related to COVID-19 that may disrupt signals in the brain, and some experience blood clots that have caused strokes.

“So there are many potential contributing factors,” Edlow said. “The degree to which each of those factors is playing a role in any given patient is still something we’re trying to understand.”

One of the first questions researchers hope to answer is how many COVID-19 patients end up in this prolonged, sleeplike condition after coming off the ventilator.

“In our experience, approximately every fifth patient that was hospitalized was admitted to the ICU and had some degree of disorders of consciousness,” said Dr. Jan Claassen, director of neurocritical care at New York’s Columbia University Medical Center. “But how many of those actually took a long time to wake up, we don’t have numbers on that yet.”

An international research group based at the University of Pittsburgh Medical Center expects to have in September some initial numbers on COVID-19 brain impacts, including the problem of persistent comas. Some COVID patients who do eventually regain consciousness still have cognitive difficulties.

To try to get a handle on this problem at Columbia, Claassen and colleagues created a “coma board,” a group of specialists that meets weekly. Claassen published a study in 2019 that found that 15% of unresponsive patients showed brain activity in response to verbal commands. A case reported by Edlow in July described a patient who moved between a coma and minimal consciousness for several weeks and was eventually able to follow commands.

This spring, as Edlow observed dozens of Mass General COVID-19 patients linger in this unresponsive state, he joined Claassen and other colleagues from Weill Cornell Medical College to form a research consortium. The researchers are sharing their data to determine the cause of prolonged coma in COVID-19 patients, find treatments and better predict which patients might eventually recover, given enough time and treatment.

The global research effort has grown to include more than 222 sites in 45 countries. Prolonged or persistent comas are just one area of research, but one getting a lot of attention.

Dr. Sherry Chou, a neurologist at the University of Pittsburgh Medical Center, is leading the international effort.

Chou said families want to know “whether a patient can wake up and be themselves.” Answering that question “depends on how accurate we are at predicting the future, and we know we’re not very accurate right now.”

A CT scan of Frank Cutitta’s brain showed residue from blood clots but was otherwise “clean.”

“From what they could tell, there was no brain damage,” Leslie Cutitta said.

And then, on May 4, after two weeks with no signs that Frank would wake up, he blinked. Leslie and her two daughters watched on FaceTime, making requests such as “Smile, Daddy” and “Hold your thumb up!”

“At least we knew he was in there somewhere,” she said.

It was another week before Frank could speak and the Cutittas got to hear his voice.

“We’d all be pressing the phone to our ears, trying to catch every word,” Leslie Cutitta recalled. “He didn’t have a lot of them at that point, but it was just amazing, absolutely amazing.”

Frank Cutitta spent a month at Spaulding Rehabilitation Hospital. He’s back home now, in a Boston suburb, doing physical therapy to strengthen his arms and legs. He said he slurs words occasionally but has no other cognitive problems.

While he was in the ICU, Cutitta’s nurses played recorded messages from his family, as well as some of his favorite music from the Beach Boys and Luciano Pavarotti. Frank Cutitta said he believes the flow of these inspiring sounds helped maintain his cognitive function.

The Cutittas said they feel incredibly lucky. Leslie Cutitta said one doctor told the family that during the worst of the pandemic in New York City, most patients in Frank’s condition died because hospitals couldn’t devote such time and resources to one patient.

“If Frank had been anywhere else in the country but here, he would have not made it,” Leslie Cutitta said. “That’s a conversation I will never forget having, because I was stunned.”

Frank Cutitta credits the Mass General doctors and nurses, saying they became his advocates.

It “could have gone the other way,” he said, if clinicians had decided “‘Look, this guy’s just way too sick, and we’ve got other patients who need this equipment.’ Or we have an advocate who says, ‘Throw the kitchen sink at him,’” Frank said. “And we happened to have the latter.”

Many hospitals use 72 hours, or three days, as the period for patients with a traumatic brain injury to regain consciousness before advising an end to life support. As COVID-19 patients fill intensive care units across the country, it’s not clear how long hospital staff will wait beyond that point for those patients who do not wake up after a ventilator tube is removed.

Joseph Giacino, director of rehabilitation neuropsychology at Spaulding, said he’s worried hospitals are using that 72-hour model with COVID-19 patients who may need more time. Even before the coronavirus pandemic, some neurologists questioned that model. In 2018, the American Academy of Neurology updated its guidelines for treating prolonged “disorders of consciousness,” noting that some situations may require more time and assessment.

Some patients, like Frank Cutitta, do not appear to have any brain damage. Whatever caused his extended period of unconsciousness cleared.

Unless a patient has previously specified that she does not want aggressive treatment, “we need to really go slow,” said Giacino, “because we are not at a point where we have prognostic indicators that approach the level of certainty that is necessary before making a decision that we should stop treatment because there is no chance of meaningful recovery.”

Doctors interviewed for this story urged everyone to tell their loved ones what you expect a “meaningful recovery” to include. If confronted with this situation, family members should ask doctors about their levels of certainty for each possible outcome.

Some medical ethicists also urge clinicians not to rush when it comes to decisions about how quickly COVID-19 patients may return to consciousness.

“A significant number of patients are going to have a prolonged recovery from the comatose state that they’re in,” said Dr. Joseph Fins, chief of medical ethics at Weill Cornell Medical College. “This is a time for prudence because what we don’t know can hurt us and can hurt patients.”

Leslie and Frank Cutitta have a final request: Wear a mask.

“This disease is nothing to be trifled with,” Leslie Cutitta said. “It’s a devastating experience.”

Frank Cutitta worries about all of the patients still suffering with COVID-19 and those who have survived but have lasting damage.

“I’m not considering myself one of those,” he said, “but there are many, many people who would rather be dead than left with what they have after this.”

This story is part of a partnership that includes WBURNPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Prognosis for Rural Hospitals Worsens With Pandemic

Jerome Antone said he is one of the lucky ones.

After becoming ill with COVID-19, Antone was hospitalized only 65 miles away from his small Alabama town. He is the mayor of Georgiana — population 1,700.

“It hit our rural community so rabid,” Antone said. The town’s hospital closed last year. If hospitals in nearby communities don’t have beds available, “you may have to go four or five hours away.”

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

Eighteen rural hospitals closed last year and the first three months of 2020 were “really big months,” said Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. Many of the losses are in Southern states like Florida and Texas. More than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center.

It’s a dangerous scenario. “We know that a closure leads to higher mortality pretty quickly” among the populations served, said Holmes, who is also a professor at UNC Gillings School of Global Public Health. “That’s pretty clear.”

One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes — and that’s when there’s not a pandemic.

Add to that what is known about the coronavirus: People who are obese or live with diabetes, hypertension, asthma and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

Congress approved billions in federal relief funds for health care providers. Initially, federal officials based what a hospital would get on its Medicare payments, but by late April they heeded criticism and carved out funds for rural hospitals and COVID-19 hot spots. Rural hospitals leapt at the chance to shore up already-negative budgets and prepare for the pandemic.

The funds “helped rural hospitals with the immediate storm,” said Dr. Don Williamson, president of the Alabama Hospital Association. Nearly 80% of Alabama’s rural hospitals began the year with negative balance sheets and about eight days’ worth of cash on hand.

Before the pandemic hit this year, hundreds of rural hospitals “were just trying to keep their doors open,” said Maggie Elehwany, vice president of government affairs with the National Rural Health Association. Then, an estimated 70% of their income stopped as patients avoided the emergency room, doctor’s appointments and elective surgeries.

“It was devastating,” Elehwany said.

Paul Taylor, chief executive of a 25-bed critical access hospital and outpatient clinics in northwestern Arkansas, accepted millions in grants and loan money Congress approved this spring, largely through the CARES (Coronavirus Aid, Relief and Economic Security) Act.

“For us, this was survival money and we spent it already,” Taylor said. With those funds, Ozarks Community Hospital increased surge capacity, expanding from 25 beds to 50 beds, adding negative pressure rooms and buying six ventilators. Taylor also ramped up COVID-19 testing at his hospital and clinics, located near some meat-processing plants.

Throughout June and July, Ozarks tested 1,000 patients a day and reported a 20% positive rate. The rate dropped to 16.9% in late July. But patients continue to avoid routine care.

Taylor said revenue is still constrained and he does not know how he will pay back $8 million that he borrowed from Medicare. The program allowed hospitals to borrow against future payments from the federal government, but stipulated that repayment would begin within 120 days.

For Taylor, this seems impossible. Medicare makes up 40% of Ozarks’ income. And he has to pay the loan back before he gets any more payments from Medicare. He’s hoping to refinance the hospital’s mortgage.

“If I get no relief and they take the money … we won’t still be open,” Taylor said. Ozarks provides 625 jobs and serves an area with a population of about 75,000.

There are 1,300 small critical access hospitals like Ozarks in rural America and, of those, 859 took advantage of the Medicare loans, sending about $3.1 billion into the local communities. But many rural communities have not yet experienced a surge in coronavirus cases — national leaders fear it will come as part of a new phase.

“There are pockets of rural America who say, ‘We haven’t seen a single COVID patient yet and we do not believe it’s real,’” Taylor said. “They will get hit sooner or later.”

Across the country, the loss of patients and increased spending required to fight and prepare for the coronavirus was “like a knife cutting into a hospital’s blood supply,” said Ge Bai, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Bai said the way the federal government reimbursed small rural hospitals through federal programs like Medicare before the pandemic was faulty and inefficient. “They are too weak to survive,” she said.

In rural Texas about two hours from Dallas, Titus Regional Medical Center chief executive Terry Scoggin cut staff and furloughed workers even as his rural hospital faced down the pandemic. Titus Regional lost about $4 million last fiscal year and broke even each of the three years before that.

Scoggin said he did not cut from his clinical staff, though. Titus is now facing its second surge of the virus in the community. “The last seven days, we’ve been testing 30% positive,” he said, including the case of his father, who contracted it at a nursing home and survived.

“It’s personal and this is real,” Scoggin said. “You know the people who are infected. You know the people who are passing away.”

Of his roughly 700 employees, 48 have tested positive for the virus and one has died. They are short on testing kits, medication and supplies.

“Right now the staff is strained,” Scoggin said. “I’ve been blown away by their selflessness and unbelievable spirit. We’re resilient, we’re nimble, and we will make it. We don’t have a choice.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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LA Hospital Seeks Vaccine Trial Participants Among Its Own High-Risk Patients

The patients at Dr. Eric Daar’s hospital are at high risk for serious illness from COVID-19, and he’s determined to make sure they’re part of the effort to fight the disease.

He also hopes they can protect themselves in the process.

When Daar and his colleagues at Harbor-UCLA Medical Center on Wednesday announce the start of enrollment for a trial to test a COVID-19 vaccine produced by AstraZeneca, they will also unveil the hospital’s community-based recruitment strategy.

Harbor-UCLA wants to recruit most, if not all, of the trial’s 500 participants from among the high-risk patients it already treats: people over 65, those with chronic illnesses and members of underserved racial and ethnic groups. Hospital officials also expect that the recruitment task will not be easy.

“It’s a priority and obligation to make sure our community is well represented in these trials,” said Daar, chief of HIV medicine at Harbor-UCLA and a researcher at the UCLA-affiliated Lundquist Institute, who dropped his other research projects last spring to focus on a COVID-19 vaccine.

The safety-net hospital in Torrance, California, serves patients in the South Bay area of Los Angeles County who are predominantly Black, Latino and Pacific Islander. Many live in crowded homes and do “essential” work that requires them to expose themselves to the virus to make a living: They’re orderlies and cooks and house cleaners, day laborers and bus drivers and sanitation workers.

The area has high rates of heart disease and stroke.

“If you don’t have a community represented in the trial, it’s hard to extrapolate your results to the community,” said Dr. Katya Corado, one of Daar’s colleagues. “We want to find something to protect our patients and loved ones.”

Latinos and Blacks in the United States are nearly three times more likely than non-Hispanic whites to be diagnosed with COVID-19 and nearly five times more likely to be hospitalized with the disease. In Los Angeles County, Latinos in particular have been disproportionately stricken by the virus.

Eight of 10 COVID-19 deaths nationwide occur among people 65 and older, according to the Centers for Disease Control and Prevention.

Historically, Blacks and Latinos have been less likely to be included in clinical trials for disease treatment, despite federal guidelines that urge minority and elder participation.

The National Institutes of Health and the Food and Drug Administration have urged infectious disease researchers to focus on these vulnerable populations in the large phase 3 trials that will test how well vaccines prevent COVID-19.

Harbor-UCLA, a public teaching hospital owned and operated by Los Angeles County, is one of roughly 100 sites nationwide testing the AstraZeneca vaccine candidate, which was developed in collaboration with Oxford University in Britain. Phase 3 trials of about the same size for vaccine candidates produced by Moderna and Pfizer are already underway. Each of the three companies seeks to recruit 30,000 people, 20,000 of whom will get the vaccine and 10,000 a placebo, or harmless saline solution, to test whether the vaccine prevents coronavirus disease.

Recruitment at Harbor-UCLA will include patients with well-controlled chronic diseases such as diabetes and hypertension, and people with HIV who’ve kept the virus under control with medication, Daar said.

According to the AstraZeneca trial protocol, patients will get up to $100 for each of 15 to 20 visits during the two-year trial. The Harbor-UCLA team will also offer car services to bring people to the hospital through L.A. traffic.

To reach its targeted recruits, the hospital will distribute leaflets to clinics and community organizations and create targeted social media campaigns, in addition to taking any free publicity it can get, Daar said.

Recruitment of high-risk patients in other COVID-19 trials so far has been mixed. Moderna, which began the first phase 3 trial of the experimental vaccines on July 27, announced Friday that 18% of its 13,000-plus enrollees so far were Black, Latino or Native American — a high percentage as clinical trials go, but only about one-third of the goal set by NIH officials.

Other AstraZeneca trial sites have also publicized their efforts to reach those most at risk from the virus. The University of Southern California’s Keck School of Medicine placed one of its AstraZeneca recruitment sites in Vernon, south of downtown Los Angeles in an area with many factories and meatpacking plants, which have experienced high COVID-19 infection rates.

Clinicians suspect that the higher rates of disease and hospitalization in minority groups are due both to health conditions — such as undertreated diabetes and heart disease — and to higher exposure to the virus in workplaces and crowded housing. Environmental factors like polluted neighborhoods may also have an impact.

While there’s little evidence that vaccines affect Blacks or Latinos differently than white people, the subject hasn’t really been studied, said Dr. Akilah Jefferson Shah, an allergist/immunologist and bioethicist at the University of Arkansas for Medical Sciences. That’s another reason for making sure these groups are well represented in trials, she said.

“We know now there are subgroup responses to drugs by sex, but no one figured it out until they started including women in these studies,” Jefferson Shah said. “Race is not genetic. It’s a social construct. But there are genetic variants more prevalent in certain populations. We won’t know until we look.”

Perhaps most important, diversity in the research will be needed to build trust and uptake of the vaccine, Corado said. In a May poll from the Associated Press-NORC Center for Public Affairs Research, just 25% of Blacks and 37% of Hispanics said they would definitely seek vaccination against the coronavirus, compared with 56% of whites.

In July, the Harbor-UCLA vaccine team began holding weekly Zoom meetings with about 25 activists and clergy members to learn what their communities were saying about the vaccine and get tips on how to design educational materials for the trial.

What they’ve heard suggests they’ll have an uphill recruitment battle.

One member of the community council, HIV activist Dontá Morrison, noted that people frequently say on social media that the vaccine is designed to give them COVID-19 as part of a plot to get rid of Black voters. (None of the vaccines contains infectious COVID virus.)

“It may seem far-fetched, but those are the conversations because we have an administration that has not shown itself to be trustworthy,” Morrison said.

He noted that the first challenge UCLA researchers face is to convince community leaders, particularly clergy members, of the vaccine’s safety. Church leaders worry they’ll be blamed for supporting the trial if the vaccine ends up making their congregants sick, he said.

If done right, the trial could build trust in medical science while helping minorities help themselves — and the rest of us — find a way out of the current mess, Morrison said.

Dr. Raphael Landovitz, another UCLA scientist working on the trial, agreed.

“We’re hoping that people understand this is a chance — if we succeed — to take back some power and control in this situation that has made so many of us feel so powerless,” he said.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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