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Updated: 2 hours 8 min ago

The Court Case That Could Upend Access To Free Birth Control

July 12, 2024

A lawsuit winding its way through the courts could undermine the power of federal agencies to mandate the services health insurance providers must cover. And that could threaten access to free birth control for millions of Americans.

The case is called Braidwood Management Inc. v. Becerra, and it was brought by plaintiffs looking to strike down Obamacare’s requirements that private insurers cover certain kinds of preventive care without cost sharing. (Think everything from no-cost cancer screenings to free IUDs.)

Studies have shown the requirements to cover preventive care have increased consumers’ use of short- and long-term birth control methods.

Without those nationwide standards, the United States would return to a “wild West” dynamic “in which insurers and employers pick and choose which services they want to cover or which services they want to charge for,” said Zachary Baron, a health policy researcher at Georgetown Law.

The plaintiffs, a group of individuals and Christian-owned businesses, argue the three groups that set coverage standards — including an independent advisory panel to the Health Resources and Services Administration — haven’t been properly appointed by Congress.

In June, the U.S. Court of Appeals for the 5th Circuit issued a self-described “mixed bag” of an opinion. It agreed that one body hadn’t been properly appointed, making its recommendations since the Affordable Care Act became law unconstitutional. But the court said only the plaintiffs get to ignore its standards.

The appeals court sent questions about the other two groups — including the advisory panel to HRSA that makes recommendations on contraception — back to a lower court to consider.

The case is likely headed back to U.S. District Judge Reed O’Connor. O’Connor’s previous ruling that one body hadn’t been properly appointed was supported by the appeals court. His remedy — blocking its mandates nationwide — wasn’t.

O’Connor is notoriously hostile to the ACA — he struck down the law in 2018. The Supreme Court later overturned that ruling.

And that makes reproductive rights advocates nervous.

O’Connor “is someone who is willing to impose remedies where he takes access to care away from everybody in the country,” said Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center.

A lack of federal requirements for birth control coverage would leave it up to the states to mandate what insurers have to provide. Fourteen states and D.C. currently protect the right to contraception.

But states can go only so far with those rules, because of a federal law that prevents them from regulating employer-funded health plans, which cover about 65 percent of workers.

“If the plaintiffs win here, it would leave significant gaps in coverage that states would be unable to fill,” Baron said.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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How to Find a Good, Well-Staffed Nursing Home

July 12, 2024

Few people want to go into a nursing home, but doing so can be the right choice if you or a loved one is physically or cognitively disabled or recovering from surgery. Unfortunately, homes vary greatly in quality, and many don’t have enough nurses and aides to give residents the care they need.

Q: How do I find nursing homes worth considering?

Start with Medicare’s online comparison tool, which you can search by city, state, ZIP code, or home name. Ask for advice from people designated by your state to help people who are older or have disabilities search for a nursing home. Every state has a “no wrong door” contact for such inquiries.

You can also reach out to your local area agency on aging, a public or nonprofit resource, and your local long-term care ombudsman, who helps residents resolve problems with their nursing home.

Find your area agency on aging and ombudsman through the federal government’s Eldercare Locator website or by calling 1-800-677-1116. Identify your ombudsman through the National Consumer Voice for Quality Long-Term Care, an advocacy group. Some people use private placement agencies, but they may refer you only to homes that pay them a referral fee.

Q: What should I find out before visiting a home?

Search online for news coverage and for reviews posted by residents or their families.

Call the home to make sure beds are available. Well-regarded homes can have long waiting lists.

Figure out how you will pay for your stay. Most nursing home residents rely primarily on private long-term care insurance, Medicare (for rehabilitation stays) or Medicaid (for long-term stays if you have few assets). In some cases, the resident pays entirely out-of-pocket. If you’re likely to run out of money or insurance coverage during your stay, make sure the home accepts Medicaid. Some won’t admit Medicaid enrollees unless they start out paying for the care themselves.

If the person needing care has dementia, make sure the home has a locked memory-care unit to ensure residents don’t wander off.

Q: How can I tell if a home has adequate staffing?

Medicare’s comparison tool gives each home a rating of one to five stars based on staffing, health inspection results, and measurements of resident care such as how many residents had pressure sores that worsened during their stay. Five is the highest rating. Below that overall rating is one specifically for staffing.

Be sure to study the annual staff turnover rate, at the bottom of the staffing page. Anything higher than the national rate — an appalling 52% — should give you pause.

You should also pay attention to the inspection star rating. The “quality” star rating is less reliable because homes self-report many of the results and have incentives to put a glossy spin on their performance.

Q: Does a home with three, four, or five stars provide good care?

Not necessarily. Medicare’s ratings compare the staffing of a home against that of other homes, not against an independent standard. The industry isn’t as well staffed as many experts think it needs to be: About 80% of homes, even some with four and five stars, are staffed below the standards the Biden administration will be requiring homes to meet in the next five years.

Q: How many workers are enough?

There’s no straightforward answer; it depends on how frail and sick a nursing home’s residents are. Medicare requires homes to prominently post their staffing each day. The notices should show the number of residents, registered nurses, licensed vocational nurses, and nurse aides. RNs are the most skilled and manage the care. LVNs provide care for wounds and catheters and handle basic medical tasks. Nurse aides help residents eat, dress, and get to the bathroom.

Expert opinions vary on the ideal ratios of staffing. Sherry Perry, a Tennessee nursing assistant who is the chair of her profession’s national association, said that preferably a nursing assistant should care for eight or fewer residents.

Charlene Harrington, an emerita professor of nursing at the University of California-San Francisco, recommends that on the day shift there be one nurse aide for every seven residents who need help with physical functioning or have behavioral issues; one RN for every 28 residents; and one LVN for every 38 residents. Patients with complex medical needs will need higher staffing levels.

Staffing can be lower at night because most residents are sleeping, Harrington said.

Nursing home industry officials say that there’s no one-size-fits-all ratio and that a study the federal government published last year found quality improved with higher staffing but didn’t recommend a particular level.

Q: What should I look for when I visit a home?

Watch to see if residents are engaged in activities or if they are alone in their rooms or slumped over in wheelchairs in hallways. Are they still in sleeping gowns during the day? Do nurses and aides know the residents by name? Is food available only at mealtimes, or can residents get snacks when hungry? Watch a meal to see whether people are getting the help they need. You might visit at night or on weekends or holidays, when staffing is thinnest.

Q: What should I ask residents and families in the home?

Are residents cared for by the same people or by a rotating cast of strangers? How long do they have to wait for help bathing or getting out of bed? Do they get their medications, physical therapy, and meals on time? Do aides come quickly if they turn on their call light? Delays are strong signs of understaffing.

Medicare requires homes to allow residents and families to form councils to address common issues. If there’s a council, ask to speak to its president or an officer.

Ask what proportion of nurses and aides is on staff or from temporary staffing agencies; temp workers won’t know the residents’ needs and likes as well. A home that relies heavily on temporary staff most likely has trouble recruiting and keeping employees.

Q: What do I need to know about a home’s leadership?

Turnover at the top is a sign of trouble. Ask how long the home’s administrator has been on the job; ideally it should be at least a year. (You can look up administrator turnover on the Medicare comparison tool: It’s on the staffing page beneath staff turnover. But be aware the information may not be up to date.) You should also ask about the tenure of the director of nursing, the top clinical supervisor in a home.

During your tour, observe how admissions staff members treat the person who would be living there. “If you walk in to visit with your mom and they greeted you and didn’t greet your mom or focused all their attention on you, go somewhere else,” advised Carol Silver Elliott, president of the Jewish Home Family, a nonprofit in Rockleigh, New Jersey.

Q: Does it matter who owns the home?

It often does. Generally, nonprofit nursing homes provide better care because they can reinvest revenue back into the home rather than paying some of it to owners and investors.

But there are some very good for-profit homes and some lousy nonprofits. Since most homes in this country are for-profit, you may not have a choice in your area. As a rule of thumb, the more local and present the owner, the more likely the home will be well run. Many owners live out of state and hide behind corporate shell companies to insulate themselves from accountability. If nursing home representatives can’t give you a clear answer when you ask who owns it, think twice.

Finally, ask if the home’s ownership has changed in the past year or so or if a sale is pending. Stable, well-run nursing homes aren’t usually the ones owners are trying to get rid of.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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States Set Minimum Staffing Levels for Nursing Homes. Residents Suffer When Rules Are Ignored or Waived.

July 12, 2024

For hours, John Pernorio repeatedly mashed the call button at his bedside in the Heritage Hills nursing home in Rhode Island. A retired truck driver, he had injured his spine in a fall on the job decades earlier and could no longer walk. The antibiotics he was taking made him need to go to the bathroom frequently. But he could get there only if someone helped him into his wheelchair.

By the time an aide finally responded, he’d been lying in soiled briefs for hours, he said. It happened time and again.

“It was degrading,” said Pernorio, 79. “I spent 21 hours a day in bed.”

Payroll records show that during his stay at Heritage Hills, daily aide staffing levels were 25% below the minimums under state law. The nursing home said it provided high-quality care to all residents. Regardless, it wasn’t in trouble with the state, because Rhode Island does not enforce its staffing rule.

An acute shortage of nurses and aides in the nation’s nearly 15,000 nursing homes is at the root of many of the most disturbing shortfalls in care for the 1.2 million Americans who live in them, including many of the nation’s frailest old people.

They get festering bedsores because they aren’t turned. They lie in feces because no one comes to attend to them. They have devastating falls because no one helps them get around. They are subjected to chemical and physical restraints to sedate and pacify them.

California, Florida, Massachusetts, New York, and Rhode Island have sought to improve nursing home quality by mandating the highest minimum hours of care per resident among states. But an examination of records in those states revealed that putting a law on the books was no guarantee of better staffing. Instead, many nursing homes operated with fewer workers than required, often with the permission of regulators or with no consequences at all.

“Just setting a number doesn’t mean anything if you’re not going to enforce it,” said Mark Miller, former president of the national organization of long-term care ombudsmen, advocates in each state who help residents resolve problems in their nursing homes. “What’s the point?”

Now the Biden administration is trying to guarantee adequate staffing the same way states have, unsuccessfully, for years: with tougher standards. Federal rules issued in April are expected to require 4 out of 5 homes to boost staffing.

The administration’s plan also has some of the same weaknesses that have hampered states. It relies on underfunded health inspectors for enforcement, lacks explicit penalties for violations, and offers broad exemptions for nursing homes in areas with labor shortages. And the administration isn’t providing more money for homes that can’t afford additional employees.

Serious health violations have become more widespread since covid-19 swept through nursing homes, killing more than 170,000 residents and driving employees out the door.

Pay remains so low — nursing assistants earn $19 an hour on average — that homes frequently lose workers to retail stores and fast-food restaurants that pay as well or better and offer jobs that are far less grueling. Average turnover in nursing homes is extraordinarily high: Federal records show half of employees leave their jobs each year.

Even the most passionate nurses and aides are burning out in short-staffed homes because they are stretched too thin to provide the quality care they believe residents deserve. “It was impossible,” said Shirley Lomba, a medication aide from Providence, Rhode Island. She left her job at a nursing home that paid $18.50 an hour for one at an assisted living facility that paid $4 more per hour and involved residents with fewer needs.

The mostly for-profit nursing home industry argues that staffing problems stem from low rates of reimbursement by Medicaid, the program funded by states and the federal government that covers most people in nursing homes. Yet a growing body of research and court evidence shows that owners and investors often extract hefty profits that could be used for care.

Nursing home trade groups have complained about the tougher state standards and have sued to block the new federal standards, which they say are unworkable given how much trouble nursing homes already have filling jobs. “It’s a really tough business right now,” said Mark Parkinson, president and chief executive of one trade group, the American Health Care Association.

And federal enforcement of those rules is still years off. Nursing homes have as long as five years to comply with the new regulations; for some, that means enforcement would fully kick in only at the tail end of a second Biden administration, if the president wins reelection. Former President Donald Trump’s campaign declined to comment on what Trump would do if elected.

Persistent Shortages

Nursing home payroll records submitted to the federal government for the most recent quarter available, October to December 2023, and state regulatory records show that homes in states with tougher standards frequently did not meet them.

In more than two-thirds of nursing homes in New York and more than half of those in Massachusetts, staffing was below the state’s required minimums. Even California, which passed the nation’s first minimum staffing law two decades ago, has not achieved universal compliance with its requirements: at least 3½ hours of care for the average resident each day, including two hours and 24 minutes of care from nursing assistants, who help residents eat and get to the bathroom.

During inspections since 2021, state regulators cited a third of California homes — more than 400 of them — for inadequate staffing. Regulators also granted waivers to 236 homes that said workforce shortages prevented them from recruiting enough nurse aides to meet the state minimum, exempting them from fines as high as $50,000.

In New York, Gov. Kathy Hochul declared an acute labor shortage, which allows homes to petition for reduced or waived fines. The state health department said it had cited more than 400 of the state’s 600-odd homes for understaffing but declined to say how many of them had appealed for leniency.

In Florida, Gov. Ron DeSantis signed legislation in 2022 to loosen the staffing rules for all homes. The law allows homes to count almost any employee who engages with residents, instead of just nurses and aides, toward their overall staffing. Florida also reduced the daily minimum of nurse aide time for each resident by 30 minutes, to two hours.

Now only 1 in 20 Florida nursing homes are staffed below the minimum — but if the former, more rigorous rules were still in place, 4 in 5 homes would not meet them, an analysis of payroll records shows.

“Staffing is the most important part of providing high-quality nursing home care,” said David Stevenson, chair of the health policy department at Vanderbilt University School of Medicine. “It comes down to political will to enforce staffing.”

The Human Toll

There is a yawning gap between law and practice in Rhode Island. In the last three months of 2023, only 12 of 74 homes met the state’s minimum of three hours and 49 minutes of care per resident, including at least two hours and 36 minutes of care from certified nursing assistants, payroll records show. One of the homes below the minimum was Heritage Hills Rehabilitation & Healthcare Center in Smithfield, where Pernorio, president of the Rhode Island Alliance for Retired Americans, went last October after a stint in a hospital.

“From the minute the ambulance took me in there, it was downhill,” he said in an interview.

Sometimes, after waiting an hour, he would telephone the home’s main office for help. A nurse would come, turn off his call light, and walk right back out, and he would push the button again, Pernorio reported in his weekly e-newsletter.

While he praised some workers’ dedication, he said others frequently did not show up for their shifts. He said staff members told him they could earn more flipping hamburgers at McDonald’s than they could cleaning soiled patients in a nursing home.

In a written statement, Heritage Hills did not dispute that its staffing, while higher than that of many homes, was below the minimum under state law.

Heritage Hills said that after Pernorio complained, state inspectors visited the home and did not cite it for violations. “We take every resident concern seriously,” it said in the statement. Pernorio said inspectors never interviewed him after he called in his complaint.

In interviews, residents of other nursing homes in the state and their relatives reported neglect by overwhelmed nurses and aides.

Jason Travers said his 87-year-old father, George, fell on the way to the bathroom because no one answered his call button.

“I think the lunch crew finally came in and saw him on the floor and put him in the bed,” Travers said. His father died in April 2023, four months after he entered the home.

Relatives of Mary DiBiasio, 92, who had a hip fracture, said they once found her sitting on the toilet unattended, hanging on to the grab bar with both hands. “I don’t need to be a medical professional to know you don’t leave somebody hanging off the toilet with a hip fracture,” said her granddaughter Keri Rossi-D’entremont.

When DiBiasio died in January 2022, Rhode Island was preparing to enact a law with nurse and aide staffing requirements higher than anywhere else in the country except Washington, D.C. But Gov. Daniel McKee suspended enforcement, saying the industry was in poor financial shape and nursing homes couldn’t even fill existing jobs. The governor’s executive order noted that several homes had closed because of problems finding workers.

Yet Rhode Island inspectors continue to find serious problems with care. Since January 2023, regulators have found deficiencies of the highest severity, known as immediate jeopardy, at 23 of the state’s 74 nursing homes.

Homes have been cited for failing to get a dialysis patient to treatment and for giving one resident a roommate’s methadone, causing an overdose. They have also been cited for violent behavior by unsupervised residents, including one who shoved pillow stuffing into a resident’s mouth and another who turned a roommate’s oxygen off because it was too noisy. Both the resident who was attacked and the one who lost oxygen died.

Bottom Lines

Even some of the nonprofit nursing homes, which don’t have to pay investors, are having trouble meeting the state minimums — or simply staying open.

Rick Gamache, chief executive of the nonprofit Aldersbridge Communities, which owns Linn Health & Rehabilitation in East Providence, said Rhode Island’s Medicaid program paid too little for the home to keep operating — about $292 per bed, when the daily cost was $411. Aldersbridge closed Linn this summer and converted it into an assisted living facility.

“We’re seeing the collapse of post-acute care in America,” Gamache said.

Many nursing homes are owned by for-profit chains, and some researchers, lawyers, and state authorities argue that they could reinvest more of the money they make into their facilities.

Bannister Center, a Providence nursing home that payroll records show is staffed 10% below the state minimum, is part of Centers Health Care, a New York-based private chain that owns or operates 31 skilled nursing homes, according to Medicare records. Bannister lost $430,524 in 2021, according to a financial statement it filed with Rhode Island regulators.

Last year, the New York attorney general sued the chain’s owners and investors and their relatives, accusing them of improperly siphoning $83 million in Medicaid funds out of their New York nursing homes by paying salaries for “no-show” jobs, profits above what state law allowed, and inflated rents and fees to other companies they owned. For instance, one of those companies, which purported to provide staff to the homes, paid $5 million to the wife of Kenny Rozenberg, the chain’s chief executive, from 2019 to 2021, the lawsuit said.

The defendants argued in court papers that the payments to investors and owners were legal and that the state could not prove they were Medicaid funds. They have asked for much of the lawsuit to be dismissed.

Jeff Jacomowitz, a Centers Health Care spokesperson, declined to answer questions about Bannister, Centers’ operations, or the chain’s owners.

Miller, the District of Columbia’s long-term care ombudsman, said many nursing home owners could pay better wages if they didn’t demand such high profits. In D.C., 7 in 10 nursing homes meet minimum standards, payroll records show.

“There’s no staffing shortage — there’s a shortage of good-paying jobs,” he said. “I’ve been doing this since 1984 and they’ve been going broke all the time. If it really is that bad of an investment, there wouldn’t be any nursing homes left.”

The new federal rules call for a minimum of three hours and 29 minutes of care each day per resident, including two hours and 27 minutes from nurse aides and 33 minutes from registered nurses, and an RN on-site at all times.

Homes in areas with worker shortages can apply to be exempted from the rules. Dora Hughes, acting chief medical officer for the U.S. Centers for Medicare & Medicaid Services, said in a statement that those waivers would be “time-limited” and that having a clear national staffing minimum “will facilitate strengthened oversight and enforcement.”

David Grabowski, a health policy professor at Harvard Medical School, said federal health authorities have a “terrible” track record of policing nursing homes. “If they don’t enforce this,” he said, “I don’t imagine it’s going to really move the needle a lot.”

Methodology for Analysis of Nursing Home Staffing

The KFF Health News data analysis focused on five states with the most rigorous staffing requirements: California, Florida, Massachusetts, New York, and Rhode Island.

To determine staffing levels, the analysis used the daily payroll journals that each nursing home is required to submit to the federal government. These publicly available records include the number of hours each category of nursing home employee, including registered nurses and certified nursing assistants, worked each day and the number of residents in each home. We used the most recent data, which included a combined 1.3 million records covering the final three months of 2023.

We calculated staffing levels by following each state’s rules, which specify which occupations are counted and what minimums homes must meet. The analysis differed for each state. Massachusetts, for instance, has a separate requirement for the minimum number of hours of care registered nurses must provide each day.

In California, we used state enforcement action records to identify homes that had been fined for not meeting its law. We also tallied how many California homes had been granted waivers from the law because they couldn’t find enough workers to hire.

For each state and Washington, D.C., we calculated what proportion of homes complied with state or district law. We shared our conclusions with each state’s nursing home regulatory agency and gave them an opportunity to respond.

This analysis was performed by senior correspondent Jordan Rau and data editor Holly K. Hacker.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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When Hospital Cyberattacks Compromise Care, Not Just Data

July 09, 2024

When hospitals are hit by cyberattacks that compromise crucial technology systems for managing patient care, the stakes are staggering.

“We’ve started to think about these as public health issues and disasters on the scale of earthquakes or hurricanes,” said Jeff Tully, a co-director of the Center for Healthcare Cybersecurity at the University of California at San Diego.

Many hospitals are unprepared for long outages, cybersecurity experts say. And the federal government has offered little in the way of required protocols or standards to protect patient safety in attacks on the health sector, which have risen precipitously in recent years.

Long-held concerns about protecting patients’ sensitive health information have been overtaken by fears of harm to patients themselves. Kate Wells and I dug into one of the latest and biggest examples for the news organization Michigan Public and KFF Health News: the ransomware attack against Ascension that for weeks locked clinicians out of electronic health records, medication systems and other technology at one of the nation’s largest health systems.

The federal government requires hospitals to protect patient data, according to cybersecurity experts. Yet there are no requirements for hospitals to have basic cybersecurity protocols in place, which could include things like multifactor authentication, email controls and basic cybersecurity training for employees. The Biden administration, however, has indicated it will soon attempt to institute some mandatory measures.

When Denise Anderson, president of the Health Information Sharing and Analysis Center, began working in the health sector, federal officials were focused mostly on data privacy and the Health Insurance Portability and Accountability Act (HIPAA), the landmark 1996 patient privacy law.

“We weren’t pairing cybersecurity and health care in the same sentence,” said Anderson, whose organization works to protect the health sector from physical and cyberthreats.

Lawmakers have taken notice. “It is clear that HHS’ current approach to healthcare cybersecurity — self-regulation and voluntary best practices — is woefully inadequate and has left the health care system vulnerable to criminals and foreign government hackers,” Sen. Ron Wyden (D-Ore.) wrote in a June 5 letter to Health and Human Services Secretary Xavier Becerra.

Clinicians working for Ascension hospitals say the cyberattack led to harrowing lapses, including delayed or lost lab results, medication errors and an absence of routine safety checks via technology to prevent potentially fatal mistakes. More than a dozen doctors and nurses who work for the sprawling health system told Michigan Public and KFF Health News that patient care at its hospitals was compromised in the fallout of the cyberattack.

Ascension declined to answer questions about claims that care has been affected by the ransomware attack. “We are confident that our care providers in our hospitals and facilities continue to provide quality medical care,” Sean Fitzpatrick, Ascension’s vice president of external communications, said last month.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Falsa terapeuta engañó a cientos de pacientes en Internet, y solo se supo porque murió

July 05, 2024

Cientos de estadounidenses pueden haber recibido terapia, sin saberlo, de una impostora sin formación que se hizo pasar por terapeuta en sesiones por internet, posiblemente durante dos años. El engaño sólo se descubrió cuando murió, según registros de departamentos de salud estatales.

Peggy A. Randolph, trabajadora social con licencia en Florida y Tennessee, quien trabajaba para Brightside Health, una empresa nacional de terapia en línea, está acusada de ayudar a su esposa a hacerse pasar por ella en sesiones de internet, según el informe de una investigación del Departamento de Salud de Florida.

El informe de Florida indica que la pareja “estafaba” a los pacientes mediante un “esfuerzo coordinado”: mientras Randolph trataba a pacientes en persona, su esposa se hacía pasar por ella en sesiones de telesalud con pacientes de Brightside. El engaño se descubrió después que la esposa impostora muriera el año pasado, y un paciente se diera cuenta de que había estado hablando con la persona equivocada, según un acuerdo de conciliación del Departamento de Salud de Tennessee.

Los registros de ambos estados identifican a la esposa de Randolph sólo por sus iniciales, T.R., pero su nombre completo figura en su obituario: Tammy G. Heath-Randolph. Tradicionalmente, se espera que los terapeutas tengan al menos una maestría, pero la esposa de Randolph “no tenía licencia ni formación para prestar ningún tipo de servicios de consejería”, según revela el acuerdo de Tennessee.

Según consta en el acuerdo: “[Randolph] niega saber que T.R. estuviera utilizando sus credenciales de acceso al portal de terapeutas de Brightside Health o tratando a clientes con su cuenta. Sin embargo, [ella] recibió compensación por las sesiones realizadas”.

La presunta artimaña no había sido denunciada anteriormente y sus detalles y alcance salieron a la luz recientemente en las páginas de unos documentos públicos divulgadas por los agencias estatales.

El acuerdo de Tennessee, publicado en mayo, indica que Randolph debió haber proporcionado terapia en línea a “cientos de clientes” mientras trabajaba para Brightside Health desde enero de 2021 hasta febrero de 2023. Sin embargo, una investigación interna de Brightside descubrió que en realidad era Heath-Randolph quien “veía a todos los pacientes y lo estuvo haciendo durante mucho tiempo”, según el informe de la investigación de Florida.

Randolph declinó hacer comentarios.

Los registros de Florida y Tennessee dicen que Randolph renunció voluntariamente a sus licencias de trabajadora social en ambos estados. Esto dio lugar a que los departamentos de salud abandonaran sus investigaciones, lo que limitó los detalles del caso y los documentos disponibles en el registro público.

El informe de la investigación interna de Brightside no se ha divulgado.

Brightside Health, una empresa de San Francisco que ofrece sesiones de psiquiatría y terapia en línea en todo el país, declinó hacer ningún tipo de declaración por medio de una entrevista.

La vocera de la empresa, Hannah Changi, dijo en un correo electrónico que en cuanto Brightside se enteró de las acusaciones, hizo una auditoría de su seguridad, despidió a Randolph y la denunció ante las autoridades estatales que concede las licencias. Changi señaló que Brightside no puede decir cuántos pacientes fueron atendidos por la esposa de Randolph “debido a la naturaleza del incidente y los procedimientos legales en curso”, pero aseguró que la compañía notificó y reembolsó a todos los “pacientes potencialmente afectados”.

“Nos tomamos muy en serio la experiencia de nuestros pacientes y tenemos un elevado código ético de conducta”, dijo Changi. “Nos decepciona profundamente que uno de nuestros proveedores haya traicionado la confianza que Brightside y, más importante, sus pacientes habían depositado en ella”.

Además, Brightside se vio obligada a alertar al Departamento de Salud y Servicios Humanos de Estados Unidos, que investiga la filtración de datos que exponen información médica privada. En esta filtración, un “individuo no autorizado” accedió a la información de 767 personas, incluidos números de seguro social y diagnósticos, según la base de datos en línea de la agencia.

Ni las autoridades de salud de Florida ni las de Tennessee respondieron a las preguntas sobre el caso.

Dean Flener, vocero del Departamento de Salud de Tennessee, dijo que los detalles del caso de Randolph siguen siendo confidenciales en virtud de la ley estatal.

Jae Williams, vocero del Departamento de Salud de Florida, señaló que no se llevó a cabo una investigación completa porque Randolph renunció a su licencia, lo que tiene el mismo efecto que la revocación por parte del estado, pero le permitió conservar “la dignidad que le quedaba”.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Two Rival Hospitals Want To Join Forces. Will Patients Lose?

July 03, 2024

In Terre Haute, Ind., two rival hospitals want to merge, a move that supporters say will save patients money and help people live longer.

But similar hospital consolidations in Tennessee, Virginia and North Carolina have resulted in government reports documenting diminished care.

In more than a dozen states, certificates of public advantage (COPAs) permit deals like the one on the table in Indiana, even though the Federal Trade Commission otherwise considers them illegal because they reduce competition. As a result, the FTC has warned states to avoid COPAs and the mergers they create.

In Terre Haute, state regulators will decide whether to allow Union Hospital to purchase the surrounding county’s only other acute care facility, Terre Haute Regional Hospital. The merger would be the first deal under the state’s 2021 COPA law. Aside from the FTC’s concerns about the anti-competitive nature of these deals, there’s another, potentially bigger question: Does allowing hospitals to combine forces improve patient care?

The largest COPA-created hospital system in the country, Tennessee-based Ballad Health, has reported that the time patients spend in its ERs in Virginia and Tennessee before being hospitalized has more than tripled, reaching nearly 11 hours, in the six years since that monopoly of 20 hospitals formed.

The FTC has been closely examining the effects mergers have on prices, quality and even employee wages. In 2019, the FTC ordered multiple insurers and COPA-created health systems, including Ballad, to turn over information. The FTC declined to provide an update on the status of its findings.

To mitigate the negative effects of a monopoly, merged hospitals typically agree to conditions imposed by state regulators. Still, Tennessee has awarded Ballad top marks even when certain quality metrics, including its ER speed, fall below its established benchmarks.

Ballad Health spokesperson Molly Luton said the system’s performance has improved since statistics were collected for its 2023 fiscal year, which ended June 30, 2023, and that ER wait times have shortened.

COPA arrangements have also led to fallout in nearby North Carolina. When the state repealed its 2015 COPA law, it removed state oversight of Asheville’s Mission Health system, which was required as part of the merger. That meant the local monopoly remained but none of the COPA’s conditions applied when a subsidiary of HCA Healthcare bought the system for $1.5 billion in 2019.

Last year, government inspectors found “deficiencies” at Mission Health that contributed to four patient deaths and posed an “immediate jeopardy” to patients’ health and safety, according to the 384-page federal inspection report.

North Carolina Attorney General Joshua Stein sued HCA’s subsidiary, alleging that the ER was “significantly degraded” and that the company did not maintain certain critical services, including oncology care, a violation of a purchase agreement Stein’s office negotiated because the company acquired a nonprofit.

HCA said it promptly addressed the issues found in the inspections and denied Stein’s allegations in its response to the ongoing lawsuit, arguing that it has expanded services. HCA also contended the agreement is silent about maintaining the quality of care.

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Lack of Affordability Tops Older Americans’ List of Health Care Worries

July 03, 2024

What weighs most heavily on older adults’ minds when it comes to health care?

The cost of services and therapies, and their ability to pay.

“It’s on our minds a whole lot because of our age and because everything keeps getting more expensive,” said Connie Colyer, 68, of Pleasureville, Kentucky. She’s a retired forklift operator who has lung disease and high blood pressure. Her husband, James, 70, drives a dump truck and has a potentially dangerous irregular heart rhythm.

Tens of millions of seniors are similarly anxious about being able to afford health care because of its expense and rising costs for housing, food, and other essentials.

A new wave of research highlights the reach of these anxieties. When the University of Michigan’s National Poll on Healthy Aging asked people 50 and older about 26 health-related issues, their top three areas of concern had to do with costs: of medical care in general, of long-term care, and of prescription drugs. More than half of 3,300 people surveyed in February and March reported being “very concerned” about these issues.

In fact, five of the top 10 issues identified as very concerning were cost-related. Beyond the top three, people cited the cost of health insurance and Medicare (52%), and the cost of dental care (45%). Financial scams and fraud came in fourth place (53% very concerned). Of much less concern were issues that receive considerable attention, including social isolation, obesity, and age discrimination.

In an election year, “our poll sends a very clear message that older adults are worried about the cost of health care and will be looking to candidates to discuss what they have done or plan to do to contain those costs,” said John Ayanian, director of the University of Michigan’s Institute for Healthcare Policy and Innovation.

Older adults have good reason to worry. One in 10 seniors (about 6 million people) have incomes below the federal poverty level. About 1 in 4 rely exclusively on Social Security payments, which average $1,913 a month per person.

Even though inflation has moderated since its 2022 peak, prices haven’t come down, putting a strain on seniors living on fixed incomes.

Meanwhile, traditional Medicare doesn’t cover several services that millions of older adults need, such as dental care, vision care, or help at home from aides. While private Medicare Advantage plans offer some coverage for these services, benefits are frequently limited.

All of this contributes to a health care affordability squeeze for older adults. Recently published research from the Commonwealth Fund’s 2023 Health Care Affordability Survey found that nearly a third of people 65 or older reported difficulty paying for health care expenses, including premiums for Medicare, medications, and expenses associated with receiving medical services.

One in 7 older adults reported spending a quarter or more of their average monthly budget on health care; 44% spent between 10% and 24%. Seventeen percent said they or a family member had forgone needed care in the past year for financial reasons.

The Colyers in Pleasureville are among them. Both need new dentures and eyeglasses, but they can’t afford to pay thousands of dollars out-of-pocket, Connie said.

“As the cost of living rises for basic necessities, it’s more difficult for lower-income and middle-income Medicare beneficiaries to afford the health care they need,” said Gretchen Jacobson, vice president of the Medicare program at the Commonwealth Fund. Similarly, “when health care costs rise, it’s more difficult to afford basic necessities.”

This is especially worrisome because older adults are more prone to illness and disability than younger adults, resulting in a greater need for care and higher expenses. In 2022, seniors on Medicare spent $7,000 on medical services, compared with $4,900 for people without Medicare.

Not included in this figure is the cost of assisted living or long-term stays in nursing homes, which Medicare also doesn’t cover. According to Genworth’s latest survey, the median annual cost of a semiprivate room in a nursing home was $104,000 in 2023, while assisted living came to $64,200, and a week’s worth of services from home-health aides averaged $75,500.

Many older adults simply can’t afford to pay for these long-term care options or other major medical expenses out-of-pocket.

“Seventeen million older adults have incomes below 200% of the federal poverty level,” said Tricia Neuman, executive director of the Program on Medicare Policy for KFF. (That’s $30,120 for a single-person household in 2024; $40,880 for a two-person household.) “For people living on that income, the risk of a major expense is very scary.”

How to deal with unanticipated expenses in the future is a question that haunts Connie Colyer. Her monthly premiums for Medicare Parts B and D, and a Medigap supplemental policy come to nearly $468, or 42% of her $1,121 monthly income from Social Security.

With a home mortgage of $523 a month, and more than $150 in monthly copayments for her inhalers and her husband’s heart medications, “we wouldn’t make it if my husband wasn’t still working,” she told me. (James’ monthly Social Security payment is $1,378. His premiums are similar to Connie’s and his income fluctuates based on the weather. In the first five months of this year, it approached $10,000, Connie told me.)

The couple makes too much to qualify for programs that help older adults afford Medicare out-of-pocket costs. As many as 6 million people are eligible but not enrolled in these Medicare Savings Programs. Those with very low incomes may also qualify for dual coverage by Medicaid and Medicare or other types of assistance with household costs, such as food stamps.

Older adults can check their eligibility for these and other programs by contacting their local Area Agency on Agency, State Health Insurance Assistance Program, or benefits enrollment center. Enter your ZIP code at the Eldercare Locator and these and other organizations helping seniors locally will come up.

Persuading older adults to step forward and ask for help often isn’t easy. Angela Zeek, health and government benefits manager at Legal Aid of the Bluegrass in Kentucky, said many seniors in her area don’t want to be considered poor or unable to pay their bills, a blow to their pride. “What we try to say is, ‘You’ve worked hard all your life, you’ve paid your taxes. You’ve given back to this government so there’s nothing wrong with the government helping you out a bit.’”

And the unfortunate truth is there’s very little, if any, help available for seniors who aren’t poor but have modest financial resources. While the need for new dental, vision, and long-term care benefits for older adults is widely acknowledged, “the question is always how to pay for it,” said Neuman of KFF.

This will become an even bigger issue in the coming years because of the burgeoning aging population.

There is some relief on the horizon, however: Assistance with Medicare drug costs is available through the 2022 Inflation Reduction Act, although many older adults don’t realize it yet. The act allows Medicare to negotiate the price of prescription drugs for the first time. This year, out-of-pocket costs for medications will be limited to a maximum $3,800 for most beneficiaries. Next year, a $2,000 cap on out-of-pocket drug costs will take effect.

“We’re already seeing people who’ve had very high drug costs in the past save thousands of dollars this year,” said Frederic Riccardi, president of the Medicare Rights Center. “And next year, it’s going to get even better.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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El dolor ya no se puede medir en una escala de cero a 10

July 02, 2024

En los últimos dos años, una solicitud simple pero desconcertante ha precedido la mayoría de mis encuentros con profesionales médicos: “Califique su dolor en una escala del cero al 10”.

Me formé como médica y he hecho esta misma pregunta a los pacientes miles de veces, así que pienso mucho en cómo cuantificar la suma de caderas doloridas, muslos punzantes y el dolor adormecedor cerca de mi omóplato izquierdo. Hago una pausa y luego, generalmente de manera arbitraria, elijo un número. “¿Tres o cuatro?”, aventuro, sabiendo que la respuesta real es larga, complicada e imposible de medir de esta manera unidimensional.

El dolor es algo escurridizo. A veces es ardiente, a veces perforante, a veces oprime profundo en los músculos. El mío puede depender de mi estado de ánimo o de cuánto le preste atención, y puede “desaparecer” casi por completo si estoy concentrada en una película o tarea.

El dolor también puede ser lo suficientemente incapacitante como para cancelar vacaciones, o tan abrumador que vuelve a las personas adictas a los opioides. Incluso el dolor de 10+ puede ser soportable cuando se tolera por una buena razón, como dar a luz.

Pero, ¿cuál es el propósito de los dolores que tengo ahora, efectos persistentes de una lesión en la cabeza?

El concepto de reducir estos matices del dolor a un solo número data de la década de 1970. Pero hoy en día la escala del cero a 10 parece vetusta debido a lo que se llamó una “revolución del dolor” en los años 90, cuando la nueva forma de abordar el dolor —principalmente con opioides— se presentó como un progreso.

Los médicos de hoy tienen una comprensión más completa del tratamiento del dolor, así como de las terribles consecuencias de recetar opioides con liviandad. Lo que están aprendiendo ahora es cómo medir mejor el dolor y tratar sus muchas formas.

Hace unos 30 años, los médicos que defendían el uso de opioides dieron nueva vida a lo que había sido hasta el momento una especialidad marginal: la gestión del dolor. Comenzaron a promover la idea de que el dolor debería medirse en cada cita como un “quinto signo vital”. La Sociedad Americana del Dolor llegó a registrar la frase. Pero a diferencia de los otros signos vitales —presión arterial, temperatura, frecuencia cardíaca y frecuencia respiratoria— el dolor no tenía una escala objetiva.

¿Cómo medir lo inmensurable?

La sociedad alentó a los médicos y enfermeras a usar el sistema de calificación de cero a 10. Alrededor de esa época, la Administración de Drogas y Alimentos (FDA) aprobó OxyContin, un analgésico opioide de liberación lenta fabricado por Purdue Pharma.

El propio fabricante de medicamentos instó a los médicos a registrar y tratar el dolor de manera rutinaria, y promovió agresivamente los opioides como una solución obvia. Para ser justos, en una época en la que el dolor a menudo se ignoraba o se trataba de manera insuficiente, el sistema de calificación de cero a 10 podría considerarse un avance.

Las bombas de morfina no estaban disponibles para aquellos pacientes con cáncer que vi en los años 80, incluso aquellos con un dolor agonizante por cáncer en los huesos; los médicos consideraban el dolor como una parte inevitable de la enfermedad. En la sala de emergencias donde trabajé a principios de los 90, recetar incluso unas pocas píldoras de opioides era un inconveniente: requería pedirle a la enfermera jefe que desbloqueara un recetario especial y hacer una copia para la agencia estatal que rastreaba los patrones de prescripción.

Los reguladores (con razón) se preocupaban de que repartir narcóticos llevara a la adicción. Como resultado, algunos pacientes necesitados de alivio probablemente se quedaron sin él.

Después que los médicos del dolor y los fabricantes de opioides hicieran campaña para un uso más amplio de estas drogas — alegando que las formas más nuevas no eran adictivas, o mucho menos que las formulaciones anteriores — recetar los medicamentos se volvió mucho más fácil y se promovieron para todo tipo de dolor, ya sea una artritis de rodilla o problemas de espalda.

Como joven médica que se unía a la “revolución del dolor”, probablemente les pregunté a los pacientes miles de veces que calificaran su dolor en una escala de cero a 10 y escribí muchas recetas cada semana para medicamentos para el dolor, ya que monitorear “el quinto signo vital” se volvió rápidamente rutinario en el sistema médico.

Con el tiempo, la medición del dolor de cero a 10 se convirtió en caja necesaria para llenar en los registros médicos electrónicos. La Commission on the Accreditation of Healthcare Organizations hizo que evaluar el dolor regularmente fuera un requisito previo para que los centros médicos recibieran dólares federales de atención médica.

Los grupos médicos agregaron el tratamiento del dolor a su lista de derechos de los pacientes, y la satisfacción con el tratamiento del dolor se convirtió en un componente de las encuestas de pacientes posteriores a la cita médica. (Una mala calificación podría significar un menor reembolso por parte de algunos aseguradoras).

Pero este enfoque para la gestión del dolor tenía claros inconvenientes. Estudios revelaban que medir el dolor de los pacientes no resultaba en un mejor control del dolor. Los médicos mostraban poco interés en, o no sabían cómo responder a la respuesta registrada. Y que los pacientes estuvieran satisfechos con discutir su dolor con el médico no significaba necesariamente que recibieran un tratamiento adecuado.

Al mismo tiempo, los medicamentos estaban alimentando la creciente epidemia de opioides. La investigación mostró que se estimaba que entre el 3% y el 19% de las personas que recibían una receta de medicamentos para el dolor desarrollaban una adicción.

Sin embargo, los médicos que querían tratar el dolor tenían pocas otras opciones. “Teníamos un buen sentido de que estos medicamentos no eran la única forma de manejar el dolor”, me dijo Linda Porter, directora de la Oficina de Políticas y Planificación del Dolor de los Institutos Nacionales de Salud. “Pero no teníamos una buena comprensión de la complejidad o las alternativas”.

El entusiasmo por los narcóticos dejó muchas variedades de dolor sin explorar y sin tratar durante años.

Solo en 2018, un año en que casi 50,000 estadounidenses murieron por una sobredosis, el Congreso comenzó a financiar un programa —la Red de Investigación Clínica de la Fase Temprana del Dolor, o EPPIC-Net— diseñado para explorar tipos de dolor y encontrar mejores soluciones. La red conecta especialistas en 12 centros clínicos académicos especializados y está destinada a iniciar nuevas investigaciones en este campo y encontrar soluciones a medida para diferentes tipos de dolor.

Una escala de cero a 10 puede tener sentido en ciertas situaciones, como cuando una enfermera la usa para ajustar la dosis de medicación para un paciente hospitalizado después de una cirugía o un accidente. Y los investigadores y especialistas en dolor han intentado crear mejores herramientas de calificación — docenas, de hecho, ninguna de las cuales fue adecuada para capturar la complejidad del dolor, concluyó un panel de expertos europeos.

Por ejemplo, la Administración de Salud de Veteranos creó una que tenía preguntas adicionales e indicaciones visuales: una calificación de 5 se correlacionaba con un ceño fruncido y un nivel de dolor que “interrumpe algunas actividades”. La encuesta tardaba mucho más y producía resultados que no eran mejores que el sistema de cero a 10.

Para la década de 2010, muchas organizaciones médicas, incluida la Asociación Médica Estadounidense y la Academia Estadounidense de Médicos de Familia, estaban rechazando no solo la escala de cero a 10, sino toda la noción de que un paciente podía informar su dolor de manera numérica y significativa.

En los años en que los opioides habían dominado los remedios para el dolor, algunos medicamentos — como la gabapentina y la pregabalina para la neuropatía, y los parches y cremas de lidocaína para los dolores musculoesqueléticos — estaban disponibles.

“Había una creciente conciencia de la increíble complejidad del dolor, y de que tendrías que encontrar los medicamentos adecuados para los pacientes adecuados”, me dijo Rebecca Hommer, directora interina de EPPIC-Net.

Los investigadores ahora están buscando biomarcadores asociados con diferentes tipos de dolor para que los estudios de medicamentos puedan usar medidas más objetivas para evaluar sus efectos. Una mejor comprensión de las vías neurales y los neurotransmisores que crean diferentes tipos de dolor también podría ayudar a los investigadores a diseñar medicamentos para interrumpirlos y domesticarlos.

Es poco probable que cualquier tratamiento que surja de esta investigación sea un éxito de taquilla como los opioides; por diseño, serán útiles para menos personas. Eso también los hace prospectos menos atractivos para las compañías farmacéuticas.

Así que EPPIC-Net está ayudando a pequeños laboratorios, académicos e incluso a médicos individuales a diseñar y realizar ensayos en etapa temprana para probar la seguridad y eficacia de moléculas prometedoras para aliviar el dolor.

Esa información se entregará a las farmacéuticas para ensayos en etapa tardía, todo con el objetivo de obtener nuevos medicamentos aprobados por la FDA más rápidamente. Los primeros ensayos de EPPIC-Net están comenzando. Encontrar mejores tratamientos no será una tarea fácil, porque el sistema nervioso es un universo en gran parte inexplorado de moléculas, células y conexiones eléctricas.

El Premio Nobel de Fisiología o Medicina 2021 fue para los científicos que descubrieron los mecanismos que nos permiten sentir las sensaciones más básicas: el frío y el calor. En comparación, el dolor es una hidra, un monstruo de muchas cabezas. Un simple número puede parecer definitivo. Pero no ayuda a nadie a que el dolor desaparezca.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Pain Doesn’t Belong on a Scale of Zero to 10

July 02, 2024

Over the past two years, a simple but baffling request has preceded most of my encounters with medical professionals: “Rate your pain on a scale of zero to 10.”

I trained as a physician and have asked patients the very same question thousands of times, so I think hard about how to quantify the sum of the sore hips, the prickly thighs, and the numbing, itchy pain near my left shoulder blade. I pause and then, mostly arbitrarily, choose a number. “Three or four?” I venture, knowing the real answer is long, complicated, and not measurable in this one-dimensional way.

Pain is a squirrely thing. It’s sometimes burning, sometimes drilling, sometimes a deep-in-the-muscles clenching ache. Mine can depend on my mood or how much attention I afford it and can recede nearly entirely if I’m engrossed in a film or a task. Pain can also be disabling enough to cancel vacations, or so overwhelming that it leads people to opioid addiction. Even 10+ pain can be bearable when it’s endured for good reason, like giving birth to a child. But what’s the purpose of the pains I have now, the lingering effects of a head injury?

The concept of reducing these shades of pain to a single number dates to the 1970s. But the zero-to-10 scale is ubiquitous today because of what was called a “pain revolution” in the ’90s, when intense new attention to addressing pain — primarily with opioids — was framed as progress. Doctors today have a fuller understanding of treating pain, as well as the terrible consequences of prescribing opioids so readily. What they are learning only now is how to better measure pain and treat its many forms.

About 30 years ago, physicians who championed the use of opioids gave robust new life to what had been a niche specialty: pain management. They started pushing the idea that pain should be measured at every appointment as a “fifth vital sign.” The American Pain Society went as far as copyrighting the phrase. But unlike the other vital signs — blood pressure, temperature, heart rate, and breathing rate — pain had no objective scale. How to measure the unmeasurable? The society encouraged doctors and nurses to use the zero-to-10 rating system. Around that time, the FDA approved OxyContin, a slow-release opioid painkiller made by Purdue Pharma. The drugmaker itself encouraged doctors to routinely record and treat pain, and aggressively marketed opioids as an obvious solution.

To be fair, in an era when pain was too often ignored or undertreated, the zero-to-10 rating system could be regarded as an advance. Morphine pumps were not available for those cancer patients I saw in the ’80s, even those in agonizing pain from cancer in their bones; doctors regarded pain as an inevitable part of disease. In the emergency room where I practiced in the early ’90s, prescribing even a few opioid pills was a hassle: It required asking the head nurse to unlock a special prescription pad and making a copy for the state agency that tracked prescribing patterns. Regulators (rightly) worried that handing out narcotics would lead to addiction. As a result, some patients in need of relief likely went without.

After pain doctors and opioid manufacturers campaigned for broader use of opioids — claiming that newer forms were not addictive, or much less so than previous incarnations — prescribing the drugs became far easier and were promoted for all kinds of pain, whether from knee arthritis or back problems. As a young doctor joining the “pain revolution,” I probably asked patients thousands of times to rate their pain on a scale of zero to 10 and wrote many scripts each week for pain medication, as monitoring “the fifth vital sign” quickly became routine in the medical system. In time, a zero-to-10 pain measurement became a necessary box to fill in electronic medical records. The Joint Commission on the Accreditation of Healthcare Organizations made regularly assessing pain a prerequisite for medical centers receiving federal health care dollars. Medical groups added treatment of pain to their list of patient rights, and satisfaction with pain treatment became a component of post-visit patient surveys. (A poor showing could mean lower reimbursement from some insurers.)

But this approach to pain management had clear drawbacks. Studies accumulated showing that measuring patients’ pain didn’t result in better pain control. Doctors showed little interest in or didn’t know how to respond to the recorded answer. And patients’ satisfaction with their doctors’ discussion of pain didn’t necessarily mean they got adequate treatment. At the same time, the drugs were fueling the growing opioid epidemic. Research showed that an estimated 3% to 19% of people who received a prescription for pain medication from a doctor developed an addiction.

Doctors who wanted to treat pain had few other options, though. “We had a good sense that these drugs weren’t the only way to manage pain,” Linda Porter, director of the National Institutes of Health’s Office of Pain Policy and Planning, told me. “But we didn’t have a good understanding of the complexity or alternatives.” The enthusiasm for narcotics left many varietals of pain underexplored and undertreated for years. Only in 2018, a year when nearly 50,000 Americans died of an overdose, did Congress start funding a program — the Early Phase Pain Investigation Clinical Network, or EPPIC-Net — designed to explore types of pain and find better solutions. The network connects specialists at 12 academic specialized clinical centers and is meant to jump-start new research in the field and find bespoke solutions for different kinds of pain.

A zero-to-10 scale may make sense in certain situations, such as when a nurse uses it to adjust a medication dose for a patient hospitalized after surgery or an accident. And researchers and pain specialists have tried to create better rating tools — dozens, in fact, none of which was adequate to capture pain’s complexity, a European panel of experts concluded. The Veterans Health Administration, for instance, created one that had supplemental questions and visual prompts: A rating of 5 correlated with a frown and a pain level that “interrupts some activities.” The survey took much longer to administer and produced results that were no better than the zero-to-10 system. By the 2010s, many medical organizations, including the American Medical Association and the American Academy of Family Physicians, were rejecting not just the zero-to-10 scale but the entire notion that pain could be meaningfully self-reported numerically by a patient.

In the years that opioids had dominated pain remedies, a few drugs — such as gabapentin and pregabalin for neuropathy, and lidocaine patches and creams for musculoskeletal aches — had become available. “There was a growing awareness of the incredible complexity of pain — that you would have to find the right drugs for the right patients,” Rebecca Hommer, EPPIC-Net’s interim director, told me. Researchers are now looking for biomarkers associated with different kinds of pain so that drug studies can use more objective measures to assess the medications’ effect. A better understanding of the neural pathways and neurotransmitters that create different types of pain could also help researchers design drugs to interrupt and tame them.

Any treatments that come out of this research are unlikely to be blockbusters like opioids; by design, they will be useful to fewer people. That also makes them less appealing prospects to drug companies. So EPPIC-Net is helping small drug companies, academics, and even individual doctors design and conduct early-stage trials to test the safety and efficacy of promising pain-taming molecules. That information will be handed over to drug manufacturers for late-stage trials, all with the aim of getting new drugs approved by the FDA more quickly.

The first EPPIC-Net trials are just getting underway. Finding better treatments will be no easy task, because the nervous system is a largely unexplored universe of molecules, cells, and electronic connections that interact in countless ways. The 2021 Nobel Prize in Physiology or Medicine went to scientists who discovered the mechanisms that allow us to feel the most basic sensations: cold and hot. In comparison, pain is a hydra. A simple number might feel definitive. But it’s not helping anyone make the pain go away.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Fake Therapist Fooled Hundreds Online Until She Died, State Records Say

July 02, 2024

Hundreds of Americans may have unknowingly received therapy from an untrained impostor who masqueraded as an online therapist, possibly for as long as two years, and the deception crumbled only when she died, according to state health department records.

Peggy A. Randolph, a social worker who was licensed in Florida and Tennessee and formerly worked for Brightside Health, a nationwide online therapy company, is accused of helping her wife impersonate her in online sessions, according to an investigation report from the Florida Department of Health.

The Florida report says the couple “defrauded” patients through a “coordinated effort”: As Randolph treated patients in person, her wife pretended to be her in telehealth sessions with Brightside patients. The deceit was discovered after the wife died last year and a patient realized they’d been talking to the wrong person, according to a Tennessee Department of Health settlement agreement.

Records from both states identify Randolph’s wife only by her initials, T.R., but her full name is in her obituary: Tammy G. Heath-Randolph. Therapists are generally expected to have at least a master’s degree, but Randolph’s wife was “not licensed or trained to provide any sort of counseling services,” according to the Tennessee agreement.

“[Randolph] denies knowing that T.R. was using her Brightside Health Therapist Portal log-in credentials or treating clients under her account. However, [she] received compensation for the sessions conducted,” the agreement states.

The alleged ruse has not been previously reported and its details and scope were only recently glimpsed in a few pages of public documents released by the state agencies. The Tennessee settlement, released in May, states that Randolph was supposed to provide online therapy to “hundreds of clients” while working for Brightside Health from January 2021 to February 2023. However, a Brightside internal investigation found it was actually Heath-Randolph who was “seeing all her patients and had been for a long time,” according to the Florida investigation report.

Randolph declined to comment.

The Florida and Tennessee records say Randolph voluntarily surrendered her social worker’s licenses in both states. This resulted in the health departments dropping their investigations, which limited the case details and documents available in the public record. Brightside’s internal investigation report has not been made public.

Brightside Health, a San Francisco company that offers nationwide online psychiatry and therapy sessions, declined to make an official available for an interview.

Company spokesperson Hannah Changi said in an email that as soon as Brightside learned of the allegations, it audited its security, fired Randolph, and reported her to state licensing authorities. Changi said Brightside can’t say how many patients were seen by Randolph’s wife “due to the nature of the incident and ongoing legal proceedings,” but said the company notified and refunded all “potentially impacted patients.”

“We take our patient experience seriously and hold ourselves to a high ethical code of conduct,” Changi said. “We’re extremely disappointed that a single provider was willing to violate the trust that Brightside and, most importantly, her patients had placed in her.”

Brightside was also required to alert the U.S. Department of Health and Human Services, which investigates data breaches that expose private medical information. In this breach, an “unauthorized individual” accessed the info of 767 people, including Social Security numbers and diagnoses, according to the agency’s online database.

Neither Florida nor Tennessee health officials answered questions about the case.

Dean Flener, a spokesperson for the Tennessee Department of Health, said details of Randolph’s case remain confidential under state law.

Jae Williams, a Florida Department of Health spokesperson, said a full investigation was not completed because Randolph surrendered her license, which has the same effect as the state revoking it but allowed her to keep “what dignity she had left.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Supreme Court Just Limited Federal Power. Health Care Is Feeling the Shockwaves.

July 01, 2024

A landmark Supreme Court decision that reins in federal agencies’ authority is expected to hold dramatic consequences for the nation’s health care system, calling into question government rules on anything from consumer protections for patients to drug safety to nursing home care.

The June 28 decision overturns a 1984 precedent that said courts should give deference to federal agencies in legal challenges over their regulatory or scientific decisions. Instead of giving priority to agencies, courts will now exercise their own independent judgment about what Congress intended when drafting a particular law.

The ruling will likely have seismic ramifications for health policy. A flood of litigation — with plaintiffs like small businesses, drugmakers, and hospitals challenging regulations they say aren’t specified in the law — could leave the country with a patchwork of disparate health regulations varying by location.

Agencies such as the FDA are likely to be far more cautious in drafting regulations, Congress is expected to take more time fleshing out legislation to avoid legal challenges, and judges will be more apt to overrule current and future regulations.

Health policy leaders say patients, providers, and health systems should brace for more uncertainty and less stability in the health care system. Even routine government functions such as deciding the rate to pay doctors for treating Medicare beneficiaries could become embroiled in long legal battles that disrupt patient care or strain providers to adapt.

Groups that oppose a regulation could search for and secure partisan judges to roll back agency decision-making, said Andrew Twinamatsiko, director of the Health Policy and the Law Initiative at Georgetown University’s O’Neill Institute. One example could be challenges to the FDA’s approval of a medication used in abortions, which survived a Supreme Court challenge this term on a technicality.

“Judges will be more emboldened to second-guess agencies,” he said. “It’s going to open agencies up to attacks.”

Regulations are effectively the technical instructions for laws written by Congress. Federal agency staffers with knowledge related to a law — say, in drugs that treat rare diseases or health care for seniors — decide how to translate Congress’ words into action with input from industry, advocates, and the public.

Up until now, when agencies issued a regulation, a single rule typically applied nationwide. Following the high court ruling, however, lawsuits filed in more than one jurisdiction could result in contradictory rulings and regulatory requirements — meaning health care policies for patients, providers, or insurers could differ greatly from one area to another.

One circuit may uphold a regulation from the Centers for Disease Control and Prevention, for example, while other circuits may take different views.

“You could have eight or nine of 11 different views of the courts,” said William Buzbee, a professor at Georgetown Law.

A court in one circuit could issue a nationwide injunction to enforce its interpretation while another circuit disagrees, said Maura Monaghan, a partner at Debevoise & Plimpton. Few cases are taken up by the U.S. Supreme Court, which could leave clashing directives in place for many years.

In the immediate future, health policy leaders say agencies should brace for more litigation over controversial initiatives. A requirement that most Affordable Care Act health plans cover preventive services, for example, is already being litigated. Multiple challenges to the mandate could mean different coverage requirements for preventive care depending on where a consumer lives.

Drugmakers have sued to try to stop the Biden administration from implementing a federal law that forces makers of the most expensive drugs to negotiate prices with Medicare — a key cog in President Joe Biden’s effort to lower drug prices and control health care costs.

Parts of the health care industry may take on reimbursement rates for doctors that are set by the Centers for Medicare & Medicaid Services because those specific rates aren’t written into law. The agency issues rules updating payment rates in Medicare, a health insurance program for people 65 or older and younger people with disabilities. Groups representing doctors and hospitals regularly flock to Washington, D.C., to lobby against trims to their payment rates.

And providers, including those backed by deep-pocketed investors, have sued to block federal surprise-billing legislation. The No Surprises Act, which passed in 2020 and took effect for most people in 2022, aims to protect patients from unexpected, out-of-network medical bills, especially in emergencies. The high court’s ruling is expected to spur more litigation over its implementation.

“This really is going to create a tectonic change in the administrative regulatory landscape,” Twinamatsiko said. “The approach since 1984 has created stability. When the FDA or CDC adopt regulations, they know those regulations will be respected. That has been taken back.”

Industry groups, including the American Hospital Association and AHIP, an insurers’ trade group, declined to comment.

Agencies such as the FDA that take advantage of their regulatory authority to make specific decisions, such as the granting of exclusive marketing rights upon approval of a drug, will be vulnerable. The reason: Many of their decisions require discretion as opposed to being explicitly defined by federal law, said Joseph Ross, a professor of medicine and public health at Yale School of Medicine.

“The legislation that guides much of the work in the health space, such as FDA and CMS, is not prescriptive,” he said.

In fact, FDA Commissioner Robert Califf said in an episode of the “Healthcare Unfiltered” podcast last year that he was “very worried” about the disruption from judges overruling his agency’s scientific decisions.

The high court’s ruling will be especially significant for the nation’s federal health agencies because their regulations are often complex, creating the opportunity for more pitched legal battles.

Challenges that may not have succeeded in courts because of the deference to agencies could now find more favorable outcomes.

“A whole host of existing regulations could be vulnerable,” said Larry Levitt, executive vice president for health policy at KFF.

Other consequences are possible. Congress may attempt to flesh out more details when drafting legislation to avoid challenges — an approach that may increase partisan standoffs and slow down an already glacial pace in passing legislation, Levitt said.

Agencies are expected to be far more cautious in writing regulations to be sure they don’t go beyond the contours of the law.

The Supreme Court’s 6-3 decision overturned Chevron U.S.A. v. Natural Resources Defense Council, which held that courts should generally back a federal agency’s statutory interpretation as long as it was reasonable. Republicans have largely praised the new ruling as necessary for ensuring agencies don’t overstep their authority, while Democrats said in the aftermath of the decision that it amounts to a judicial power grab.

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The Concierge Catch: Better Access for a Few Patients Disrupts Care for Many

July 01, 2024

“You had to pay the fee, or the doctor wasn’t going to see you anymore.”

That was the takeaway for Terri Marroquin of Midland, Texas, when her longtime physician began charging a membership fee in 2019. She found out about the change when someone at the physician’s front desk pointed to a posted notice.

At first, she stuck with the practice; in her area, she said, it is now tough to find a primary care doctor who doesn’t charge an annual membership fee from $350 to $500.

But last year, Marroquin finally left to join a practice with no membership fee where she sees a physician assistant rather than a doctor. “I had had enough. The concierge fee kept going up, and the doctor’s office kept getting nicer and nicer,” she said, referring to the décor.

With the national shortage of primary care physicians reaching 17,637 in 2023 and projected to worsen, more Americans are paying for the privilege of seeing a doctor — on top of insurance premiums that cover most services a doctor might provide or order. Many people seeking a new doctor are calling a long list of primary care practices only to be told they’re not taking new patients.

“Concierge medicine potentially leads to disproportionately richer people being able to pay for the scarce resource of physician time and crowding out people who have lower incomes and are sicker,” said Adam Leive, lead author of a 2023 study on concierge medicine and researcher at University of California-Berkeley’s Goldman School of Public Policy.

Leive’s research showed no decrease in mortality for concierge patients compared with similar patients who saw non-concierge physicians, suggesting concierge care may not notably improve some health outcomes.

A 2005 study showed concierge physicians had smaller proportions of patients with diabetes than their non-concierge counterparts and provided care for fewer Black and Hispanic patients.

There’s little reliable data available on the size of the concierge medicine market. But one market research firm projects that concierge medicine revenue will grow about 10.4% annually through 2030. About 5,000 to 7,000 physicians and practices provide concierge care in the United States, most of whom are primary care providers, according to Concierge Medicine Today. (Yes, the burgeoning field already has a trade publication.)

The concierge pitch is simple: More time with your doctor, in-person or remotely, promptly and at your convenience. With many primary care physicians caring for thousands of patients each in appointments of 15 minutes or less, some people who can afford the fee say they feel forced to pay it just to maintain adequate access to their doctor.

As primary care providers convert to concierge medicine, many patients could face the financial and health consequences of a potentially lengthy search for a new provider. With fewer physicians in non-concierge practices, the pool available to people who can’t or won’t pay is smaller. For them, it is harder to find a doctor.

Concierge care models vary widely, but all involve paying a periodic fee to be a patient of the practice.

These fees are generally not covered by insurance nor payable with a tax-advantaged flexible spending account or health savings account. Annual fees range from $199 for Amazon’s One Medical (with a discount available for Prime members) to low four figures for companies like MDVIP and SignatureMD that partner with physicians, to $10,000 or more for top-branded practices like Massachusetts General Hospital’s.

Many patients are exasperated with the prospect of pay-to-play primary care. For one thing, under the Affordable Care Act, insurers are required to cover a variety of preventive services without a patient paying out-of-pocket. “Your annual physical should be free,” said Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation. “Why are you paying $2,000 for it?”

Liz Glatzer felt her doctor in Providence, Rhode Island, was competent but didn’t have time to absorb her full health history. “I had double mastectomy 25 years ago,” she said. “At my first physical, the doctor ran through my meds and whatever else, and she said, ‘Oh, you haven’t had a mammogram.’ I said, ‘I don’t have breasts to have mammography.’”

In 2023, after repeating that same exchange during her next two physicals, Glatzer signed up to pay $1,900 a year for MDVIP, a concierge staffing service that contracts with her new doctor, who is also a friend’s husband. In her first couple of visits, Glatzer’s new physician took hours to get to know her, she said.

For the growing numbers of Americans who can’t or won’t pay when their doctor switches to concierge care, finding new primary care can mean frustration, delayed or missed tests or treatments, and fragmented health care.

“I’ve met so many patients who couldn’t afford the concierge services and needed to look for a new primary care physician,” said Yalda Jabbarpour, director of the Robert Graham Center and a practicing family physician. Separating from a doctor who’s transitioning to concierge care “breaks the continuity with the provider that we know is so important for good health outcomes,” she said.

That disruption has consequences. “People don’t get the preventive services that they should, and they use more expensive and inefficient avenues for care that could have otherwise been provided by their doctor,” said Abbie Leibowitz, chief medical officer at Health Advocate, a company that helps patients find care and resolve insurance issues.

What happens to patients who find themselves at loose ends when a physician transitions to concierge practice?

Patients who lose their doctors often give up on having an ongoing relationship with a primary care clinician. They may rely solely on a pharmacy-based clinic or urgent care center or even a hospital emergency department for primary care.

Some concierge providers say they are responding to concerns about access and equity by allowing patients to opt out of concierge care but stay with the practice group at a lower tier of service. This might entail longer waits for shorter appointments, fewer visits with a physician, and more visits with midlevel providers, for example.

Deb Gordon of Cambridge, Massachusetts, said she is searching for a new primary care doctor after hers switched to concierge medicine — a challenge that involves finding someone in her network who has admitting privileges at her preferred hospitals and is accepting new patients.

Gordon, who is co-director of the Alliance of Professional Health Advocates, which provides support services to patient advocates, said the practice that her doctor left has not assigned her a new provider, and her health plan said it was OK if she went without one. “I was shocked that they literally said, ‘You can go to urgent care,’” she said.

Some patients find themselves turning to physician assistants and other midlevel providers. But those clinicians have much less training than physicians with board certification in family medicine or internal medicine and so may not be fully qualified to treat patients with complex health problems. “The expertise of physician assistants and nurse practitioners can really vary widely,” said Russell Phillips, director of the Harvard Medical School Center for Primary Care.

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Idaho’s OB-GYN Exodus Throws Women in Rural Towns Into a Care Void

July 01, 2024

SANDPOINT, Idaho — The ultrasound in February that found a mass growing in her uterus and abnormally thick uterine lining brought Jonell Anderson more than anxiety over diagnosis and treatment.

For Anderson and other patients in this rural community who need gynecological care, stress over discovering an illness is compounded by the challenges they face getting to a doctor.

After that initial ultrasound, Anderson’s primary care provider referred her to an OB-GYN nearly an hour’s drive away in Coeur d’Alene for more testing.

Getting care for more serious gynecological issues, like a hysteroscopy, endometriosis, or polycystic ovary syndrome, has become much more difficult in Sandpoint, a town of about 10,000 people in Idaho’s panhandle region. A state law criminalizing abortions drove multiple OB-GYNs to leave town about a year ago.

The effects have been far-reaching. The OB-GYNs who left Sandpoint were also providing care to patients in nearby outlying areas, like Bonners Ferry, a roughly 40-minute drive into Idaho’s northernmost county. Doctors have spoken out about not feeling safe practicing medicine where they could face criminal charges for providing care to their patients. Republican lawmakers in Idaho contend doctors are being used in an effort to roll back the ban, and they declined to amend the law this year.

According to the Idaho Coalition for Safe Healthcare, a group advocating for a rollback of the state’s strict abortion ban, at least two hospitals, including Bonner General Health in Sandpoint, ended labor and delivery services in the 15 months after the state criminalized abortion in 2022. During that same time period, the number of OB-GYNs practicing in Idaho dropped by 22%. The report’s authors noted that many rural residents rely on consultations from medical specialists in urban parts of the state that are already struggling to provide care.

Those departures have expanded care deserts and added obstacles between patients and care, including for Anderson, 49.

Anderson’s car broke down when she was on the way to see an OB-GYN in Coeur d’Alene a few weeks after her initial ultrasound. Her husband took off work to drive her to a rescheduled appointment the same day. After hours of mishaps, she arrived for the visit, which lasted about 15 minutes. There, the doctor told her she’d need to come back for a hysteroscopy — an exam that shows the inside of the cervix and uterus — a few weeks later, followed by another appointment to go over results.

Four months later, in June, early results showed that the mass in Anderson’s uterus did not appear to be cancerous. She’s relieved, she said, but still concerned about nearing menopause and not having the support of an OB-GYN nearby to help her manage any symptoms or health issues that could come up.

“It sure was a whole level of stress that just added on because I had so much further to transport,” Anderson said. “Three years ago I would have been 10 minutes away from my appointment, not 60 minutes away.”

Those hardships patients face weigh heavily on the specialists who left.

Amelia Huntsberger, an OB-GYN, said that she and her husband are still grappling with a feeling of grief after being “forced out of Idaho” last year. They had lived in the state for more than a decade and practiced in Sandpoint. While leaving was a difficult decision, she said, she has no doubt it was the right one for her; her husband, who was a doctor in the emergency room at Bonner General; and their children.

“I think about things like who we are as a people,” Huntsberger said. “What do we value, and do our actions reflect our values?” Limiting access to care for women, pregnant or not, and their infants suggests lawmakers do not consider them important, she said.

Usha Ranji, an associate director for Women’s Health Policy at KFF, said she has heard anecdotally about providers leaving states with strict abortion bans like Idaho’s. Some recent medical graduates are also avoiding residency positions in states restricting abortion, making it harder to replace the outgoing providers, Ranji said.

Sandy Brower, a spokesperson for Bonner General, said the hospital is working to hire a gynecologist and is focused on building out its family provider team. She said other providers at the hospital are still treating women before and after pregnancy, but not during delivery unless it’s an emergency and the person cannot be transported.

Susie Keller, CEO of the Idaho Medical Association, said there’s a growing number of doctor vacancies in the state and that the number of applicants has “absolutely plummeted and those jobs are taking about twice as long as normal to fill.

“We are witnessing the dismantling of our health system,” Keller said.

As more community members feel the effects of a strained health system, some are following in the path of the doctors — they’re considering leaving. Anderson is among them.

Local education issues play a large part in that decision-making process, she said, as she considers her 9-year-old daughter’s future. But access to women’s health care is another piece of the puzzle.

“If I don’t have the care I need and she doesn’t have the care she needs,” Anderson said, “is that really somewhere we want to live?”

Ranji said polling indicates health care is a priority for people, so it could play into decisions about where they want to plant roots. And that leads into another way community members could respond to the changes in local care — by voting in state elections.

Primary election results from May in northern Idaho, where Sandpoint is located, showed signs of voters backing Republican candidates who hold more moderate views on abortion. Former state Sen. Jim Woodward narrowly beat Sen. Scott Herndon, a fellow Republican who sought reelection to his seat in the legislature.

Woodward, a self-described pro-life candidate with a stance against elective abortions, supports efforts to include exceptions for the health of the mother and removing the threat of felony charges against doctors who perform abortions. Herndon, on the other hand, provoked strong reactions during last year’s legislative session when he sponsored a bill that would have removed the already strict law’s current narrow exceptions for rape and incest.

Kathryn Larson, 66, has been campaigning as a Democrat for a seat representing most of Boundary and Bonner counties, the two northernmost in the panhandle region, in the state’s House of Representatives. She also has had recent firsthand experience falling into the care gap created by the exodus of OB-GYNs in Sandpoint.

In January, Larson went to the emergency room at Bonner General, a 25-bed critical access hospital, with severe chest pains. A cardiologist suggested an infection could be to blame. Larson said she also experienced vertigo and rapid heartbeat and later developed symptoms of a urinary tract infection. She was given rounds of antibiotics to treat the infection, but the symptoms returned.

More testing finally revealed the crux of the issue — Larson was dealing with a prolapsed bladder, which is not life-threatening but causes discomfort or pain and affects 1 in 3 women in their 60s.

After about five months of back-and-forth communication with providers in Post Falls and the eastern Washington city of Spokane, she scheduled an appointment for surgery in early June in Spokane, more than an hour’s drive from Sandpoint. Following surgery, during which doctors implanted a mesh structure to support her bladder, Larson is spending six to eight weeks recovering before heading into the final stretches of election season.

She said the November election will help others in her party tell if it will be possible to work across the aisle to loosen restrictions on the abortion policy during next year’s legislative session. She wants to slow the loss of needed providers across the state.

“People don’t feel safe,” Larson said.

The U.S. Supreme Court ruled on June 27 that Idaho must for now continue to allow abortions in medical emergencies. The ruling came in a lawsuit filed by the Biden administration, which argued that the federal Emergency Medical Treatment and Labor Act requires such care.

But the ruling does not provide a permanent solution. It kicks the case back to lower courts. Confusion remains over a doctor’s ability to perform abortions even in emergency settings, and the Idaho Medical Association said it will continue to work toward a clear health-of-the-mother exception within state law during next year’s legislative session.

“We still need more clarity for our state’s doctors,” OB-GYN Megan Kasper said in a medical association press release.

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1st Biden-Trump Debate of 2024: What They Got Wrong, and Right

June 28, 2024

President Joe Biden and former President Donald Trump, the presumptive Democratic and Republican presidential nominees, shared a debate stage June 27 for the first time since 2020, in a confrontation that — because of strict debate rules — managed to avoid the near-constant interruptions that marred their previous encounters.

Biden, who spoke in a raspy voice and often struggled to articulate his arguments, said at one point that his administration “finally beat Medicare.” Trump, meanwhile, repeated numerous falsehoods, including that Democrats want doctors to be able to abort babies after birth.

Trump took credit for the Supreme Court’s 2022 decision that upended Roe v. Wade and returned abortion policy to states. “This is what everybody wanted,” he said, adding “it’s been a great thing.” Biden’s response: “It’s been a terrible thing.”

In one notable moment, Trump said he would not repeal FDA approval for medication abortion, used last year in nearly two-thirds of U.S. abortions. Some conservatives have targeted the FDA’s more than 20-year-old approval of the drug mifepristone to further restrict access to abortion nationwide.

“The Supreme Court just approved the abortion pill. And I agree with their decision to have done that, and I will not block it,” Trump said. The Supreme Court ruled this month that an alliance of anti-abortion medical groups and doctors lacked standing to challenge the FDA’s approval of the drug. The court’s ruling, however, did not amount to an approval of the drug.

CNN hosted the debate, which had no audience, at its Atlanta headquarters. CNN anchors Jake Tapper and Dana Bash moderated. The debate format allowed CNN to mute candidates’ microphones when it wasn’t their turn to speak.

Our PolitiFact partners fact-checked the debate in real time as Biden and Trump clashed on the economy, immigration, and abortion, and revisited discussion of their ages. Biden, 81, has become the oldest sitting U.S. president; if Trump defeats him, he would end his second term at age 82. You can read the full coverage here and excerpts detailing specific health-related claims follow:

Biden: “We brought down the price [of] prescription drug[s], which is a major issue for many people, to $15 for an insulin shot, as opposed to $400.”

Half True. Biden touted his efforts to reduce prescription drug costs by referring to the $35 monthly insulin price cap his administration put in place as part of the 2022 Inflation Reduction Act. But he initially flubbed the number during the debate, saying it was lowered to $15. In his closing statement, Biden corrected the amount to $35.

The price of insulin for Medicare enrollees, starting in 2023, dropped to $35 a month, not $15. Drug pricing experts told PolitiFact when it rated a similar claim that most Medicare enrollees were likely not paying a monthly average of $400 before the changes, although because costs vary depending on coverage phases and dosages, some might have paid that much in a given month.

Trump: “I’m the one that got the insulin down for the seniors.”

Mostly False. When he was president, Trump instituted the Part D Senior Savings Model, a program that capped insulin costs at $35 a month for some older Americans in participating drug plans.

But because it was voluntary, only 38% of all Medicare drug plans, including Medicare Advantage plans, participated in 2022, according to KFF. Trump’s plan also covered only one form of each dosage and insulin type.

Biden points to the Inflation Reduction Act’s mandatory $35 monthly insulin cap as a major achievement. This cap applies to all Medicare prescription plans and expanded to all covered insulin types and dosages. Although Trump’s model was a start, it did not have the sweeping reach that Biden’s mandatory cap achieved.

Biden: Trump “wants to get rid of the ACA again.”

Half True. In 2016, Trump campaigned on a promise to repeal and replace the Affordable Care Act, or ACA. In the White House, Trump supported a failed effort to do just that. He repeatedly said he would dismantle the health care law in campaign stops and social media posts throughout 2023. In March, however, Trump walked back this stance, writing on his Truth Social platform that he “isn’t running to terminate” the ACA but to make it “better” and “less expensive.” Trump hasn’t said how he would do this. He has often promised Obamacare replacement plans without ever producing one.

Trump: “The problem [Democrats] have is they’re radical, because they will take the life of a child in the eighth month, the ninth month, and even after birth.”

False. Willfully terminating a newborn’s life is infanticide and illegal in every U.S. state. 

Most elected Democrats who have spoken publicly about this have said they support abortion under Roe v. Wade’s standard, which allowed access up to fetal viability — typically around 24 weeks of pregnancy, when the fetus can survive outside the womb. Many Democrats have also said they support abortions past this point if the treating physician deems it necessary.

Medical experts say situations resulting in fetal death in the third trimester are rare — fewer than 1% of abortions in the U.S. occur after 21 weeks — and typically involve fatal fetal anomalies or life-threatening emergencies affecting the pregnant person. For fetuses with very short life expectancies, doctors may induce labor and offer palliative care. Some families choose this option when facing diagnoses that limit their babies’ survival to minutes or days after delivery.

Some Republicans who have made claims similar to Trump’s point to Democratic support of the Women’s Health Protection Act of 2022, which would have prohibited many state government restrictions on access to abortion, citing the bill’s provisions that say providers and patients have the right to perform and receive abortion services without certain limitations or requirements that would impede access. Anti-abortion advocates say the bill, which failed in the Senate by a 49-51 vote, would have created a loophole that eliminated any limits on abortions later in pregnancy.

Alina Salganicoff, director of KFF’s Women’s Health Policy program, said the legislation would have allowed health providers to perform abortions without obstacles such as waiting periods, medically unnecessary tests and in-person visits, or other restrictions. The bill would have allowed an abortion after viability when, according to the bill, “in the good-faith medical judgment of the treating health care provider, continuation of the pregnancy would pose a risk to the pregnant patient’s life or health.”

Trump: “Social Security, he’s destroying it, because millions of people are pouring into our country, and they’re putting them onto Social Security. They’re putting them onto Medicare, Medicaid.”

False. It’s wrong to say that immigration will destroy Social Security. Social Security’s fiscal challenges stem from a shortage of workers compared with beneficiaries.

Immigration is far from a fiscal fix-all for Social Security’s challenges. But having more immigrants in the United States would likely increase the worker-to-beneficiary ratio, potentially for decades, thus extending the program’s solvency.

Most immigrants in the U.S. without legal permission are also ineligible for Social Security. However, people who entered the U.S. without authorization and were granted humanitarian parole — temporary permission to stay in the country — for more than one year are eligible for benefits from the program.

Immigrants lacking legal residency in the U.S. are generally ineligible to enroll in federally funded health care coverage such as Medicare and Medicaid. (Some states provide Medicaid coverage under state-funded programs regardless of immigration status. Immigrants are eligible for emergency Medicaid regardless of their legal status.)

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Supreme Court Upends Purdue Pharma Opioid Settlement

June 27, 2024

In a 5-4 vote, the court ruled that the Sackler family cannot be shielded from future claims through Purdue’s bankruptcy.

Since the case was first heard, victims of the opioid crisis and recovery advocates have been split on the desired outcome. Some wanted the bankruptcy deal to go through so that settlement money could start flowing and fund urgently needed addiction services. Others said it would be unacceptable to allow the Sacklers to evade responsibility for their actions.

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✍️: Aneri Pattani/KFF Health News

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Battleground Wisconsin: Voters Feel Nickel-and-Dimed by Health Care Costs

June 27, 2024

BIRNAMWOOD, Wis. — The land of fried cheese curds and the Green Bay Packers is among a half-dozen battleground states that could determine the outcome of the expected November rematch between President Joe Biden and former President Donald Trump — a contest in which the cost and availability of health care are emerging as defining issues.

At church picnics and summertime polka festivals that draw voters of all political stripes, Wisconsinites said they’re struggling to pay for even the most basic health care, from common blood tests to insulin prescriptions. A proposal by Wisconsin’s Democratic governor to expand the state’s Medicaid program to thousands of low-income residents has become a partisan lightning rod in the affordability debate: Democrats want it; Republicans don’t.

In 2020, voters here gave Biden, a Democrat, a narrow win after favoring Trump, a Republican, in 2016. Recent polling indicates that the two rivals were neck and neck in this year’s race. They were scheduled to square off tonight in the first televised debate of the campaign.

Many Wisconsin voters still can’t figure out whom to vote for — or whether to vote at all.

“I know he’s trying to improve health care and inflation, but I’m not happy with Biden,” said Bob Prelipp, 79, a Republican who lives in Birnamwood, a village of about 700 people in rural central Wisconsin. He reluctantly voted for Biden in 2020, after voting for Trump in 2016.

Prelipp was serving beer at the Birnamwood Polka Days festival on a muggy June day. Pro-Trump hats peppered the crowd, and against the backdrop of cheerful polka tunes, peppy dancing, and the sweet smell of freshly cut hay, candidates for local and state office mingled with voters.

This rural part of the state is ruby red. Trump flags fly over the landscape and businesses proudly display pro-Trump paraphernalia. Biden supporters are more visible and vocal in the Wisconsin population centers of Madison, the capital, and Milwaukee.

Biden “needs to get prices down. Everything is getting so unaffordable, even health care,” said Prelipp, a Vietnam War veteran who said his federal health care for veterans has improved markedly under Biden, including wait times for appointments. Yet he said he can’t stomach the idea of voting for him again, or for Trump, who has disparaged military veterans.

Prelipp said people are feeling nickel-and-dimed, not only at the grocery store and gas pump, but also at doctors’ offices and hospitals.

Greg Laabs, a musician in one of the polka bands at Birnamwood, displayed a pro-Trump sticker on his tuba. He said he likes his federal Medicare health coverage but worries that if Biden is reelected Democrats will provide publicly subsidized health care to immigrants lacking legal residency.

“There are thousands of people coming across the border,” said Laabs, 71. He noted that both Biden and Vice President Kamala Harris endorsed providing public health care to immigrants without legal residency as presidential candidates in 2019, a position that Harris’ home state of California has enthusiastically embraced. “We cannot support the whole world,” Laabs said.

The two main political parties will pick presidential nominees at their national conventions, and Biden and Trump are widely expected to be their choices. Republicans will gather in Milwaukee in July. Democrats will convene in Chicago in August.

Biden is trying to make health care a key issue ahead of the Nov. 5 election, arguing that he has slashed the cost of some prescription medications, lowered health insurance premiums, and helped get more Americans covered under the Affordable Care Act, also known as Obamacare. He has also been a strong supporter of reproductive rights and access to abortion, particularly since the U.S. Supreme Court struck down Roe v. Wade two years ago.

“The choice is clear: President Biden will protect our health care,” claims one of Biden’s campaign commercials.

Trump has said he wants to repeal Obamacare, despite multiple failed Republican attempts to do so over several years. “The cost of Obamacare is out of control,” Trump wrote last year. “I’m seriously looking at alternatives.”

Even Democrats who back Biden say the president must make it easier and cheaper to get medical care.

“I signed up for one of the Obamacare plans and got my cholesterol and blood sugar tested and it was like $500,” said Mary Vils, 63, a Democrat who lives in Portage County in central Wisconsin.

She strongly supports Biden but said people are feeling squeezed. “We’re fortunate because we had some savings, but that’s a lot of money out-of-pocket.”

Wisconsin Gov. Tony Evers, a Democrat, said he understands “the frustration that people have.”

Evers has repeatedly attempted to expand Medicaid to low-income adults who don’t have children, which all but 10 states have done since the enactment of Obamacare in 2010. The state’s Republican-controlled legislature has repeatedly blocked his efforts, yet Evers is trying again. Expanding Medicaid would provide coverage to nearly 90,000 low-income people, according to his administration.

Evers, who supports Biden, has argued that expanding Medicaid would bring in $2 billion in federal funding that would help reimburse hospitals and insurers for uncompensated care, and ultimately “make health care more affordable.”

Many states that have expanded Medicaid have realized savings in health care spending while providing coverage to more people, according to the Center on Budget and Policy Priorities, a think tank based in Washington, D.C.

“We have to get the Medicaid expansion money,” Evers told KFF Health News. “That would solve a lot of problems.”

Biden’s campaign is opening field offices in Wisconsin, and he and federal health care officials make frequent visits to the state. They’re touting Biden’s record of increasing subsidies for Obamacare insurance plans, and promising to expand access to care, especially in rural communities.

“Millions more people have coverage today,” said Neera Tanden, a domestic policy adviser to Biden, at a mid-June town hall event in Rothschild, Wisconsin, to announce $11 million in new federal funding to recruit and train health care workers.

She said the gains in Obamacare coverage have helped achieve “the lowest rate of uninsurance at any time in American history. That’s not an accident.”

But attendees at the town hall event told Tanden and the secretary of Health and Human Services, Xavier Becerra, that they have lost access to care as hospitals and rural health clinics have closed.

“We had a hospital that’s been serving our community for over 100 years close very suddenly,” said Michael Golat, an Altoona, Wisconsin, resident who described himself as an independent voter. “It’s really a crisis here.”

Becerra encouraged Wisconsin lawmakers to expand Medicaid. “Instantaneously, you would have hundreds of thousands of Americans in rural America, and including in rural Wisconsin, who now have access to care,” he said.

Cory Sillars, a Republican running for the Wisconsin State Assembly who campaigned at the Birnamwood polka festival, opposes Medicaid expansion and said the state should instead grant nurses the authority to practice medicine without doctor supervision, which he argued would help address gaps in rural care.

“If you’re always expanding government programs, you get people hooked on government and they don’t want to do it themselves. They expect it,” he said.

Sillars is running as a “pro-life” candidate with “traditional, Christian values,” an anti-abortion stance that some Democrats hope will backfire up and down the ballot.

Kristin Lyerly, an obstetrician-gynecologist and a Democrat, has made access to abortion and contraception central to her campaign to fill the congressional seat vacated by Mike Gallagher, a Republican who resigned in April.

Lyerly lives outside Green Bay but practices in Minnesota after facing threats and harassment, largely from conservative extremists, she said. She was a plaintiff in the state’s legal bid to block Republicans from halting access to abortions. Abortions still are not available everywhere in Wisconsin, she said.

“It is incumbent upon me as a physician and a woman to stand up and to use my voice,” Lyerly said. “This is an issue that people in this district might not be shouting about, but they’re having conversations about it, and they’re going to vote on it.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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An Arm and a Leg: Meet the Middleman’s Middleman

June 25, 2024

Some people who expected their health insurance to cover some out-of-network care have been getting stuck with enormous bills.

One Kansas City, Kansas, couple paid thousands of dollars out-of-pocket and up-front for care. They expected to get a partial reimbursement from their insurer. So, they were shocked when instead they got a bill saying they owed even more than what they’d already paid.

It turns out, a little-known data firm called MultiPlan was working with their insurance company to suggest cuts to their coverage. MulitPlan says it’s helping control ballooning health care costs by keeping hospitals and providers from overbilling. But it’s often patients left paying the difference.In this episode of “An Arm and a Leg,” host Dan Weissmann breaks down this confusing world of out-of-network care with New York Times reporter Chris Hamby, who recently published an investigation into MultiPlan.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Claire Davenport Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: Meet the Middleman’s Middleman

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there! Paul and Kristin live in Kansas City with their two kids. Kristin and their daughter, the older kid– they have some complex medical issues, need to see some specialized folks. And some of those folks don’t take Kristin and Paul’s insurance. They’re “out of network,” so Kristin and Paul pay out of pocket– a lot. Maybe $20,000 a year. BUT their health insurance plan does reimburse some out-of-network care. 

o, in January 2023, Kristin called a help line connected with the insurance plan to find out how that was gonna work. 

Kristin H: They basically said, sure, easy peasy, you pay and then you get online and you click this form, you show what you paid, and then we send you a check and reimburse you. 

Dan: Kristin was on it. She built a whole spreadsheet to track every bill she paid, every reimbursement form she’d submitted. And she waited for the checks. The insurance company gave itself months just to process the claims. And when they finally sent statements, the statements seemed … weird. They were like: 

Kristin H: Here’s what you paid, and here’s your discounts, and here’s what you may owe. 

Dan: And Kristin was like … what? 

Kristin H: Because I was thinking, well, I don’t owe anything. We paid out of pocket, but then I was thinking, well, this must be the portion that they’re paying us back. But then the math didn’t add up. 

Dan: Yeah. Not at all. Kristin was expecting to get 50 percent back, like her plan said she would. But this amount wasn’t anything like 50 percent. And what’s this “discount” business? 

It took months– and a lot of digging from Paul, and ultimately a talk with a NewYork Times reporter– before Kristin and Paul understood what was going on, and why it was costing them thousands of dollars. 

What they didn’t know until that New York Times story came out was: Someone was making a multi-billion dollar business out of experiences like theirs. As that story made clear, LOTS of people who expected their insurance to cover them for expensive out-of-network care ended up on the hook for a lot more than they’d expected. 

That story introduced readers to a character who’s become kind of a TYPE on this show. Not a type of person, but a type of business: A middleman that works behind the scenes with insurance companies. So we’ve seen that dynamic with pharmacy benefit managers– the folks who decide what drugs you can get and for how much– and more recently, we looked at a company that uses an algorithm to justify kicking folks out of nursing homes. The middleman in this New York Times story was a company called MultiPlan. 

Reporter Chris Hamby found MultiPlan and insurance companies they worked with were leaving patients on the hook for huge amounts that they absolutely had not expected to pay. MultiPlan was also, along with those insurance companies, pocketing big fees. That story got some folks’ attention. A U.S. Senator has called for action from antitrust regulators. Those regulators might get interested. And we may wanna egg them on– so we’re gonna need to understand the whole scheme. Whothis middleman is– MultiPlan– and how they got themselves in the middle of 60 million people’s health insurance, by their own estimate … and how they make a lot of money. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So, our job on this show is to take one of the most enraging, terrifying, depressing parts of American life– and bring you a show that’s entertaining, empowering, and useful. 

And this time, I’ve got help. 

Chris Hamby: My name is Chris Hamby. I’m a reporter on the investigations desk at the New York Times. 

Dan: Yeah, and of course, Chris is the one who spent months figuring out the story of this middleman company, MultiPlan. 

Chris Hamby: I was poking around a number of areas related to health insurance, and this name just kept coming up. 

Dan: Like in lawsuits. 

Chris Hamby: And it wasn’t always terribly clear what they did exactly or how they were compensated. 

Dan: Or how doctors and patients– regular people– were affected. 

Chris Hamby: So that’s why I decided to try and figure this out, and it’s sort of an opaque space as so many areas of health care are these days. 

Dan: Yeah. In fact, in order to understand this story at all– to understand who’s doing WELL in this scenario– we’ve gotta peel back a layer. It’s something we’ve talked about here before, but not for a while, and you know, not even my mom remembers everything I’ve ever said here. 

This is about the mechanics of how most health insurance people get from their job actually works: about who actually pays medical bills when your insurance settles a claim. It’s not the insurance company. It’s actually the employer paying those bills. 

Of course, employers don’t know how to actually RUN an insurance plan. [Unless the employer is Aetna, I guess]. So they hire insurance companies to administer them. You get a card that says Cigna or Blue Cross, but your employer’s funds actually pay the medical bills, so these are called “self-funded” plans. But this is all stuff most of us are just not aware of. 

Here’s Chris Hamby: 

Chris Hamby: I hadn’t, until about a year ago, even heard of a self-funded plan. And I like to think that I’m reasonably well informed on this stuff. 

Dan: Yeah, that is putting it mildly. Chris made his name and won a Pulitzer Prize covering workplace health issues. So, just park that for a minute: self-funded plan, where the employer is the “self,” actually paying the bills, and paying the insurance company a fee. The insurance company is a middleman. 

OK, now, next layer: The middleman’s middleman. In this case, the company MultiPlan that Chris wrote about. What’s their job? So in this story, the job they’re doing– their middleman job– is to address what is admittedly kind of a tough question: If you go see somebody– a doctor, a therapist– who doesn’t take your insurance, what happens? 

Chris Hamby: How do you determine what a fair amount to pay the provider is? And by extension, how much is the patient potentially on the hook for the unpaid balance? And that has long been a contentious issue. 

Dan: Because, if they don’t take your insurance, a provider could charge … absolutely anything. So is your insurer– and again, that’s often actually your employer– supposed to pay absolutely anything? How much are they supposed to pay? Figuring that out, it’s a job. 

About 15 years ago, another middleman company doing that job got sued by the NewYork state attorney general. The state said this earlier middleman’s way of figuring out what to pay was screwing over both providers and patients. And the state’s lawsuit produced a solution. 

Chris Hamby: The insurance companies agreed to fund the creation of a nonprofit entity that was going be sort of an independent, neutral arbiter of fair prices. It was going to collect data from all the insurers and just make it publicly available. Make sure it was transparent to everyone. 

Dan: This nonprofit is called FAIR Health, and its data is actually public. It still exists. Like, you can use it yourself — you can look up the going rate for a knee replacement, a blood test, whatever. 

Chris Hamby: You can plug in your zip code, plug in your medical procedure and see an estimate of what, you know, typical out-of-network charges and in-network charges would be for these. 

Dan: It’s cool! Check it out yourself; it’s useful. And all the major insurance companies agreed to use it– to use FAIR Health’s benchmarks– to decide what to pay for out-of-network stuff. But, those agreements only committed insurance companies to using FAIR Health for … five years. They expired in 2014. 

Enter middleman companies like MultiPlan, saying to insurance companies: Hey, you COULD use FAIR Health– or you could route out-of-network bills to us: Hire us to get you an even better deal– better prices. 

Chris Hamby: And it’s important to note also that this is a time when private equity is investing in healthcare, and there are some legitimate concerns about driving up those list prices to ridiculously high levels in a lot of cases. So, there were real issues that insurers were saying that they were responding to at the time.

Dan: OK, so that’s the pitch. MultiPlan is saying to insurance companies: We’ll help you hold the line. We can save you more money than if you used FAIR Health. Well, kind of. Because here’s where we come back to the whole thing about self-funded insurance. MultiPlan isn’t saying, “We can save YOU, insurance company, more money than if you used FAIR Health.” They’re saying, “We can help you save your CLIENTS– employers who do self-funded health insurance– more money. And when you save them money, you’re gonna make money. Because you can charge them a percentage of what you’re saving them. And we’ll get a percentage too.” A percentage of the savings. On every single bill. That’s a very different deal than just using FAIR Health’s data. 

Chris Hamby: FAIR Health is not taking a percentage of the savings that they obtain. They’re just selling you their data. And the insurers typically are not charging employers a fee for using FAIR Health’s data. But if they use MultiPlan’s data, both MultiPlan and the insurer typically charge a fee. 

Dan: A percentage. In examples from Chris’s story, the insurance company gets 35 percent of those savings. 

Chris Hamby: And this has become a significant amount of money for a lot of insurance companies. Overall, UnitedHealthcare, is up to, you know, around a billion dollars per year in recent years. 

Dan: UnitedHealthcare collects like a billion dollars in fees for these services, basically, for using MultiPlan specifically? 

Chris Hamby: And they couch that by saying some other out-of-network savings programs, but yes. 

Dan: Whooh! 

Chris Hamby: One thing that the insurers say is that the employers are aware of this; they’ve signed up for it. 

Dan: That employers are hiring, say, Cigna, with MultiPlan to find savings. And employers are agreeing to the fees. 

Chris Hamby: Where it gets a little bit dicier from the employer’s perspective is when you see claims where, for instance, you end up paying the insurance company more in fees than you paid the doctor for treating your employee. 

Dan: yeah, one example from Chris’s story: An out-of-network provider wanted more than $150,000 on one bill. And after the insurance company and MultiPlan did their bit, the employer, a trucking company, ended up paying $58,000. Eight thousand for the provider, and $50,000 to the insurance company and MultiPlan. So, on the one hand, the employer maybe saved $90,000. But paying $50,000 for “cost containment?” Maybe doesn’t sound like such a bargain. 

Some employers and a union that runs a health plan have filed lawsuits looking for some of that money back. And there’s also a big irony here because MultiPlan’s pitch is, you need us because sticker prices are super-wildly high. But MultiPlan isn’t doing anything to contain the sticker prices as a systemic problem. In fact, the higher providers crank up their sticker prices, the more money MultiPlan and the insurance companies they work with can make. But then there’s a big question too, which is, what happens to the rest of that bill for the sticker price? Who pays that? That’s next … 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. The folks at KFF Health News are amazing journalists. Their work wins all kinds of awards, every year. We’re honored to work with them. 

So, a provider sends a bill. MultiPlan and the insurance company say, “Woah, way too much.” And then what happens? Well, it depends. Sometimes, MultiPlan negotiates with the provider. They’ve got people who do this. And those negotiators drive hard bargains. According to Chris’s story, negotiators sometimes tell providers: Here’s my offer, you’ve got a few hours to take it or leave it, and my next offer might be lower. 

Chris talked with a pediatric therapist who said an offer based on MultiPlan’s calculation was less than half of what Medicaid pays. Less than half. And Medicaid rates– they’re notoriously pretty low. Chris talked with some of MultiPlan’s negotiators too. 

Chris Hamby: It was interesting because some of the negotiators felt that they were doing their part to hold down costs and really sort of stick it to providers and hospitals that were price gouging. 

Dan: But …one told Chris she knew the offers she made– they weren’t fair. “It’s just a game,” another one said. “It’s sad.” And maybe the difference is that some of these negotiators were thinking of a big hospital charging $150,000  for something. And maybe some of them were thinking of someone like that therapist– the one who got offered less than half of Medicaid’s rate. 

And I’m not gonna get into the question of who should be doing this kind of negotiating, or what’s fair. I mean, not today, anyway. Because: in a lot of cases with MultiPlan, there’s no negotiation at all. Negotiation only happens when the employer has told the insurance company, look, protect my people. Figure out SOMETHING with the provider so they don’t go after my workers for the rest. 

But that doesn’t always happen. A lot of the time, what happens is: The provider sends a bill. The insurance company kicks in whatever it decides to … and that’s it. 

So Chris’s story opens with a woman who had surgery. With MultiPlan’s help, her insurance company decided to pay about $5,400. And she got stuck with a bill for more than $100,000. 

And then there’s Kristin and Paul in Kansas City. They paid their bills upfront and then looked to get reimbursed– kept a spreadsheet. But when their claims finally got processed, the numbers didn’t add up. Here’s what they saw: Like pretty much every insurance plan, Kristin and Paul’s had a “deductible”– an amount they had to pay out of pocket before insurance would reimburse anything. 

Kristin H: Then I started watching the deductible and you know, when I calculated my spreadsheet of how much we had paid out of pocket, and when we saw what was on like our out-of-network spend, those two weren’t matching. 

Dan: She really couldn’t figure this out. 

Kristin H: I just kind of handed over all of my spreadsheets to Paul, and so that’s when he started digging into the “your discount.” 

Dan: “Your discount…” That was this mysterious number on all the statements from the insurance company. In addition to the provider’s rate, and what insurance might pay, the statements listed, quote, “your discount.” 

Paul H: And I’m like, what is this? I don’t understand why it’s talking about a discount. We are paying cash out of pocket to the provider at their billed rate, and our insurance is saying that there’s some sort of discount. 

Dan: After a bunch of phone calls, he figured it out: The discount was … the difference between the amount on the bill and what the insurance company– with MultiPlan’s help– had decided was a “fair price.” 

Paul H: For example, an occupational therapy bill that might be $125, this third party adjuster might come back and say, essentially what the market rate for that should be is $76. And so, your discount, quote, unquote, is $49. 

Dan: Except of course, it wasn’t a discount for Kristin and Paul. They had already paid that $49, when they paid the provider upfront. Once Kristin and Paul learned what the “discount” actually meant, they started to understand who actually got the benefit– the insurer. Because … 

Kristin H: That discounted rate is actually what will be applied to your deductible. So you’re not going to hit your deductible nearly as quickly as you think. Right? Because we’ve essentially ignored half of your payment. 

Dan: This hits Kristin and Paul in two ways. 

First, it means they’re actually spending a lot more before their insurance kicks in. It also means that when their insurance does start reimbursing them a percentage of what they’ve spent, the insurance is only paying a percentage of that lower amount. Overall, it means the reimbursements Kristin and Paul get are gonna be thousands of dollars less than they’d expected. 

I mean, it took a LOT of work for Kristin and Paul to figure this out. At one point, Paul posted to Reddit asking for help– that’s where Chris Hamby found him. In Paul’s post, he noted how nobody ever even mentioned this third-party adjuster– not until he had already talked to his insurance company for what he said was “about 18 times.” Frequently on hold for 45 minutes or more. 

Kristin says once they finally figured out what was going on, they could figure out how to budget for it. There were sacrifices. She stopped seeing one of her providers as often. But finally figuring out what was going on also allowed them to live with it. 

Kristin H: The infuriating part was telling, like doing exactly what we were told to do, following the process, and then feeling like you are crazy. Like why, why doesn’t this make sense? You know? And so I think I’m fortunate that Paul just wouldn’t let it die and was gonna research until he figured it out. 

Dan: You did all of the work, you tracked it down, you identified the problem, and you, as you say, kind of resigned yourself to it. You’re like, okay, this Goliath is not– we don’t have the slingshot for this. Goliath is stomping all over our town, and we have to live in that reality. Having the knowledge, having done that work, gives you, it sounds like, an ability to have some peace. Like having tracked it down means that this sucks, but it’s not the same as living in a situation where like, now what? Like anything could happen.

Kristin H: Yeah, you feel crazy or hopeless. You know? Like I’ve done everything and this doesn’t … So there’s just the sense of like, am I missing something? You know, is there anything left for me to do? I recognize that everyone is not like this, but for me, knowledge is a gift. 

Dan: Chris Hamby says there’s rarely a way to get this kind of knowledge in advance. He says you’re unlikely to find these kinds of details in your insurance plan document. 

Chris Hamby: It typically will not say when you go out of network, we’re going to send your claim to a third party that you’ve never heard of to price it. It will just give some sort of vague language about competitive rates in your geographic area. And if you call up in advance of seeking the care to try and get an estimate, most of the time you will not get much more specifics than that. They tell you you have to just go and they’ll process the claim and you’ll see when the explanation of benefits comes through. 

Dan: Yeah, and look, I hate to get you even angrier, but Chris says the rules can change on you, without notice. 

Chris Hamby: A lot of people that I talk with also have seen no change in their insurance plan, but they’ve seen their reimbursement rates decline over time. 

Dan: Turns out, behind the scenes, their insurance made a switch from a service like FAIR Health, which looks at what’s getting paid in general, to a service like MultiPlan, which looks for the steepest possible price cuts. 

Chris Hamby: And the difference between those two amounts can be vast. So you have people who in some cases stop seeing their doctors because their costs doubled almost overnight. 

Dan: Oh god. And still. Better to know. Better that as many of us know as possible. That’s why Chris reviewed more than 50,000 pages of documents, and interviewed more than a hundred people for that story. And why lawyers for the New York Times helped get courts to agree to give him documents that had been under seal. 

Kristin and Paul– who had figured most of this out for themselves– they definitely appreciated all that work. 

Paul H: When Chris published the article that he did, it was very validating to know we’re not the only ones who are in this same boat. And there’s actually people who have had far worse experiences than ours. Like, ours kind of pale in comparison. And then immediately, like, within 24 hours to see 1,500 or 1,600 comments on the article talking about it. It’s like, okay, I might not have the stone that can slay the giant, but maybe The NewYork Times has the right sling and they might have the right stone to at least start the conversation. 

Dan: A few weeks after Chris’s article came out, U.S. Senator Amy Klobuchar sent the top federal antitrust regulators a letter: She wanted them to take a hard look at MultiPlan. 

Chris Hamby: She expressed concern about the potential for price fixing here. 

Dan: Actually, Chris says some providers have already filed lawsuits against MultiPlan based on antitrust allegations. 

Chris Hamby: The idea is that all the insurance companies outsource their pricing decisions to a common vendor. They’re essentially fixing prices via algorithm is the allegation. 

Dan: As we noted here a few episodes ago, these antitrust regulators in the Biden administration have gotten pretty feisty. [That was the episode about the cyberattack on a company called Change Healthcare. It was called “The Hack,” if you missed it. Pretty fun!] 

And I mean, those antitrust regulators have their work cut out for them. And a lot of targets. But I do want to egg them on here. I suspect you do too. Meanwhile, you’re egging US on. 

Listener 1: The first thought that went through my head was I’m going to fight this because this is absolutely ridiculous. I’ve already paid for this. 

Dan: A few weeks ago, we asked you for stories about your experiences with sneaky fees, often called facility fees. 

Listener 2: When the facility fee is twice the office visit fee, it’s just crazy. I mean, it’s a 10-minute appointment for a prescription. 

Dan: You came through, and now we’re making some calls, digging in for more details, and learning so much. We’re gonna have a sneak preview for you in a few weeks. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport– our summer intern. Welcome aboard, Claire!– and edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism. Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thanks to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/

Thanks for pitching in if you can, and thanks for listening.

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

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Medicaid for Millions in America Hinges on Deloitte-Run Systems Plagued by Errors

June 24, 2024

Deloitte, a global consultancy that reported revenue last year of $65 billion, pulls in billions of dollars from states and the federal government for supplying technology it says will modernize Medicaid.

The company promotes itself as the industry leader in building sophisticated and efficient systems for states that, among other things, screen who is eligible for Medicaid. However, a KFF Health News investigation of eligibility systems found widespread problems.

The systems have generated incorrect notices to Medicaid beneficiaries, sent their paperwork to the wrong addresses, and been frozen for hours at a time, according to findings in state audits, allegations and declarations in court documents, and interviews. It can take months to fix problems, according to court documents from a lawsuit in federal court in Tennessee, company documents, and state agencies. Meanwhile, America’s poorest residents pay the price.

Deloitte dominates this important slice of government business: Twenty-five states have awarded it eligibility systems contracts — with 53 million Medicaid enrollees in those states as of April 1, 2023, when the unwinding of pandemic protections began, according to the Centers for Medicare & Medicaid Services. Deloitte’s contracts are worth at least $5 billion, according to a KFF Health News review of government contracts, in which Deloitte commits to design, develop, implement, or operate state systems.

State officials work hand in glove with Deloitte behind closed doors to translate policy choices into computer code that forms the backbone of eligibility systems. When things go wrong, it can be difficult to know who’s at fault, according to attorneys, consumer advocates, and union workers. Sometimes it takes a lawsuit to pull back the curtain.

Medicaid beneficiaries bear the brunt of system errors, said Steve Catanese, president of Service Employees International Union Local 668 in Pennsylvania. The union chapter represents roughly 19,000 employees — including government caseworkers who troubleshoot problems for recipients of safety-net benefits such as health coverage and cash assistance for food.

“Are you hungry? Wait. You sick? Wait,” he said. “Delays can kill people.”

KFF Health News interviewed Medicaid recipients, attorneys, and former caseworkers and government employees, and read thousands of pages from contracts, ongoing lawsuits, company materials, and state audits and documents that show problems with Deloitte-operated systems around the country — including in Arkansas, Colorado, Florida, Georgia, Kentucky, Pennsylvania, Rhode Island, Tennessee, and Texas.

In an interview, Kenneth Smith, a Deloitte executive who leads its national human services division, said Medicaid eligibility technology is state-owned and agencies “direct their operation” and “make decisions about the policies and processes that they implement.”

“They’re not Deloitte systems,” he said, noting Deloitte is one player among many who together administer Medicaid benefits.

Alleging “ongoing and nationwide” errors and “unfair and deceptive trade practices,” the National Health Law Program, a nonprofit that advocates for people with low incomes, urged the Federal Trade Commission to investigate Deloitte in a complaint filed in January.

“Systems built by Deloitte have generated numerous errors, resulting in inaccurate Medicaid eligibility determinations and loss of Medicaid coverage for eligible individuals in many states,” it argued. “The repetition of the same errors in Deloitte eligibility systems across Texas and other states and over time demonstrates that Deloitte has failed.”

FTC spokesperson Juliana Gruenwald Henderson confirmed receipt of the complaint but did not comment further.

Smith called the allegations “without merit.”

The system problems are especially concerning as states wade through millions of Medicaid eligibility checks to disenroll people who no longer qualify — a removal process that was paused for three years to protect people from losing insurance during the covid-19 public health emergency. In that time, nationwide Medicaid enrollment grew by more than 22 million, to roughly 87 million people. At least 22.8 million have been removed as of June 4 , according to a KFF analysis of government data.

Advocates worry many lost coverage despite being eligible. A KFF survey of adults disenrolled from Medicaid during the first year of the unwinding found that nearly 1 in 4 adults who were removed are now uninsured. Nearly half who were removed were able to reenroll, the survey showed, suggesting they should not have been dropped in the first place.

“If there is a technology challenge or reason why someone can’t access health care that they're eligible for, and we're able to do something,” Smith said, “we work tirelessly to do so.”

Deloitte’s contracts with states regularly cost hundreds of millions of dollars, and the federal government pays the bulk of the cost.

“States become very dependent on the consultant for operating complex systems of all kinds” to do government business, said Michael Shaub, an accounting professor at Texas A&M University.

Georgia’s contract with Deloitte to build and maintain its system for health and social service programs, inked in 2014, as of January 2023 was worth $528 million. This January, state officials wrote in an assessment obtained by KFF Health News that its eligibility system “lacks flexibility and adaptability, limiting Georgia’s ability to serve its customers efficiently, improve the customer and worker experience across all programs, ensure data security, reduce benefit errors and fraud, and advance the state’s goal of streamlining eligibility.”

Deloitte and the Georgia Department of Community Health declined to comment.

Deloitte is looking ahead with its “path to Medicaid in 2040,” anticipating sweeping changes that will expand its own business opportunity.

“State Medicaid leaders and policymakers are hungry to know what the future of health care holds,” the company said. “Deloitte brings the innovative tools, subject matter expertise, and time-tested experience to help states.”

Trouble in Tennessee

When Medicaid eligibility systems fail, beneficiaries suffer the consequences.

DiJuana Davis had chronic anemia that required iron infusions. In 2019, the 39-year-old Nashville resident scheduled separate surgeries to prevent pregnancy and to remove the lining of her uterus, which could alleviate blood loss and ease her anemia.

Then Davis, a mom of five, received a shock: Her family’s Medicaid coverage had vanished. The hospital canceled the procedures, according to testimony in federal court in November.

Davis had kept her insurance for years without trouble. This time, Tennessee had just launched a new Deloitte-built eligibility system. It autofilled an incorrect address, where Davis had never lived, to send paperwork, an error that left her uninsured for nearly two months, according to an ongoing class-action lawsuit Davis and other beneficiaries filed against the state.

The lawsuit, which does not name Deloitte as a defendant, seeks to order Tennessee to restore coverage for those who wrongly lost it. Kimberly Hagan, Tennessee Medicaid’s director of member services, said in a court filing defending the state’s actions that many issues “reflect some unforeseen flaws or gaps” with the eligibility system and “some design errors.”

Hagan’s legal declaration in 2020 gave a view of what went wrong: Davis lost coverage because of missteps by both Tennessee and Deloitte during what’s known as the “conversion process,” when eligibility data was migrated to a new system.

Tennessee’s Medicaid agency, known as “TennCare, along with its vendor, Deloitte, designed rules to govern the logic of conversion,” Hagan said in the legal declaration. She also cited a “manual, keying error by a worker” made in 2017.

Davis’ family was “incorrectly merged with another family during conversion,” Hagan said.

Davis regained coverage, but before she could rebook the surgeries, she testified, she became pregnant and a serious complication emerged. In June 2020, Davis rushed to the hospital. A physician told her she had preeclampsia, a leading cause of maternal death. Labor was induced and her son was born prematurely.

“Preeclampsia can kill the mom. It can kill the baby. It can kill both of you,” she testified. “That’s like a death sentence.”

Deloitte’s Tennessee contract is worth $823 million. Deloitte declined to comment on Davis’ case or the litigation.

Speaking broadly, Smith said, “data conversion is incredibly challenging and difficult.”

Hagan called the problems one-time issues: “None of the Plaintiffs’ cases reflect ongoing systemic problems that have not already been addressed or are scheduled to be addressed.”

States leverage Deloitte’s technology as part of a larger push toward automation, legal aid attorneys and former caseworkers said.

“We all know that big computer projects are fraught,” said Gordon Bonnyman, co-founder of the nonprofit Tennessee Justice Center. “But a state that was concerned about inflicting collateral damage when they moved to a different automated system would have a lot of safeguards.”

TennCare spokesperson Amy Lawrence called its eligibility system “a transformative tool, streamlining processes and enhancing accessibility.”

When enrollees seek help at county offices, “you don’t get to sit down across from a real human being,” Bonnyman said. “They point you to the kiosk and say, ‘Good luck with that.’”

A Backlog of 50,000 Cases

As part of the Affordable Care Act rollout about a decade ago, states invested in technological upgrades to determine who qualifies for public programs. It was a financial boon to Deloitte and such companies as Accenture and Optum, which landed government contracts to build those complex systems.

Problems soon emerged. In Kentucky, a Deloitte-built system that launched in February 2016 erroneously sent at least 25,000 automated letters telling people they would lose benefits, according to local news reports. State officials manually worked through a backlog of 50,000 cases caused by conflicting information from newly merged systems, the reports say.

“We know that the rollout of Benefind has caused frustration and concern for families and for field staff,” senior Deloitte executive Deborah Sills said during a March 2016 news conference alongside Gov. Matt Bevin and other senior officials after Kentucky was bombarded with complaints. Within two months, roughly 600 system defects were identified, found a report by the Kentucky state auditor.

In Rhode Island, a botched rollout in September 2016 delayed tens of thousands of Social Security payments, The Providence Journal reported. Advocacy groups filed two class-action lawsuits, one related to Medicaid and the other to food stamp benefits. Both were settled, with Rhode Island officials denying wrongdoing. Neither named Deloitte as a defendant.

In a 2018 statement for a Statehouse hearing, Sills of Deloitte said, “We are very sorry for the impact that our system issues have had on your constituents, on state workers, and on service providers.” The state’s top human services official resigned.

A 2017 audit by a top Rhode Island official prepared for Gov. Gina Raimondo found that Deloitte “delivered an IT system that is not functioning effectively” and had “significant defects.” “Widespread issues,” it said, “caused a significant deterioration in the quality of service provided by the State.”

“Deloitte held itself out as the leading vendor with significant experience in developing integrated eligibility systems for other states,” the audit read. “It appears that Deloitte did not sufficiently leverage this experience and expertise.” Deloitte declined to comment further about Rhode Island and Kentucky.

Deloitte invokes the phrase “no-touch” to describe its technology — approving benefits “without any tasks performed by the State workers,” it wrote in documents vying for an Arkansas contract.

In practice, enrollee advocates and former government caseworkers say, the systems frequently have errors and require manual workarounds.

As it considered hiring Deloitte, Arkansas officials asked the company about problems, particularly in Rhode Island.

In response, the company said in 2017, “We do not believe Deloitte Consulting LLP has had to implement a corrective action plan” for any eligibility system project in the previous five years.

Arkansas awarded Deloitte a $345 million contract effective in 2019 to develop its system.

“It had a lot of bugs,” said Bianca Garcia, a program eligibility specialist for the Arkansas Department of Human Services from August 2022 to October 2023.

Garcia said it could take weeks to fix errors in a family’s details and Medicaid enrollees wouldn’t receive the state’s requests for information because of glitches. They would lose benefits because workers couldn’t confirm eligibility, she added.

The enrollees “were doing their part, but the system just failed,” Garcia said.

Arkansas Department of Human Services spokesperson Gavin Lesnick said: “With any large-scale system implementation, there occasionally are issues that need to be addressed. We have worked alongside our vendor to minimize these issues and to correct any problems.”

Deloitte declined to comment.

‘Heated’ Negotiations

In late 2020, Colorado officials were bracing for the inevitable unwinding of pandemic-era Medicaid protections.

Colorado was three years into what is now a $354.4 million contract with Deloitte to operate its eligibility system. A state-commissioned audit that September had uncovered widespread problems, and Kim Bimestefer, the state’s top Medicaid official, was in “heated” negotiations with the company.

The audit found 67% of the system notices it sampled contained errors. Notices are federally required to safeguard against eligible people being disenrolled, said MaryBeth Musumeci, an associate teaching professor in public health at George Washington University.

“This is, for many people, what’s keeping them from being uninsured,” Musumeci said.

The Colorado audit found many enrollee notices contained inaccurate response deadlines. One dated Dec. 19, 2019, requested a beneficiary return information by Sept. 27, 2011 — more than eight years earlier.

“We’re in intense negotiations with our vendor because we can’t turn around to the General Assembly and say, ‘Can I get money to fix this?’” Bimestefer told lawmakers during the 2020 legislative audit hearing. “I have to hold the vendor accountable for the tens of millions we’ve been paying them over the years, and we still have a system like this.”

She said officials had increased oversight of Deloitte. Also, dozens of initiatives were created to “improve eligibility accuracy and correspondence,” and the state renegotiated Deloitte’s contract, said Marc Williams, a state Medicaid agency spokesperson. A contract amendment shows Deloitte credited Colorado with $5 million to offset payments for additional work.

But Deloitte’s performance appeared to get worse. A 2023 state audit found problems in 90% of sampled enrollee notices. Some were violations of state Medicaid rules.

The audit blamed “flaws in system design” for populating notices with incorrect dates.

In September, Danae Davison received a confusing notice at her Arvada home stating that her daughter did not qualify for coverage.

Lydia, 11, who uses a wheelchair and is learning to communicate via a computer, has a seizure disorder that qualifies her for a Medicaid benefit for those with disabilities. The denial threatened access to nursing care, which enables her to live at home instead of in a facility. Nothing had changed with Lydia’s condition, Davison said.

“She so clearly has the need,” Davison said. “This is a system problem.”

Davison appealed. In October, a judge ruled that Lydia qualified for coverage.

The notice generated by the Deloitte-operated system was deemed “legally insufficient” because it omitted the date Lydia’s coverage would end. Her case highlights a known eligibility system problem: Beneficiary notices contain “non-compliant or inconsistent dates” and are “missing required elements and information,” according to the 2023 audit.

Deloitte declined to comment on Colorado. Speaking broadly, Smith said, “Incorrect information can come in a lot of forms.”

Last spring in Pennsylvania, Deloitte’s eligibility role expanded to include the Children’s Health Insurance Program and 126,000 enrollees.

Pennsylvania’s Department of Human Services said an error occurred when converting to the state’s eligibility system, maintained by Deloitte through a $541 million contract. DHS triaged the errors, but, for “a small window of time,” some children who still had coverage “were not able to use it.”

These issues affected 9,269 children last June and 2,422 in October, DHS said. A temporary solution was implemented in December and a permanent fix came through in April.

Catanese, the union representative, said it was another in a long history of problems. Among the most prevalent, he said: The system freezes for hours. When asked about that, Smith said “it's hyperbole.”

Instead of the efficiency that Deloitte touted, Catanese said, “the system constantly runs into errors that you have to duct tape and patchwork around.”

KFF Health News senior correspondent Renuka Rayasam and correspondents Daniel Chang, Bram Sable-Smith, and Katheryn Houghton contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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KFF Health News' 'What the Health?': Live From Aspen: Health and the 2024 Elections

June 21, 2024
The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The presidential election is less than five months away, and while abortion is the only health policy issue expected to play a leading role, others are likely to be raised in the presidential and down-ballot races. This election could be critical in determining the future of key health care programs, such as Medicaid and the Affordable Care Act.

In this special episode of KFF Health News’ “What the Health?” taped at the Aspen Ideas: Health festival in Aspen, Colorado, Margot Sanger-Katz of The New York Times and Sandhya Raman of CQ Roll Call join Julie Rovner, KFF Health News’ chief Washington correspondent, to discuss what the election season portends for top health issues.

Panelists Margot Sanger-Katz The New York Times @sangerkatz Read Margot's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this week’s episode:

  • Policies surrounding abortion — and reproductive health issues, in general — likely will dominate in many races, as Democrats try to exploit an issue that is motivating their voters and dividing Republican voters. The topics of contraception and in vitro fertilization are playing a more prominent role in 2024 than they have in past elections.
  • High prescription drug prices — which, for frustrated Americans, are a longtime symbol, and symptom, of the nation’s dysfunctional health care system — have been a priority for the Biden administration and, previously, the Trump administration. But the issue is so confusing and progress so incremental that it is hard to say whether either party has an advantage.
  • The fate of many major health programs will be determined by who wins the presidency and who controls Congress after this fall’s elections. For example, the temporary subsidies that have made Affordable Care Act health plans more affordable will expire at the end of 2025. If the subsidies are not renewed, millions of Americans will likely be priced out of coverage again.
  • Previously hot-button issues like gun violence, opioid addiction, and mental health are not playing a high-profile role in the 2024 races. But that could change case by case.
  • Finally, huge health issues that could use public airing and debate — like what to do about the nation’s crumbling long-term care system and the growing shortage of vital health professionals — are not likely to become campaign issues.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Las pruebas para la gripe aviar son difíciles de conseguir. ¿Cómo saber si estamos en una pandemia?

June 21, 2024

Últimamente, Abraar Karan, médico especialista en enfermedades infecciosas en la Universidad de Stanford, ha atendido a muchos pacientes con goteo nasal, fiebre e irritación en los ojos. Estos síntomas podrían ser señales de alergias, covid o un resfriado.

Y este año, existe una posibilidad más, la gripe aviar, pero la mayoría de los médicos no tienen forma de detectarla.

Médicos como Karan advierten que, si el gobierno no se prepara para que las pruebas para la gripe aviar H5N1 estén más disponibles, otra pandemia podría tomar al país por sorpresa de nuevo. 

“Estamos cometiendo los mismos errores que cometimos con el covid”, dijo Deborah Birx, quien fue coordinadora del equipo de respuesta al coronavirus bajo el ex presidente Donald Trump, en un programa de CNN el 4 de junio.

Para convertirse en una pandemia, el virus de la gripe aviar H5N1 tendría que propagarse entre las personas. La mejor manera de monitorear si eso está ocurriendo es realizando pruebas.

Muchos laboratorios de diagnóstico están capacitados para detectar el virus. Sin embargo, la burocracia, los problemas de facturación y la falta de inversión no permiten aumentar rápidamente la disponibilidad generalizada de pruebas.

Por el momento, la Administración de Alimentos y Medicamentos (FDA) ha autorizado únicamente la prueba de gripe aviar de los Centros para el Control y Prevención de Enfermedades (CDC), que se utiliza solo en personas que trabajan cerca de ganado.

Autoridades estatales y federales han detectado gripe aviar en vacas lecheras en 12 estados. Tres personas que trabajan en distintas granjas lecheras dieron positivo, presuntamente contagiadas de vacas infectadas con el virus. Sin embargo, los investigadores coinciden en que hay un subregistro de casos, dado que los CDC sólo han realizado pruebas de detección a unas 40 personas.

“Es importante saber si el virus está contenido en las granjas, pero no tenemos información porque no la estamos buscando”, dijo Helen Chu, especialista en enfermedades infecciosas de la Universidad de Washington en Seattle, quien alertó al país sobre la propagación del covid en 2020 realizando pruebas de manera más amplia.

Informes de trabajadores agrícolas enfermos a los que no se les hizo pruebas y de una partera que tenía síntomas de gripe en las áreas de Texas donde hubo brotes de H5N1 en el ganado sugieren que las cifras son más altas. Además, los síntomas de quienes dieron positivo (tos e inflamación en los ojos, sin fiebre) fueron leves, lo cual indica que las personas infectadas podrían no buscar atención médica y, por lo tanto, no hacerse la prueba.

Los CDC han pedido a los trabajadores agrícolas con síntomas de gripe que se hagan la prueba, pero a los investigadores les preocupa la falta de acceso y de incentivos para estimular a la gente a hacerse el test, sobre todo en personas con baja seguridad laboral y acceso limitado a la atención médica.

Además, al realizar las pruebas sólo en granjas lecheras, los CDC probablemente pasarían por alto las señales de un brote más amplio.

“Es difícil no comparar esto con covid, cuando al principio solo hacíamos pruebas a las personas que habían viajado”, dijo Benjamin Pinsky, director médico del laboratorio de virología clínica de la Universidad de Stanford. “Eso hizo que no reconociéramos de inmediato que el virus se estaba transmitiendo en la comunidad”.

En los primeros meses de covid, la distribución de pruebas en Estados Unidos fue catastróficamente lento. Aunque la Organización Mundial de la Salud había aprobado una prueba y otros grupos habían desarrollado sus propias versiones utilizando técnicas básicas de biología molecular, al principio los CDC insistieron en desarrollar y utilizar su propia prueba.

La primera versión que enviaron a los laboratorios estatales no funcionó, agravando las demoras.

La FDA también se retrasó. La agencia no autorizó pruebas de laboratorios de diagnóstico por fuera de la de los CDC hasta fines de febrero de 2020.

El 27 de febrero de 2020, el laboratorio de investigación de Chu detectó covid en un adolescente que no cumplía con los estrictos criterios de prueba de los CDC. Este caso fue la voz de alarma de que covid se había extendido de manera desapercibida. Ampliar los suministros para satisfacer la demanda llevó tiempo, y pasaron meses antes de que cualquier persona que necesitara una prueba de covid pudiera hacérsela.

Chu señala que no es 2020, ni mucho menos. Los hospitales no están llenos de pacientes con gripe aviar. Además, el país tiene las herramientas para actuar mucho mejor esta vez, dijo, si hay voluntad política.

Para empezar, las pruebas que detectan la amplia categoría de influenza a la que pertenece el H5N1, llamada influenza A, están aprobadas por la FDA y están disponibles. Se realizan de forma habitual durante la “temporada de gripe”, de noviembre a febrero. Si los investigadores detectan un número inusual de resultados positivos en las pruebas de gripe comunes durante la primavera y el verano, podría ser una mala señal.

Sin embargo, es poco probable que los médicos pidan pruebas de influenza A para pacientes con síntomas respiratorios fuera de la temporada de gripe, en parte porque algunas aseguradoras no las cubren excepto en circunstancias limitadas, dijo Alex Greninger, subdirector del laboratorio de virología clínica de la Universidad de Washington.

Este problema tiene solución, aclaró. En el pico de la pandemia de covid, el gobierno obligó a las compañías de seguros a cubrir las pruebas, y fijó un precio atractivo para que valiera la pena para los fabricantes. “En Manhattan, te encontrabas con un centro de testeo cada dos cuadras, porque las empresas recibían $100 cada vez que insertaban un hisopo en una nariz”, dijo Greninger.

Otro obstáculo es que la FDA aún no ha permitido que las empresas realicen pruebas de influenza A con muestras oculares, aunque los CDC y los laboratorios de salud pública sí pueden. En el caso de un trabajador agrícola infectado este año, el virus de la gripe aviar se detectó sólo en un hisopado ocular y no en muestras extraídas de la nariz o la garganta.

Superar estas barreras es esencial para aumentar el testeo de influenza A en áreas ganaderas, dijo Chu. “La estrategia más eficaz sería ofrecer estas pruebas de forma rutinaria en los consultorios que atienden a las comunidades de trabajadores agrícolas”, dijo, y sugirió que también estén disponibles en las ferias estatales.

Mientras tanto, se podrían actualizar las nuevas pruebas que detectan el virus H5N1. La prueba actual de los CDC no es muy sensible ni fácil de usar, dijeron investigadores.

Stanford, la Universidad de Washington, la Clínica Mayo y otros laboratorios de diagnóstico que prestan servicios en los sistemas hospitalarios han desarrollado alternativas para detectar el virus que está circulando. Sin embargo, su alcance es limitado, y los investigadores destacan la necesidad de poner en marcha esfuerzos para ampliar la capacidad de testeo antes de que se produzca una crisis.

“Si esto se convierte en una emergencia de salud pública, ¿cómo asegurarnos de no quedar estancados como en los primeros días de covid, cuando no podíamos avanzar rápidamente?”, dijo Pinski.

Una norma reciente que otorga a la FDA más control sobre las pruebas desarrolladas en laboratorio puede demorar la autorización. Un representante de la FDA le dijo a KFF Health News que, por ahora, la agencia tal vez permitirá que se realicen pruebas sin un proceso de aprobación completo.

Los CDC no respondieron a las solicitudes de comentarios.

Pero la Asociación Estadounidense de Laboratorios Clínicos ha exigido a la FDA y a los CDC más claridad sobre la nueva regla. “Está retrasando el proceso porque aumenta la confusión sobre lo que está permitido”, dijo Susan Van Meter, presidenta del grupo comercial de laboratorios de diagnóstico.

Labcorp, Quest Diagnostics y otras grandes empresas de pruebas son las más capacitadas para gestionar el aumento en la demanda de pruebas, ya que pueden procesar cientos al día, en lugar de docenas. Pero esto implicaría adaptar los procesos de testeo para sus equipos especializados, algo que requiere tiempo y dinero, dijo Matthew Binnicker, director de virología clínica de la Clínica Mayo.

“En los últimos años sólo ha habido unos pocos casos de H5N1 en humanos”, dijo, “por lo tanto, les resulta difícil invertir millones cuando no sabemos qué va a pasar”.

El gobierno podría proporcionar fondos para financiar la investigación o comprometerse a adquirir pruebas al por mayor, tal como en el proyecto Operación Warp Speed, que avanzó el desarrollo de la vacuna contra covid.

“Si tenemos que ampliar el testeo, necesitaríamos una inversión de dinero”, dijo Kelly Wroblewski, directora de programas de enfermedades infecciosas de la Asociación de Laboratorios de Salud Pública. Al igual que una póliza de seguro, el gasto inicial sería mínimo comparado con el golpe económico de otra pandemia.

También son fundamentales otros medios para rastrear el virus H5N1. La detección de anticuerpos contra la gripe aviar en trabajadores agrícolas ayudaría a revelar si más personas se han infectado, y si se han recuperado. Analizar las aguas residuales para detectar el virus podría indicar un aumento de las infecciones en personas, aves o ganado.

Como ocurre con todos los esfuerzos de preparación para una pandemia, la dificultad radica en enfatizar la importancia de actuar antes de que ocurra una crisis, dijo Greninger.

“Definitivamente debemos estar preparados”, dijo, “pero hasta que el gobierno no se haga cargo de parte del riesgo, es difícil dar un paso en esa dirección”.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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